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CONTINUING EDUCATION The American College of Forensic Examiners International (ACFEI), sister organization to the American Psychotherapy Association, provides continuing education credits for accountants, nurses, physicians, dentists, psychologists, psychiatrists, counselors, social workers, and marriage and family therapists. ACFEI is an approved provider of continuing education by the following: Accreditation Council for Continuing Medical Education National Association of State Boards of Accountancy National Board for Certified Counselors California Board of Registered Nursing American Psychological Association California Board of Behavioral Sciences Association of Social Work Boards American Dental Association (ADA CERP) Diplomate status with the American Psychotherapy Association is recognized by the National Certification Commission. For more information on recognitions and approvals, please visit www.americanpsychotherapy.com

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Just Do It! By Daniel J. Reidenberg, PsyD, Fellow, American Psychotherapy Association, Board Certified Professional Counselor, Master Therapist

There is more to the Nike Swoosh than anyone might ever imagine. According to Nike company lore, one of the most famous and easily recognized slogans in advertising history was coined at a 1988 meeting of Nike’s ad agency, Wieden & Kennedy, and a group of Nike employees. Dan Weiden, speaking admiringly of Nike’s can-do attitude, reportedly said,“You Nike guys, you just do it.” The rest, as they say, is (advertising) history. “After stumbling badly against archrival Reebok in the 1980s, Nike rose about as high and fast in the ’90s as any company can. It took on a new religion of brand consciousness and broke advertising sound barriers with its indelible Swoosh, “Just Do It” slogan, and deified sports figures. Nike managed the deftest of marketing tricks: to be both anti-establishment and mass market, to the tune of $9.2 billion in sales in 1997.“ — Jolie Soloman ”When Nike Goes Cold,” Newsweek, March 30, 1998

Could we all have the same level of success as Nike? Could our patients?

I say YES!

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Most of us in Minnesota live for what are called the 90 days of summer, from Memorial Day to Labor Day. There is extensive advertising done around this period. Some businesses open and close by these precious 90 days, and weather forecasters are loved and hated during the three months that seem to define who we are as Minnesotans—basically all by what we can do and get done in this small window of opportunity to be outside. The other day I was in town and driving to work. As I was listening to the radio, the DJ got my attention when he started talking about something that he wanted to do: “A bucket list for the summer.” I happen to know this person and have worked with him in the past on many volunteer events. Full disclosure: He is a good friend with a huge heart and one who does a lot for the community, so I know him from both a personal and professional place. Dave Ryan is the host of the Dave Ryan in the Morning show on KDWB 101.3 FM in Minneapolis/St. Paul. This is one of seven Clear Channel radio stations in the Twin Cities, and KDWB is one of the highest-rated stations in the country for the 15- to 34-year-old demographic. Dave has been with KDWB since the early 1990s, and many in the community have literally grown up listening to him (along with radio show cast mates Lena, Crisco, and Steve) through junior and senior high school, college, and now as adults. Dave says to the others: “So here’s what I want to do. I’m going to have a bucket list for the summer. These are going to be three things that I am going to do this summer just because. For no particular reason or anything like that, just because.” He went on to tell them that he wanted each of them to come up with their own “summer bucket list,” and he told them—and everyone liswww.americanpsychotherapy.com


tening—what his three things were going to be. For example, he was going to grill the perfect steak. He told the listening audience that he can cook a steak, but he cuts into it so many times and checks it over and over again that by the time it is ready to serve, the steak is mangled, and while it tastes fine, he just wants to learn how to cook the perfect steak. So that’s one thing. Dave bought himself a book about cooking steak and he was going to read it, practice, and by the end of summer, do it. The next item on his list was to fly his small plane to International Falls. “Why? I have no idea why. There’s nothing special about it, nothing special about the 3-hour flight, and nothing in particular I want to see or do in International Falls. All I know is that I’ve always wanted to take my plane and fly there, so I’m going to do it.” Third was his dream to write the book he’s started but never finished. After he talked about what his three things were, the others on the show listed theirs. Each person gave a truly personal perspective of why he or she chose that particular thing to do. For example, Lena talked about taking dance lessons (and how excited she was to get started), taking (800) 592-1125

French, and going skydiving. Steve planned to also go skydiving and to build a swing set for his kids. Crisco’s bucket list included running 10 miles and going camping with his nephew. As I listened to their conversation, I couldn’t help but wonder: Was I wrong in my keynote address last fall? Some of you who are reading this may recall my keynote address during the banquet at our association’s last annual meeting in Orlando, Florida. For those of you who weren’t there, I started that talk by saying: “This isn’t about The Bucket List, and it’s not about the song Live Like You Were Dying.” I didn’t want the presentation to be about the things that we all get to a certain point and think to ourselves that we must do X, Y, or Z before we die. Instead, I spoke about “living every day, every moment.” And key to that message was not living as if it might be your last moment or near the end or anything like that. Rather, “live the way you want to be remembered—by, for, and how you did the things you did when you could.” Did I not only start the presentation with the wrong premise (i.e., this isn’t about a bucket list), but did I send the audience on the wrong path by suggesting that a bucket list was what you do in response to wanting to get something done before you die, as opposed to doing something now, just because you want to or love to do it? I decided to call and talk to Dave. I wanted to know: Where did this idea come from? Why did he have it? What made him want

