Prof. Joseph Levine

Senior Psychiatrist




Third Session

By Prof. Levine & Dr. Salganik

At the end of the previous blog we hinted that the treatment effectiveness in REFERENCE GROUP FOCUSED THERAPY (RGFT) that makes extensive use of internalized figures in our inner world, has contributed to the creation of the model of the Self, the one we metaphorically call the "Fabergé Egg of the Soul". In this conversation or session we will bring therapeutic examples of different types of problems or mental disorders in order to give a taste of what is happening in

.this type of a treatment

Here are some examples:

A] Fainting perceived as death

Fear belongs to the range of our basic emotions, just like sadness, joy, anger. But some of us are attacked by extreme fear whenever we encounter certain objects or situations. This is called phobia. Phobia is very common among us – it is estimated that between 9-18% of Americans suffer from various phobias, with the similar number in Israel’ while women are reported to suffer from phobias more than from any other mental disorder. Examples of phobias are countless – fear of flying, fear of traveling in an elevator, fear of enclosed spaces, fear of elevated places, fear of dental care, fear of crowds and more. Agoraphobia – fear of leaving home or another familiar place – can limit us to quite a marginal functioning.

There are a number of treatments that help people in these situations – among others we have different types of behavioral therapies and psychopharmacological treatment with antidepressants and antianxiety medications.

Here we discuss the treatment of REFERENCE GROUP FOCUSED THERAPY (RGFT) in a patient with particularly severe agoraphobia. Of course, the details of the patient's life were changed in a way that prevents any identification.

Pazit, a pseudonym, a young woman in her twenties, was first brought in for treatment by her best friend.

Pazit, a pseudonym, a young woman in her twenties, was first brought in for treatment through her best friend. The visit was preceded by many persuasions that encountered Pazit's refusal again and again until the friend was almost forced to physically carry her to the treatment room. During a first conversation with Pazit, it became clear that she had not left her home for about 3 years, not even for a single moment. She spent every day in her room reading books and chatting on the computer. For 3 years she has not left home for entertainment, for family events, for shopping. Needless to say, she did not work anywhere and had no romantic relationships unlike most of her friends.

How did it start?

"About 3 years ago I was on a trip to Europe … so I went on a diet because I thought I were too fat, the day before it happened, I attended a birthday party with friends and barely slept …. I hardly drank water that day even though we walked a lot .. "

“Suddenly, I fainted. When I regained consciousness, I saw myself surrounded by my worried friends. I was terrified, I felt like I was going to die …"

And then?

"That's how it started. I could not be left alone for even a moment … Very quickly my range of activities narrowed, wherever I went, my main thought was about a nearby hospital that could help me out if I fainted again … Gradually I went out less and less until I found I'm locked in my room without even being able to dream of going out. "

Later on, it turned out that Pazit's mother had very similar attitudes regarding fainting to those of Pazit herself. She used to repeat the sentence: "Fainting is death." She also expressed distrust about people’s willingness to help in such situations.

Apart from the mother, there were other characters who "implanted" a terrible fear of fainting and conveyed to her that fainting is the end of life.

According to the here used treatment method, the therapist asked Pazit to approach an empty chair in which she would sit and on behalf of one of the characters. She experienced the therapist interviewing that character while Pazit herself experienced the character she was playing. This is how the therapist brought up the "phobic" characters from Pazit's consciousness – and she got to know their attitudes. Her condition improved rapidly. Each encounter with one more character brought her on the path to liberation from the influence of those characters’ attitudes and helped her to develop attitudes of her own.

For the third session she had already arrived at the clinic on her own, unaccompanied by the friend. This was the beginning of Pazit's journey on the path to her independence and self-fulfillment.

