For those battling depression, both cognitive-behavioral therapy and interpersonal psychotherapy have long been recognized as very effective means of overcoming depression. A new study printed in the British Journal of Psychiatry and published on PsychiatryOnline.org shows that differing personality traits can affect how responsive people are to these two main types of therapy. The researchers wanted to know if certain personality traits made treatment less effective. Their conclusion: the success of interpersonal therapy seemed to vary based on the individual’s personality and temperament, while the success of cognitive-behavioral therapy showed no difference based on personality traits. This can help therapists further match clients with the best form of treatment not only for their struggles (e.g. depression), but their personality as well.

If you’ve done any channel surfing at all in the last year or so, you might have come across a couple of documentary shows (Hoarders on A&E; Hoarding, Buried Alive on TLC) featuring people who are living with massive amounts of clutter and/or trash in their homes. The piles of “stuff” often reach to the ceilings, and there is barely space to stand, much less walk across a room. The programs show professional organizers and psychotherapists working with people to clean out their homes. If you’ve seen either of these shows, then you know what I mean when I say it’s something you don’t forget easily. Although the people being featured on the shows are treated with respect and compassion, the images are shocking and disturbing. How does this happen? Why do people do this? Can they be helped?

Contrary to what you might think, people experiencing compulsive hoarding are not just being lazy or careless. They are experiencing an anxiety related condition; although, there is disagreement in the medical/psychiatric community as to whether hoarding is its own issue, or that compulsive hoarding is a subtype of obsessive compulsive disorder (OCD). Although many people experiencing OCD also exhibit hoarding behavior, not all people experiencing OCD also hoard, and many people who hoard have no other symptoms of OCD.

People who compulsively hoard do experience excessive extreme anxiety, doubting, checking, and reassurance seeking before discarding items, which does suggest a close relationship to OCD. However, recent research suggests that compulsive hoarding may also be associated with a range of other psychiatric conditions, in addition to OCD. Compulsive hoarding behavior has been reported in disorders including schizophrenia, social phobia, eating disorders, depression, and dementia. In studies of the brain, researchers compared neurochemical activity and patterns of blood flow in the brain of people who compulsively hoard and people who experience OCD who did not hoard. They found that the neurochemical activity and blood flow patterns in people who hoard were different than those in people with OCD, suggesting that compulsive hoarding is a separate symptom/condition from OCD.

Many, if not most, people have a certain amount of clutter in at least one part of their homes. Where is the line between average messiness and compulsive hoarding? Hoarding behavior includes:

• Acquiring and keeping, indefinitely, a large number of possessions which appear to be useless or of limited value
• Living in spaces so intensely cluttered as to preclude activities for which those spaces were designed
• Significant distress or impairment in functioning caused by the hoarding (e.g., health problems, inability to keep a job, difficult relationships or lack of relationships with other people)
• Reluctance or inability to return borrowed items; impulsiveness and compulsion to acquire more “things” sometimes leading to stealing or shoplifting

Why/how does a person cross the line from messiness to hoarding? There are several proposed explanations for the causes of hoarding behavior. Investigators have suggested that errant cognitive processing leads to hoarding. These include information processing deficits, meaning that people who hoard have substantial problems focusing and sustaining attention, difficulty categorizing and prioritizing their possessions, and difficulty in making decisions about their possessions.

Maladaptive beliefs about, and extreme emotional attachment to, possessions may also contribute to a person’s hoarding behavior. People who hoard have an exaggerated sense of responsibility for their possessions, and desire complete control over them. They experience intense emotional distress (anxiety, grief, or guilt) about the ideas of discarding or losing an object, leading to avoidance, and escape in the form of saving and acquiring.

There are also studies showing that difference in brain activity and /or brain injury can lead to hoarding behavior. Scientists have identified the areas of the brain involved in hoarding. One study showed reduced glucose metabolism in certain areas of the brains of compulsive hoarders. Some people with traumatic brain injury, stroke, and neurodegenerative diseases have also developed hoarding behavior.

In the past, clinicians have used the same treatment methods for compulsive hoarding that they used for OCD, with poor results. While medication, cognitive behavioral therapy for OCD, exposure and response prevention therapy have all been effective treatments for OCD, they have been shown to be of little benefit for compulsive hoarding. People with hoarding behavior have high instances of poor insight, refusal of treatment, lack of cooperation, and inability to recognize hoarding as a problem, all contributing to difficulty in effective treatment.