to share it with the world listening to him? I suppose, almost selfishly, I called to find out if I was wrong about my presentation, but honestly, I really just wanted to hear from my friend, where did this all come from? Well, in my conversation with Dave the DJ, he was really honest and clear with me. There was no agenda for him other than this: “Action is everything in our life. Do it now.” Dave went on to tell me that in his personal life and as a DJ coming in contact with people all the time, he has seen that “people muddle through life, and they just seem to get by. So many are not enjoying anything; they are so busy that they miss other things and just generally they wonder what this is all for.” He said he’s watched people put things off, over and over again. And he, too, has done the same thing. I asked whether this idea was in response to something — the “did you get some bad news, Dave?” question —but he said no. I asked if this was a midlife crisis, and he told me that he and his wife actually talked about that, but it wasn’t that either. For Dave, this was really pretty simple: “Don’t put it off. You can’t keep saying you’re going to do it and then you never do. Just do it and do it right now. Make it happen!” Dave went on to say that he thought about this and came to the conclusion that “you need to take action to improve what you can.” I then asked him: “Why go public with this?” What was behind it? Was it just another bit for the radio? Something gimmicky that he and the morning show could do to engage its listeners? None of that. Dave’s response to this was interesting. He told me that many listeners think of him as a role model. Whether he does or not, they do, so “I have to live up to that.” He went on to say that the morning show has really evolved over the years and that his life has centered around that evolution. He is open with his listeners about things going on in his life, and this is a big thing for him, so it was natural for him to share it with the au-

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CHAIR’S CORNER dience. However, beyond that, Dave said he has heard from so many listeners that they “have no role models in their life. They have no direction. I have to be that direction for them, at least on some level. And this was my way of saying, ‘find something you want to do and just do it!’” About the same time that I heard Dave’s radio challenge, I was reading the June issue of the Psychiatric Times. As I read through the articles, I came across a poll: What percentage of your patients do you see primarily for medication checks? A recent New York Times article, “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” focuses on the practice of one psychiatrist who, for a variety of reasons, now provides only 15-minute “med checks” for his patients.” The very next page in the Psychiatric Times was an article by H. Steven Moffic, MD, “What’s in It for Psychiatrists?” which was Moffic’s reaction to the New York Times article. What struck me was that all my life, I wanted to be a doctor. From the time I was 5 years old, that is all I wanted to be. I was going to grow up and become a medical doctor. Over the years, what type of doctor I was going to be changed and, ultimately, I was going to become a psychiatrist. I thought this would meet all of my needs and desires: to be able to talk to people and help them therapeutically and to be able to prescribe medications to augment therapy. I thought that was the best thing for me and for my future patients. But then there was organic chemistry and calculus, and my thoughts started to change, although I kept on course to become a psychiatrist. Then, somewhere along the way, I had a feeling that someday psychiatrists wouldn’t be practicing psychiatry the way it was done before. A gut instinct told me that psychiatrists were just going to prescribe medications and never really “talk” to patients. I wanted to talk to my patients! So my career path changed again, and I landed in clinical psychology. However, the problem was that in the back of my mind, I never let go of that part of me that wanted to be a medical doctor/psychiatrist. I still haven’t; even now when I read the articles that indicate my gut instinct was correct, the thought or desire still lingers that I should “just do it.” So how does this apply to you, and how does it apply to your clients? I think if I had one message, it would be Dave’s message: “Action is everything; just do it.” I 14

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Dave Ryan, the host of the Dave Ryan in the Morning show on KDWB 101.3 FM in Minneapolis/St. Paul, with his cast mate Lena Svenson.

think that we all put up, create, and build walls, rules, defenses, excuses, explanations, etc., so much so that we rarely (sometimes never) do what we really want to do. We don’t say things to our clients that we really want to (and could). I don’t think we push clients in ways that challenge them, at least not enough. We cover up our real wants with things for others and while this is noble, it doesn’t necessarily help them in any greater way. I think we try to act as role models, as Dave described, but in a very different way. And if we are role models, I wonder how much we are really modeling the right role. With that, I pose this challenge to you. Randomly, but safely and ethically, select four of your clients, and take two of them on a “just do it” path. Talk with them about this. See if it fits for them. Let them know that you believe this would be a good treatment option or route to try. Create open, realistic, but challenging goals with them. Keep working with them to achieve these goals, but in a more direct way than you had previously. Talk with them about a bucket list and ask them: “How long do you put off this thing we call being happy?” Do this for 90 days, and see what happens. Keep working with the other two clients with just as much passion and care as you had, change nothing in their treatment plans, and see what happens. At the end of the 90 days, compare the two test groups

Annals of Psychotherapy & Integrative Health

and see what you find. Hopefully, all will continue to make progress. Maybe you will find new ways of working with your clients that help them. As Dave said to me and to the audience: “You can do this. Make it happen!” As for me, I’m signing up for the next mini-medical school program offered at the university!

References Harris, G. (2011, March 5). Talk doesn’t pay, so psychiatry turns instead to drug therapy. The New York Times. Retrieved from www.nytimes. com/2011/03/06/health/policy/06doctors.html Moffic, H. S. (2011). What’s in it for psychiatrists? Psychiatric Times, 28(5). Soloman, J. (1998, March 30). When Nike goes cold. Newsweek.