There is hope for people who hoard, though. In a recent study, researchers designed a new cognitive-behavioral treatment especially for treating compulsive hoarding. In this treatment, motivational interviewing (getting people excited about the seriousness of the hazards of hoarding and the benefits of clearing out their homes), skills training for organizing and problem solving, and modification of beliefs about possessions are emphasized. Also, treatment includes frequent off-site sessions in which therapists helped people to sort, discard, and learn to resist acquiring more items. People typically respond more positively when the therapists are at the home with them, assisting them with sorting and discarding.

The sight of such intense messiness and disarray is certainly disturbing to see, but knowing that hoarding is a symptom of a person who is possibly experiencing severe emotional distress, hopefully, helps to engender compassion and patience in friends and family members. Information about help for hoarding can be found online at www.ocfoundation.org/hoarding/.

This is a continuation of last month’s article, “Are You Your Own Worst Enemy?” After learning to identify self-destructive behavior in ourselves, we can explore why we do it and the possible motivations behind vicious cycles of attacking ourselves. It may come from past trauma, abuse, neglect, or a number of other things that may have caused low self-esteem. Below are seven reasons people attack themselves.

1. Imitating Parents
We all learn how to take care of ourselves from imitating how our parents or other caretakers take care of us. When parents or caretakers attack children emotionally, verbally, or physically, children learn to attack themselves like their parents do. Practicing over and over, people become good at self-attack and carry the skill into adulthood. It becomes an integral part of regular daily life, almost like breathing.

2. Method of Discipline
Often caretakers don’t teach children how to set limits, or boundaries, how to structure themselves, or reward themselves. These skills are needed for discipline (which is sticking with things that are hard in the present, in order to achieve a longer-term desire). If people do not learn these skills, their way of disciplining themselves can be to attack themselves, when they don’t do what they think they “should.” For example, “Stop being lazy and stupid and do your homework.” Or, “Don’t eat that pie, you’re a fat pig!” This method of shaming can provide some rudimentary support for getting through obstacles to something one wants, but it causes a great deal of destruction in the process, and often backfires—causing rebellion against the “discipline.”

3. Lack of Information about their Value
When children don’t feel valued by their caretakers, they naturally conclude they have no value. This conclusion colors the way they see themselves in every aspect of their lives. The message that they have no value becomes a pretty constant “voice” in their thoughts that follows them into adulthood. This conclusion that they have no value can come from caretakers overtly shaming kids.

But it can also come from neglect, or lack of love or attention. Children who don’t get what they need emotionally gather that they must not have deserved it. This can even happen when there is no abuse involved. For example, children who are adopted into a loving family may determine that they had no value to their birth parents, and therefore aren’t worthy of much from others they encounter.

4. Preserving Parents and Power
When caretakers are brutal, absent, or unable to meet the emotional, needs of their children, the children have a choice to conclude either that there is something wrong with the parent or caretaker who is causing pain the child experiences, or there is something wrong with “me” (the child) for causing the caretaker’s behavior. For the child to conclude it is the parent, generally means acknowledging that the parent isn’t competent to take good care of their children.

For a child, not having a competent caretaker is life-threatening. So children generally do anything to avoid believing that their parent is unable to take care of them. This leaves children with the only other conclusion they can come to, given their limited experience, and great need—that there is something wrong with themselves. This preserves the belief that the parent is safe to depend on, and has the added advantage of allowing children to believe they have some control in their painful circumstances.

If I, as the child, believe I caused the abuse, then I can also believe that changing my behavior will stop the abuse. If I am a helpless victim of my caretaker, there is very little hope for my life to improve. So, most children attack themselves when their parents are hurting them to preserve their positive image of their parents, and to give themselves an illusion of control over the hurt, abuse or neglect.

5. Guilt
Sometimes children blame themselves for anything that goes wrong in the family (illness, death, mental illness, accidents, injuries, divorce, etc.) for various reasons. Common motives for self-blame include misunderstanding, attempting to feel powerful, being blamed for the problem by someone else, or, on occasion, having something directly to do with what went wrong. Children can carry that guilt into adulthood, punishing themselves with self-attack about much more than the original problem.

6. Imitating Peers
Sometimes people are repeatedly shamed, but not by parents or caretakers. Instead, siblings, and/or peers may be responsible. This can also turn the child’s belief system into one that legitimizes the bad treatment. They take on the belief that they deserve it. When they come to this conclusion, they have learned to continue this attack inside themselves.

7. A Way of Coping
Children who are overwhelmed with their feelings and are not given any skills for handling them have to scramble to use whatever resources they have to deal with these feelings on their own. Sometimes one of these resources is self-attack. Rather than feeling sharp, intense or disorienting emotional pain, children can convert these overwhelming, confusing feelings into a focused activity.