ABOUT THE AUTHOR DANIEL J. REIDENBERG, PsyD, FAPA, DAPA, MTAPA, is the chair of the American Psychotherapy Association’s Executive Advisory Board and has been a member since 1997. He is a Fellow and Master Therapist of the American Psychotherapy Association and executive director of Suicide Awareness Voices of Education (SAVE) in Minneapolis, Minnesota. Contact him with your thoughts at dreidenberg@save.org. www.americanpsychotherapy.com


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Culture Notes:

Sexting, Lies, and Twitterland By Irene Rosenberg Javors, LMHC, MEd, Diplomate, American Psychotherapy Association

s I sit writing, the news media are reporting that Representative Anthony Weiner has decided to resign from office. After weeks of a media circus providing the public with endless details about lewd photos and tweets sent by Weiner to several women online, we are finally spared further distractions about the congressman’s sexting. Weiner—a rising star in the Democratic Party who aspired to run for mayor of New York City—is, for the moment, an embarrassment to his pregnant wife, his mentors, his constituents, and his political party. I am not quite sure if he is an embarrassment to himself. From the battery of self-serving lies he has told, I am inclined to think that Weiner is less ashamed of his actions than he is upset about being caught. The congressman has a reputation for being an alpha male and an aggressively vocal spokesman about issues that are dear to his heart. He is used to being in charge and flexing his political muscle with little concern for decorum. His macho, tough-guy attitude stands in stark contrast to the photo he posted of himself on his Twitter feed, where we see a 16-year-old version of the congressman. The public image of the “hard as nails” politico is a far cry from the boyish, slightly nerdy photo displayed in Twitterland. His preoccupation with sex and his sexting are very much in keeping with an adolescent self, and Weiner’s thrill-seeking behavior is also an aspect of teenage bravado. And his lack of judgment would suggest that, like many 16-yearolds, he is in need of adult supervision.

“...sometimes ‘bad’ behavior is just what it is and doesn’t fall into a diagnostic category.” The split between his public self and his private obsessions is one of many factors leading to the Weiner debacle. His narcissism is another contributing factor. Like other public figures who have suffered a fall from grace—Mel Gibson, John Edwards, Eliot Spitzer, Charlie Sheen, and Arnold Schwarzenegger, to name a few—Weiner deluded himself into believing that he could get away with what he was doing without any consequences. 16

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U.S. Representative Anthony Weiner resigned from Congress on June 16, the culmination of an online “sexting” scandal. © lev radin / Shutterstock.com

Many ask how it is possible that someone as intelligent and worldly as Weiner could put himself into such a situation. Perhaps it is because Twitter and other social media offered Weiner a space in which to enact his private fantasies. When online, he entered his own virtual world, wherein anything was allowed. He entered an altered state of mind—he forgot that tweets are public and that once they are online, they are there for all to see. A comparison can be made to what happens when we go to the movies. We enter a darkened, womb-like space wherein we can sit alone and enter the world of fantasy, both on the screen and in our www.americanpsychotherapy.com


minds. The difference is that what we fantasize about while watching a film remains private, unlike when we tweet and our thoughts are broadcast out to the Internet. Whether Weiner was aware of what he was doing is a question that he will have to confront for himself. Based on his apparent capacity for denial and lying, I suspect it was a mixture of something that I would term “aware lying.” He knew and didn’t know at the same time. How do we contextualize Congressman Weiner’s behavior? Does he need rehab? Therapy? A course in civics? Lessons in morals? Or is his behavior a reflection of character traits: the constant craving for attention, thrills, power, etc.? All of these? Some? None? My inclination is to believe that Weiner needs a dose of reality. His resignation from Congress marks a beginning step toward his acceptance that he is not above reproach. If he is serious about dealing with his mistakes, he will need to find a venue that will help him examine his actions and begin to look at the underlying values and assumptions that led him to such self-destructive behavior. Often our society interprets incomprehensible behavior as a sign of mental illness or emotional disturbance. At times, this assumption is appropriate. However, sometimes “bad” behavior is just what it is and doesn’t fall into a diagnostic category. Congressman Weiner has behaved badly and has not acted in a manner appropriate to public service. It is interesting to note that earlier this year, Weiner advocated the removal and sale of a statue located in Queens, New York. He

interpreted the work as sexist and an eyesore. The congressman and art historians/art preservationists have been locked in an ongoing conflict over what to do with the century-old sculpture by Frederick William MacMonnies called Triumph of Civic Virtue. The statue is an allegory depicting civic virtue triumphing over vice and corruption. The sad irony is that the very sculpture that so offended the beleaguered representative accurately depicted the behavior that would result in his downfall. As of now, the statue remains; the congressman does not. But Americans love a “comeback kid.” There is always room for redemption in America’s collective psyche. The Anthony Weiner (Virtual) Reality show may be in the works soon!

ABOUT THE AUTHOR IRENE ROSENBERG JAVORS, LHMC, MEd, DAPA, is a Diplomate of the American Psychotherapy Association, a licensed mental health counselor, and a psychotherapist in New York City. She is also an adjunct associate professor of mental health counseling in the Mental Health Counseling Program of the Ferkauf Graduate School of Psychology at Yeshiva University. She is the author of Culture Notes: Essays on Sane Living (ACFEI Media, 2010).

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Treatment obstacles include the patient’s reluctance to renounce the benefits derived from pleasing, the fear of having no other recourse for maintaining meaningful connections to others, and the role of guilt.

s r e k a t e r a C >>>

By Les Barbanell, EdD, Diplomate, American Psychotherapy Association

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and the

new

addiction

category Abstract

The author introduces the term “trait addiction� as an addiction category that corresponds to, but is distinct from, substance and activity addictions. Selflessness is the central character trait of the addiction to please. The Selfless Personality Scale measures degrees of selflessness and indicates the presence of an addiction or disorder. Benevolent acts such as compliance, kindness, and accommodation initially evoke respect and admiration; however, the excessive (obsessive) and relatively exclusive focus upon others ultimately yields false relationships, emotional emptiness, and social isolation. Severe anxiety, depression, and suicidal tendencies are not uncommon reactions when the addiction to please begins to fail as a coping style. The origin of the addiction is related to a history of traumata stemming from abandonment, sexual or physical abuse, or neglect from primary caregivers. In an effort to compensate for feelings associated with these early traumata, the unconscious constructs the caretaker-please syndrome. Guilt and (abandonment) anxiety keep this other-focused lifestyle intact. However, when the incessant giving of the please addict is experienced as manipulative and controlling, receivers avoid contact with them. In terms of diagnostic considerations, the addiction to please is distinguished from other personality disorders and other forms of deferential behavior, such as altruism, martyrdom, and co-dependency. Treatment obstacles include the patient’s reluctance to renounce the benefits derived from pleasing, the fear of having no other recourse for maintaining meaningful connections to others, and the role of guilt. In addition to a Relational Analytic treatment approach, the author recommends a variety of adjunctive interventions. The concepts of change and cure are discussed.

>>>

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This article is approved by the following for continuing education credit: The American College of Forensic Examiners International is an NBCC-Approved Continuing Education Provider (ACEP) and may offer NBCC-approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. The American Psychotherapy Association® provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status. After studying this article, participants should be better able to do the following: 1. Explain how character traits can be used as a shield that conceals deeply rooted crises and trauma. 2. Describe the deceptive nature of the please addiction. 3. Discuss the origin of pathological kindness and the role of the unconscious in its formation. 4. Identify the imbalance of the give-receive dimension of relationships and its destructive nature. KEY WORDS: Selflessness, abandonment, guilt, trauma, masks TARGET AUDIENCE: Psychologists, counselors (particularly addiction counselors), social workers, medical doctors, psychiatrists, nurses, vocational counselors, clergy, teachers PROGRAM LEVEL: Intermediate DISCLOSURES: The author has nothing to disclose. PREREQUISITES: None

Selfless Actions of Selfless People • A woman was walking with her daughter on a crowded city street. She saw a man losing his balance and falling without any apparent reason. As he lay face down on the pavement, passers-by glanced at him, but no one stopped to assist him. The woman said to her daughter, “They must think he’s a homeless person, but I think he may have had a heart attack.” She rushes to the man’s side, gives him one of her heart (nitroglycerin) pills, and calls an ambulance. At the hospital, the paramedic told her that she might have saved the man’s life. Who is this quick-thinking, quick-acting savior? I will refer to her as Jennifer. She had three children in addition to the child who was with her on the day of the incident. After 14 years of being a divorced single parent, she married a man whom she admired but did not love. She summed up her marriage as follows: “I cook, clean, and take care of him. 20

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He took my children and myself from poverty to respectability, and that’s all I wanted. As far as our sex life is concerned, I could eat an apple and perform at the same time, but I am sure he is satisfied.” • Jack was a high school guidance counselor with a reputation for extending himself for students beyond what was expected of him. He would help with college loan application forms and, whenever possible, accompany them and their parents to the college campus of their choice. He was equally devoted to his wife. He routinely cooked dinner, walked the dog, and kept himself busy while his wife, a writer, spent hours on the computer almost every night. On Saturdays, he accompanied his wife on visits to her elderly mother at a nursing home. Jack never complained when his wife’s children and grandchildren from her first marriage visited on weekends. • “Here comes Grandpa Allan!” Most of us fortunate enough to have grandparents recall the joy of visits with them. We didn’t really understand why they

Annals of Psychotherapy & Integrative Health

were so popular with us as kids; we just looked forward to their presence. Maybe it’s because they didn’t discipline us or tell us how we were supposed to behave, or maybe it’s because they usually came with presents. Few children I have known have had more to look forward to than Allan’s grandchildren. They always greeted him with bursts of enthusiasm. He was wealthy, generous, and frequently surprised them with gifts. He also paid for their private school education, their nanny, and trips to Disney World and Europe. • Janet, age 64, was as devoted to her 42-year-old son, Robert, as Allan was to his grandchildren. She welcomed his return home after a failed marriage, a suspended license for a DWI, and an arrest for drug possession. He was not asked to contribute to the rent, do his laundry, nor perform chores around the house. Janet also did not hesitate to wake him each day and drive him to work. While he was at work one day, she was cleaning his room and found drug paraphernalia. Several days later, she looked in his phone book and found the name of a person who she suspected was selling her son drugs. One night while Robert was sleeping, she drove to an extremely dangerous section of the Bronx to confront the drug dealer. I have heard some parents say they would face a bullet for their children— Janet actually did it! Now, that’s dedication…or is it? • Harriet, a psychotherapist in her 40s, worked six days a week and occasionally on Sundays. When she was not in the office, her patients were not discouraged from calling her at home. When family members and friends sought advice and emotional support, she was always responsive. Patients expressed their gratitude by presenting her with gifts, particularly during the holiday season. She almost always refused the gifts but awkwardly accepted the compliments that accompanied them. • His parishioners referred to Father Gary as “the best listener in God’s universe.” He was perceived to be charitable, understanding, trustworthy, and accessible. He visited the homes of the disadvantaged and, through various agencies in the community, coordinated efforts to provide www.americanpsychotherapy.com