In multiple cases, self attack presents itself as a way of coping that seems to bring matters under the child’s control. When this happens, there is actually some comfort associated with self-attacking thoughts, just as there can be comfort in starving or cutting oneself. This is one reason cognitive-behavioral therapy alone often doesn’t work—people can not afford to give up thoughts they depend on to comfort themselves.

People attack themselves as a method of self-defense, coping, or due to the fact that we all, especially as children, are hard-wired neurologically to imitate those around us. In therapy, we find the origins of the self-attack and the purposes we use it toward. We then look for ways to provide the same functions without the negative consequences self-attack brings with it.

In some cases of rewiring, Eye Movement Desensitization Reprocessing (EMDR) is a helpful option. In other cases, imitating the therapist offers a transitional alternative to the results of imitation of critical parents. However we get there, all of us ultimately have to become nurturing, compassionate parents to ourselves. That is the goal of childhood and good parenting, just as it is the badge of happiness and adulthood.

The question often comes up among LGBT (lesbian, gay, bisexual, transgender) people: should they see a gay therapist, or would they would be comfortable with a gay-friendly therapist? This is a personal decision people need to make for themselves, but as in choosing any therapist, it is important to find a professional who has the education, the empathy, and the ability to understand your individual needs.

Although there are many gay-affirmative and gay-friendly therapists, sometimes it is important to find a therapist who is a member of the gay community. The process of therapy is a very personal one, and for many people it is vital that their therapist be someone who understands and can directly relate to their life experiences. For many LGBT people, there is an internal process that makes it important for them to work with a therapist who has direct knowledge of what it is like to live as a member of the gay community.

So what should you look for when choosing a therapist who specializes in LGBT issues? First off, if having a gay therapist is important to you as a client, then you should make sure you find a therapist who is open about his or her sexual orientation and is willing to openly discuss yours. A gay therapist who is comfortable with his or her own sexuality will be more open to discussing issues that you may be facing as an LGBT person.

But sexual orientation is not all that one should look for in a therapist. It is also important to ask questions about the therapist’s education, training, and understanding of the issues that can face LGBT clients. Your therapist should be familiar with issues of sexuality, coming out, internalized homophobia, HIV/AIDS, depression, and self-destructive behaviors, as well as more traditional issues like couples, dating, social skills, and relationships as they pertain to the LGBT population. Not all gay therapists will be experts on all of these topics, but you want to find the one who has the knowledge to address your personal needs.

Beware of therapists who promise to treat or “cure” homosexuality, as this type of therapy has been found to be unsuccessful. It can often be damaging and lead to low self-esteem, guilt, self-destructive behavior, and even suicide. A good therapist will assist you in finding your personal comfort with your sexuality and not try to “cure” or “fix” you.

Another issue that can come up for discussion in therapy is sex. For many gay people, it is important to have a forum where they can talk openly about sex and the myriad issues that surround intimacy. Ask your therapist whether he or she will be comfortable talking openly about sex and other personal issues that affect you as a client.

As much as it is important to learn about your therapist’s sexuality and commitment to working with LGBT clients, it is equally important to make sure that your therapist will maintain appropriate boundaries in regard to discussing his or her personal experiences. Under no circumstances should there be sexual contact or behavior between client and therapist.

An excellent way to find an LGBT therapist is to use the Advanced Search function here at GoodTherapy.org and enter the search term “LGBT Issues.” You can also check with your local gay and lesbian center, which will often have a resource list of local therapists who work with the LGBT community. Referrals from friends are another great resource in the search for a good therapist who can address your personal needs.

Finding the right therapist for you is vital in order to create the most beneficial outcome of your commitment to go into therapy. Take the time to interview your therapist, making sure that you find the right person who will be able to assist you in your rediscovery of yourself. Whether the therapist is gay or gay-friendly, the right match of therapist and client is the foundation for an exceptional therapeutic experience.

Ten years into being trained in eye movement desensitization and reprocessing (EMDR), I am still amazed by its ability to transform a life filled with trauma, anxiety, and hypervigilance into one of presence, mindfulness, and relief. Clients and clinicians often find themselves confused about EMDR, and I would like to address what is meant by symptom-based and eight-phased trauma treatment.

Symptom-Based Protocol
EMDR is a treatment modality that is research driven and well known for its ability to reduce symptoms associated with posttraumatic stress (PTSD), and your therapist may recommend it to relieve your symptoms associated with PTSD. EMDR clinicians around the world are finding, in clinical practice, that it is also effective for addressing an even wider range of symptoms, especially those rooted in the events of the past.

With this in mind, EMDR is what you could call a symptom-based protocol. This means that EMDR therapists focus on how your present experience is rooted in old stuff, even things that you think that you are over. We look at how the symptoms you have in the present mimic, or cluster, around those events in that past.