C A R E TA K E R S A N D T H E N E W A D D I C T I O N C AT E G O R Y fronting her son’s drug dealer and derailed a dangerous connection that could have ruined his life. How many patients were helped by Harriet’s availability on weekends? Perhaps Brittany’s classmates would have failed to graduate if she did not help them with their homework, examinations, and problems with their boyfriends. The stability of her firm may have been shaken if Kate weren’t so competent, and her family would have fallen apart if she weren’t so “together.” If Father Gary was not so compassionate, his followers may have remained confused, isolated, and in some cases without sustenance. Whether adolescent or an elder, male or female, rich or poor, there are those individuals who—by virtue of their

a Allan!” p d n a r G s e m o c siasm. “Here bursts of enthu food and shelter for them. He adhered to the vows of celibacy and frequently lectured on the benefits of the personal sacrifice of joy and pleasure. • Friends, family, and co-workers viewed Kate as always agreeable and accommodating. Her best friend told Kate that if she read the dictionary, she would skip the word “no.” She was also highly regarded as strong and independent in her relationships with family members and co-workers. • Brittany was adored by her teen-age peers, teachers, and above all, her parents. She was captain of the girls’ basketball team at the local high school, worked after class at the school library, and helped her parents raise her two younger siblings. An honor student, she frequently helped her classmates with their homework. Her social life consisted of telephone conversations with friends about their boyfriends. She believed that her time for boys would come eventually. The various forms of benevolence displayed by the individuals above was not incidental but was characteristic of their day-to-day functioning—a lifestyle! For example, Allan, the financially generous grandfather, treated his employees in the same manner with which he treated his friends, children, and grandchildren. True (800) 592-1125

eeted him with sed They always gr equently surpri fr d n a s, ou er n y, ge school He was wealth for their private id pa o ls a e H s. them with gift ney World and trips to Dis y, n n a n r ei th , education and Europe.

to form, his alimony settlement with his first wife made her a wealthy woman, and thanks to Allan, neither party needed to hire an attorney.

So Far, So Good At least initially, most of us admire people of all ages who defer to the needs of others while suspending the gratification of their own need states. Their selfless acts are usually rewarded with positive responses from friends, family, and business associates that enhance their self-esteem and provide them with status in their local community. The man who fainted in a crowd might have died without Jennifer’s assistance. Several high school students may not have been accepted by a college without Jack’s intervention. If Allan had not been so forthcoming financially, his daughter may have had to send her children to a public school that she felt was unsafe. Janet risked her life by con-

energy, attentiveness, and accessibility—are capable of saving the day.

Truth and Consequences When we first encounter individuals like those described, we are unaware of the hazards of their benevolent lifestyle. Alas, in most cases they will be pushed aside and discarded like yesterday’s newspaper. Their phone calls will not be returned; they will lose friends, harmony with close relatives, and maybe, in time, their own emotional stability. They will have “coped with kindness” until they encounter the same isolation and feelings of invisibility they were seeking to avoid in the first place. For more than a few, suicide will come to seem like the only alternative. How can being so good ever go bad for those individuals in our sample and others so predisposed? How can giving while receiving so little in return have unimaginable >>>

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Table 1

The Codependent Personality and the Caretaker Personality (Please Addict):

Comparison CODEPENDENTS

PLEASERS

SIMILARITIES Control others by giving Have pervasive, albeit secret, fears of rejection and abandonment Helping of others dominates the interaction with them Their role in relationships has a superior-inferior (vertical) dimension Their role conceals their dependency and vulnerability

I

n the traditional

sense, caretakers

DIFFERENCES Enable dependent types

Help dependent types, rejected by others who are less dependent

are individuals who

Ultimately hurt those they love

Are often the hurt party

consciously and vol-

The receiver is usually rejected

Extremely susceptible to rejection

Helping is part of ego identity and the population they interact with is selective

untarily provide care

Helping IS their identity

Enhance self-esteem by rescuing others

Enhance self-esteem by helping

Do not expect much in return

Have secret feelings of entitlement

for others, such as a dependent child, an aging parent, sibling, intimate partner, or

Table 2

Narcissistic Personalities and Pleasers (Care Addicts):

Comparison

friend who is ill or otherwise unable to function indepen-

NARCISSISTS

PLEASERS

SIMILARITIES Shape asymmetrical (vertical) relationships lacking balance of giving and receiving Seek attention and admiration and are exhibitionistic in obvious and subtle ways Display a sense of entitlement (relatively covert for pleasers) Grandiosity and self-serving interests are the core of the personality

dently. Caretakers in the pathological sense are selfless individuals who focus on others in an obsessive,

DIFFERENCES Are conspicuously self-focused

Other-focused

Lack empathy and attentiveness toward others

Overly attentive

Assume others always think about them

Assume others ignore them

manner that is uncon-

Haughty, exploitative, non-giving

Humble and indulgent

sciously motivated.

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involuntary, reflexive

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C A R E TA K E R S A N D T H E N E W A D D I C T I O N C AT E G O R Y consequences? Isn’t it usually better to give than to receive? What eventually happened to Jennifer, Jack, Allan, Janet, Harriet, Father Gary, Kate, and Brittany that nearly ruined their lives? What follows exposes the “truth” beneath what I shall refer to as the Mask of Kindness. • Jennifer: When her second husband died, her entire existence centered on her children. She existed for their phone calls and visits, which decreased as she entered her 60s. Isolated, depressed, and craving the attention she previously received by pleasing others, she resorted to constant complaints about real and imagined illnesses. When these efforts failed, she slept away her days and nights until she considered seeking help. • Jack: He had a series of affairs that threatened the survival of his third marriage. Confused and upset about the obvious pattern, he sought psychotherapy. When asked what he needed, he said, “I don’t recall anyone in my entire life ever asking me that question, so I don’t know the answer.” He always had the answer for what others needed—especially the women he knew and his counselees at school—but was not in the least aware of his own needs. • Allan: The reaction to his generosity was consistent in most of his relationships. His daughter and children, the primary beneficiaries of his affluence, rarely phoned him or sent him a greeting card on holidays and birthdays. When his employees planned office parties for which he paid, they hardly noticed his presence. He felt ignored but explained in session that he didn’t do anything about it because he was too busy making certain that everyone had a good time. Eventually, he began to realize that he was taken for granted by everyone around him. • Janet: At age 67, she barely survived several suicide attempts. The extent to which she would be consumed with the lives of others, of course, was not limited to her drug-involved son. When we attempted to understand the choice to end her life, she disclosed the following (paraphrased): “I spent a lifetime rescuing everyone and couldn’t keep up with all the obligations. Ending my life seemed like the only way out of that trapped feeling.” • Harriet: Similar to Janet, her life space (800) 592-1125

was replete with obligations to others, in her case patients as well as family and friends. Her source of escape from the obligation-trap was food. Exhausted and emotionally empty, she became obese and opted for a gastric bypass operation that cost her over $25,000 out-of-pocket because she was under-insured, another example of her self-neglect. After shedding nearly 150 pounds, she returned to a life of kindness and regained the weight she had lost. • Father Gary: Although advocating the benefits of self-denial, the charismatic priest was indicted for molesting an 11-year-old boy. When the charge made headlines in the newspapers, four other victims came forward. He was transferred to another church location, where he remained in obscurity until he decided to seek help. • Kate: Compliant Kate, 42, was not remotely close to fulfilling her dream of having a child. She and her husband hadn’t had sex in nearly five years, and she rarely complained about it. Whenever she asked about this, her husband would pacify her with comments like, “Of course, you will be a mother someday.” Convinced that someday would never come, sad and disillusioned Kate concentrated even more on her work. When she was 52, Kate and her husband purchased a dog and lived miserably until they divorced. • Brittany: By the time she was a senior, she had been invited to one party during her entire high school experience and was not asked to her prom. At the age of 21, she had a lesbian experience and subsequently turned to religion, anticipating a life of celibacy. Brittany believed she suffered from being the ideal daughter, student, and friend, and she longed to return to a secular life.

Selfless Individuals Young and Old…Someone You Know? The notion that the sample above is representative of a portion of the general population and approximately one-fifth of the average practitioner’s caseload is speculative. When I first introduced the concept of the Caretaker Personality Disorder (2006), many of my colleagues revealed that such a personality type was familiar to them,

both within and outside their professional surroundings. One colleague, Dr. J., mentioned: “I know someone just like that— ME.” He told me about a patient who was unable to leave his office parking lot because her car wouldn’t start. Several hours later, he encountered the patient waiting for assistance and insisted on driving her home. Two months following the incident, the patient inexplicably terminated treatment. Six years later, she resurfaced, charging him with improper conduct and seeking monetary compensation. Dr. J.’s license was suspended for one year. His disillusionment led to depression, and he was unable to return to work. He devoted his career to working with attorneys who specialize in professional malpractice.

Definitions In the traditional sense, caretakers are individuals who consciously and voluntarily provide care for others, such as a dependent child, an aging parent, sibling, intimate partner, or friend who is ill or otherwise unable to function independently. Caretakers in the pathological sense are selfless individuals who focus on others in an obsessive, involuntary, reflexive manner that is unconsciously motivated. As such, they may be considered please or care addicts. The high or rush that fosters this addiction is motivated by at least three factors: (a) Focusing on others establishes (guarantees?) contact with others, (b) favorable responses from others accelerate the “rush,” and (c) the positive responses from others enhance self-esteem, increasing the compulsion to repeat like experiences. Substance and activity addictions are readily diagnosed by mental health professionals and in most cases easily detected by non-professionals. Drug addiction (included in the category of substance addiction) and Internet addiction (an activity addiction) are easily detectible. However, trait addictions have eluded discovery (and definition) by professional and non-professional observers alike. This distinction notwithstanding, trait addictions have the following in common with substance and activity addictions: 1. Behavior entails excessive craving that is a substitute for attention, approval, intimacy, and a variety of self-esteem needs. 2. The belief that the choice of addiction >>>

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is the exclusive manner in which the craving can be satisfied. 3. When tolerance levels are achieved, an increase in supply is required to maintain the high. 4. The addictive behavior serves as a distraction from underlying psychological pain, especially those feelings and thoughts associated with current crises often associated with early childhood trauma. 5. Addictive behavior is automatic and is usually dictated by unconscious factors, dismantling the addict’s capacity for discrimination and sound judgment. 6. The overdose of stimuli (substance, activity, kindness, etc.) manifests in the demise of relationships and acts of selfdestruction. Greenson (1965) suggested that any character trait has the potential to become extreme and central to the personality. In addition to selflessness, other trait addictions include intelligence, physical attractiveness, talent, work, and athleticism. Of course, being endowed with and addicted to one or more of these traits can yield myriad social, interpersonal, and vocational advantages in our culture. However, on an addictive level, these assets can be transformed into liabilities and mitigate against the motivation to change. Narcissistic types lack empathy and are off-putting. Obsessives are rigid and tedious. The suspicion and mistrust of paranoids make us uneasy. Hysterics and other hyper-emotional types can be equally overwhelming. Unemotional personalities may be stimulating but are not appreciably relatable. By contrast, as stated above, selfless types are initially a welcomed presence.