Trauma is tricky and can disguise itself as many things. An EMDR therapist will review your symptoms and review how your current thoughts, emotions, beliefs about yourself, and physical sensations may be related to disturbing life events and traumas from the past. Depending on when your EMDR therapist was trained, he or she may have different ways of asking you to prioritize and list what events are still contributing to your symptoms.

Even though you may not believe that those events from the past are really a big deal, they are still locked in your nervous system in what is termed a state-dependent form. Often, they are not completely processed and healed, like a record stuck in a groove. As time progresses, the record turns; it still plays, but the disturbance repeats itself over an over again, until the scratch is healed.

An Eight-Phased Treatment Model
Often mistakenly viewed as an intervention, EMDR is an inclusive treatment modality, one that includes eight comprehensive treatment phases. Each phase is a unique and necessary part of the approach. It is imperative that your EMDR therapist walk you through each of the eight phases. While they can be circular, and you may go back and forth between them, each phase will help you as you complete the therapy. The eight phases include history taking, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation. Unfortunately, EMDR has become known primarily for its desensitization phase, which is what people often confuse as the sole part of the therapy.

With this knowledge, those of you who are seeing an EMDR therapist can inquire where you are in the process, what phase you are in, or how you will prioritize the events from the past to work on them. You can also find out what symptoms you are focusing on and how the past relates to them. I often find that the more my clients know about each phase, the safer they feel and the more they feel they are part of the process.

If you have general questions about EMDR, please post them. Keep in mind that I can’t speak about your clinical work or therapy or provide clinical advice. I will try to cover your questions about the treatment in future blog posts.

Solution-focused therapy is a new type of therapy to many people, including psychology professionals. It is considered a form of brief therapy, much like cognitive behavioral therapy, though it doesn’t necessarily have to be practiced in the short term. I consider these kinds of therapies to be “strength-based” as opposed to “insight-oriented.”

What are some benefits of choosing a strength-based therapy?

1. Focusing on your strengths always produces the best return on your investment. It’s true that most clients don’t come to therapy wanting to improve something they are already good at. However, a solution-focused therapist will work hard to identify the client’s strengths in order to help the client use these strengths in areas where they do want to improve.

Imagine your life as a pie chart, with each slice of pie a different size. At any given time, some section of the pie is going to be off or not functioning at its best. That’s normal; we have a lot of pie on our plate! A client who is problem-focused is looking only at this once slice of the pie. A solution-focused therapist is going to help the client fix that slice by balancing strengths that are part of the rest of the pie.

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For example, a couple might come to therapy complaining generally of having “communication issues,” but upon further questions from a solution-focused therapist, it might turn out that these issues only arise during a specific topic, or under certain circumstances. The couple might have excellent communication skills and just have not figured out how to apply them to their problem area.

2. People are always trying to right themselves. While you might know a constant complainer who you secretly think does a pretty good job at self-sabotaging, remember that they don’t see their life this way. A solution-focused therapist doesn’t, either. When a client and therapist can tap into the right system to solve problems, the client’s constant efforts to right themselves will eventually work. A solution-focused therapist works hard to believe the best in the client and to act as a coach and facilitator toward the client’s goals.

3. Thoughts are our best predictors of happiness. Why does research show cognitive therapy to be as effective as some medication for mental issues? Because we know that there is a direct link between the thoughts you think and the feelings you feel. When practiced over time, healthy and productive thoughts produce effective long-term results.

If a client has negative ideas about himself, his future, or the world around him, then he is likely to be depressed. Instead of dwelling in these negative thoughts, a solution-focused therapist is interested in learning about when these thoughts are not present. Is there any part of the day when the client is not experiencing the problem that has brought them to therapy? Why is this?

Solution-focused therapy focuses on the present and the future. It is concerned with today’s problems and tomorrow’s concerns. The kind of therapy I do is also nonpathologizing therapy. This means that I don’t view my clients as being deficient or sick in some way. I don’t diagnose clients (unless insurance requires it) and I don’t let them diagnose themselves, either.

It’s not that insight-oriented therapy is the opposite, but it is more interested in one’s past, one’s history of repetitive patterns and relationships, and gives much more weight to subconscious drives, behaviors, and issues.

While both therapies have their places in the world of mental health, my experience has found strength-based therapy to be more effective for the type of clients that I see. My clients are not interested in making therapy a hobby that lasts for years and years. In the coming months, I’ll be writing about how solution-focused therapy is used to help a variety of couples issues and common issues such as anxiety and depression. I welcome your comments!