Diagnosis Controversy In Removing the Mask of Kindness: The Diagnosis and Treatment of the Caretaker Personality Disorder (2006), I compared caretaker personality, the disorder linked to the addiction to please, with the disorders listed in the Diagnostic and Statistical Manual (2000). The similarities and differences are tabulated in Chapter 5 of that volume. I also sought to distinguish selflessness from other deferential actions, such as altruism, compassion, empathy, burnout, masochism, and martyrdom. The comparisons between caretaker-please behavior and 24

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codependency and narcissism, respectively, have been viewed by many of my colleagues as both challenging and surprising. Both personalities (Table 1) appear to be high functioning and well adjusted in comparison to those with whom they choose to interact. Their actions reflect the belief that others need them for everything, but they do not need much of anything from anyone. Self-sustaining, independent personalities avoid enablers (codependents) but are receptive to pleasers until they feel trapped and controlled by their kindness. The enabler feels powerful with the “weaker” character types (especially substance abusers), whereas the pleaser is motivated primarily to maintain contact with those who are weak or powerful figures. In my personal and clinical experience, codependents and pleasers can be of either gender, a factor that is for the most part not recognized in the literature. Does Beattie (1992), for example, cite only women as enablers? The threat of rejection and abandonment for pleasers is profound and believed by them to be permanent. Accordingly, their mission is to maintain contact with others by giving, a self-serving, albeit unconscious motive. Whether or not the receiver is interested in what is being offered, the pleaser continues to offer favors and accommodations—essentially a narcissistic maneuver!

Measuring the Addiction to Please The Selfless Personality Scale consists of 22 statements that embody the behavior of the please addict. This measure of selflessness ranges from benign to pathological, with the latter considered the addiction level. Following is a summary of criteria for the addiction to please indicated by the scale: 1. Attachments formed by giving to others emotionally, physically, and psychologically while avoiding self-gratification. 2. Guilt and self-blame are easily evoked by others or self-induced. 3. The presence of a compulsive need to be needed. 4. The experience of joy and pleasure is minimized. 5. Responsibilities and obligations monopolize daily activities. 6. Emotional emptiness, loneliness, and physical exhaustion are caused by the over-investment in others with dimin-

Annals of Psychotherapy & Integrative Health

ishing returns. 7. The Mask of Kindness is worn to conceal past trauma and other crises. 8. The appearance of independence and strength camouflages dependency needs and fears of being abandoned, unloved, and invisible. 9. The avoidance of conflict and direct expressions of anger and the denial of need states are prominent. 10. Low self-esteem is related to abuse, neglect, shame, guilt, anxiety, and humiliation from early childhood experiences.

Guilt: The Friend and Enemy of the People Pleaser Guilt is an extremely powerful and uniquely deceptive emotion. In spite of that rather potent description, I propose that in more instances than is generally believed, guilt does not exist at all. Instead, it is an emotion that serves as a smoke screen or cover-up for anxiety. Unlike most emotions, such as sadness, anger, disappointment, love, hate, etc., “what you see is what you get” does not apply to guilt. For example, nurse Catherine worked overtime without compensation but felt guilty asking for a pay increase because, she said, “I knew entering this field that I would dedicate my skills to my patients and getting paid would be secondary.” Translation: “I am anxious about losing the approval of my patients and supervisors if I think of myself.” A more dramatic example of the illusion of guilt, as I am suggesting, are victims of domestic abuse. Does the victim absorb the punishment in order to avoid breaking up the family and ruining the children’s lives? Or is it that she is anxious about being alone? In many situations when guilt is the conscious experience, the anxiety that resides in the unconscious controls behavior. Guilt is the friend of the pleaser because feeling “no” and saying “yes” avoids conflict and confrontation and thereby keeps their people supply flowing with fewer interruptions. However, once please addicts realize that the persona they unintentionally created yields damaging returns, guilt becomes the enemy and a major impediment to change. During the course of treatment (see below), guilt is the emotion most responsible for detours on the path to self-focus and separation from early negative parental influences. www.americanpsychotherapy.com


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The Roots of the Addiction to Please How does any type of addict become an addict? In my view, “addiction by accident” is the exception rather than the rule. Addictions are usually not just a function of feeling good and a desire to repeat the pleasurable experience. In most cases, they are the result of a relentless and futile pursuit of the gratification of a need state that is out of awareness. Since the craving is only partially and temporarily satisfied, the habit (substance, activity, trait) takes on a life of its own. For example, Kevin’s involvement with cocaine could never satisfy his need to escape the grasp of his intrusive mother. Jack’s ongoing obsession with Internet pornography and compulsive masturbation only temporarily satisfies his escape from his troubled marriage. Laura’s incessant pleasing could never satisfy her desire for a true connection with others. How does pleasing become the addiction of choice? If addictions are partial and temporary forms of gratification, under what circumstances does pleasing become a lifestyle for certain individuals? • The first-born assumes a helper role with siblings. • Child or adolescent takes on the role of an absent or chronically ill parent. • One or both parents are caretaker types (identify with parent). • Childhood trauma such as incest, physical abuse, neglect, and abandonment leads to avoidance of re-trauma by inhibiting negative emotions and actions (for example, anger, confrontation, or conflict). • When faulty parenting eliminates all options for connection, with the exception of accommodation. • Genetics? Often confused with identification with parental role model (see above) characterized by kindness. (800) 592-1125

the result re a s n o ti ic d d a , In most cases pursuit of the le ti fu d n a s s e of a relentl that is out te ta s d e e n a f gratification o of awareness. Treatment and Cure The true self of the personality is evident from birth, throughout childhood, and perhaps into middle and late adolescence. At some point between late adolescence and early adulthood, we begin to act less naturally and develop what I refer to as a benign false self. This “false self ” (Winnicott, 1960) is a form of adaptation to the range of environmental expectations. We learn that we cannot, and should not, say precisely how we feel at all times. This “inauthentic communication” (Dorpat, 1999) is a learned response pattern. For example, one doesn’t say to a bride on her wedding day, “You know, I must tell you that in my opinion, white is not your color.” Nor would a recently hired employee tell his new boss that he does not approve of his management techniques, even though he may be convinced that his observations are correct. A pathological

false self, on the other hand, is metaphorically speaking, a mask that envelops the entire personality. The Mask of Kindness is the mask donned by individuals addicted to pleasing. Their personality is an amalgam of benevolent behaviors that have been choreographed by the unconscious level of the mind. Their actions toward others entail a conspicuous imbalance of giving and receiving. As a result of their one-sided interactions with others, their connections to others are superficial, artificial, and in general—fake. It is for this reason the treatment of caretakers/pleasers is probably more delicate that the treatment of other character types. Ultimately, the therapist encourages caretaker patients to renounce the benefits of being kind and to become more self-focused, a posture that is typically perceived by them as selfish. >>>

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The release, rather than the harnessin g, of true feelings asso ciated with crisis and trauma is esse ntial for a successful treatmen t outcome.

misused and can lead to failed relationships and ultimately to suicidal intentions. Masks and the addictions associated with them are a coping style until they begin to fail over time and/or a midlife crisis or trauma opens wounds that were successfully repressed.

References Relational Analysis The real person of the therapist is probably more significant with please addicts than any of the other personality disorders. Authenticity is a key concept in Relational Analysis (Mitchell, 1988). Traditional analytic methods shape a vertical parent/child dyad wherein the therapist is in an authority/parental role. Behavioral methods create a relationship that is even more asymmetrical—in effect, the therapist is directly advising the patient how to behave. Relational Analytic approaches, by contrast, create a horizontal, collaborative approach wherein mutuality and equality are the key components. Self-disclosure is another important concept in the relational approach that along with empathy forms the basis for an intimate, genuine bond—the antidote to early faulty parenting and trauma. The concurrent use of psychotropic medication and psychotherapy for addictions is dependent upon many factors, not the least of which is the provision of drugs to a personality that is already addicted. The opinions among therapists vary in this regard. In my opinion, the recommendation of medication for please addicts is contraindicated in most cases, especially during the middle and later stages of treatment. Medication tends to harness and/or numb feelings and which may inadvertently reinforce the “act” of the pleaser already in progress. The release, rather than the harnessing, of true feelings associated with crisis and trauma is essential for a successful treatment outcome. In addition to the relationship with the therapist, a variety of techniques can serve to reinforce the pleaser’s path to increasing self-focus. These include: “The Obligation Checklist,” “The Give-Receive Chart,” “The Path Diagram,” and the “Selfless Personality Scale.”

Once A Please Addict— Always A Please Addict? Change is the typical goal of psychotherapeutic endeavors, while cure is usually 26

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considered a more ambitious, if not unattainable, goal. Individuals addicted to a substance are commonly viewed as recovering, but not cured. By comparison, it is probably easier to be cured of a shopping habit—an activity addiction—than a cocaine habit. Recovery and cure from the trait addiction to please can be observed and measured. When pleasing others becomes a choice rather than an obsession, the care addict is on the path to self-focus, recovery, or cure. Progress in this regard can also be measured by the re-taking of the Selfless Personality Scale. The removal of the Mask of Kindness and the reconstruction of the true self as an attainable goal is dependent upon the collaborative work of the therapist, the patient, and when appropriate, the therapy group. “Just Me” Once upon a time I was the true me, A me no one could see. Looking for love I would roam, Just pleasing I found a home. Time passed by, it didn’t last, too much damage from the past. Again rejection, too much to take, better off remaining fake? Now, lessons learned can set me free, free to be loved, just being me!

Final Thoughts Masks are a component of the psychological immune system, an inborn protective system that corresponds to our biological immune system. The Caretaker Personality Disorder is a unique and deceptive diagnostic category. The Selfless Personality Scale is both a diagnostic and therapeutic tool, because by its very nature, it evokes self-focus. Trait addictions are a separate addiction category from substance and activity addictions. Positive emotions such as honesty, kindness, sincerity, forgiveness, romance, and love can be over-used and

Annals of Psychotherapy & Integrative Health

Barbanell, L. H. (2006). Removing the mask of kindness: The diagnosis and treatment of the caretaker personality disorder. Lanham, MD: Jason Aronson. Barbanell, L. H. (2009). Breaking the Addiction to Please: Goodbye Guilt. New York: Jason Aronson/ Rowman & Littlefield. Diagnostic and Statistical Manual of Mental Disorders (2000) 4th ed., Washington, D.C.: American Psychiatric Association. Dorpat, T. (1999). Inauthentic communication and the false self. Psychoanalytic Review 86: 209-222. Greenson, R. (1965). The problem of working through. In M. Schur (Ed)., Drives, affects, behavior. New York: International Universities Press. Mitchell, S. A. (1988) Relational concepts in psychoanalysis: an integrative approach. Cambridge, MA: Harvard University Press. Winnicott, D. W. (1960). The maturational process and the facilitating environment. New York: International Universities Press.

ABOUT THE AUTHOR

LES BARBANELL, EdD, NCPsyA, NCG, DAPA, is a psychologist, relational analyst, and nationally certified group therapist. He specializes in the treatment of “helping professionals” that include psychologists, social workers, psychiatrists, medical doctors, and nurses. He annually conducts six-week seminars in relational analysis. He received his doctorate from Columbia University and completed his postdoctoral training at the PostGraduate Center for Mental Health in New York City. His journal publications include articles on selflessness, narcissism, relationships, group therapy, and psychotherapy with helping professionals. Book publications are: Removing the Mask of Kindness: The Diagnosis and Treatment of the Caretaker Personality Disorder (2006) and Breaking the Addiction to Please: Goodbye Guilt (2009-10). His Web site is http://psychologistdynam.com/ www.americanpsychotherapy.com


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Annals of Psychotherapy & Integrative Health - Summer 2011 (Sample)  

Annals of Psychotherapy & Integrative Health is the official peer-reviewed, quarterly journal of the American Psychotherapy Association and...

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