B] "The Family Thing"

Remember the movie "The Best You Can Get" with Jack Nicholson? The main protagonist of the film, suffers from a mental problem called in psychological jargon an obsessive-compulsive disorder. He wastes tons of soap (each piece of soap goes directly to the trash after use because it is "dirty"), jumps over a pavement in danger of falling because it detects a small crack in it, brings a plastic cutlery to the restaurant because it’s a "dirty" restaurant …. As the examples suggest, the disorder is characterized by disturbing thoughts, impulses or images that are identified by the patient as involuntary and not corresponding to the reality, that often causes him great suffering and in severe cases even disrupts daily functioning. The patient develops thoughts and activities that are supposed to help him reduce anxiety, but in fact alleviate his condition only for a moment and they are perceived by the patient and his environment as morbid. About 1 in 100 people suffer from the disorder, mostly young people, men and women alike. It is sometimes accompanied by eating disorders, depression and other disorders.

The most common treatments today are mainly behavioral therapy (as well as cognitive-behavioral therapy) and psychopharmacological treatment with antidepressants and anti-anxiety drugs.

We will report here, about a patient with obsessive-compulsive disorder – who was treated with RGFT. Needless to say, the details of the patient's life were changed in a way that did not allow for any identification.

Gila, pseudonym, a young woman in her twenties, a student, came to the clinic after she stopped studying at university, became isolated, barely left the house and was in a state of severe anxiety. Thoughts to end her life often crossed her mind. She was constantly bothered by thoughts of being sexually abused like rape or indecent acts by various guys in her life, and she felt dirty. Although she did not remember any concrete detail that would indicate this, she could not get rid of those thoughts even for a moment. She went to the same places where the "acts" were performed and asked different people about the same guys, with the intention of getting to the truth.

These actions not only did not calm her down, but caused additional anxieties that for some reason the people who were asked would be apprehensive and they would look at her as a rape and "dirty" victim. Even before arriving for treatment she received for a long time antidepressants, treatment is acceptable in such cases, but without benefit.

How did it start?

"About a year ago I read an article in a newspaper about rape victims. Suddenly I had a suspicion that I had been through something similar. I remembered different guys I met in school or in the neighborhood and I had a feeling that something happened between me and them. I imagined it was unfounded but could not avoid thinking about it ".

And then?

"I was attacked with anxiety and a feeling that I was dirty and that they would eventually find out. It just kept me busy …. I dropped out of school and avoided meeting my friends because I was afraid they would find out. … I showered for hours but it did not take away the feeling of 'dirt'."

It turned out that Gila had a couple of religious parents, as well as a sister, with very rigid attitudes towards the issue of sex – a young girl should not think of it, except until after the wedding. But, despite the prohibitions, thoughts of sex first arose in her adolescence, even in the context of those guys she suspected having something to do with them. About a year ago she even developed a romantic relationship with a guy from the faculty, all before the wedding, which caused a very critical reaction from her relatives.

Gila has been invited, according to the RGFT treatment method, to work with characters who "lived" within her and dictated to her an uncompromising attitude towards anything that could be interpreted as sexual permissiveness, including thoughts about sex and several times – acts of a sexual nature. Once she discovered (herself and not through the therapist's interpretations) the connection between her feelings and the messages from her family, the "family script" that lay within her, her condition began to improve. She went back to school and friends and managed her life not according to the "family script" but this time according to her own script or plan…

C] The Lost Honor

Here is the story of Leah (pseudonym) who came to the clinic with complaints reflecting a depressive state – loss of appetite, difficulty falling asleep, poor mood and low self-esteem.

She said: "I am usually a very sociable person, always smiling, always gathering people around me. A few weeks ago renovations started in my workplace …. I connected very quickly with the workers who carried out the renovations, I dropped them coffee and pastry and I chatted with them …. one day, probably out of boredom, they decided to "make a joke" … one of the workers intended, with others’ agreement, to discover the color of my underwear …. he peeked as I went up the stairs and thus "won". At first I did not comment to the laughs that were heard from the renovation site, but very quickly I learned what they meant …. I was deeply hurt. I felt humiliated, disrespected, I almost wanted to die … "

When the therapist began to examine with her, as is the practice with the RGFT treatment method, the internalized characters, it became clear that Leah's mother had taken a very important place among the characters in her life. Her mother’s figure was portrayed as a dependent person on the one hand, and on the other hand as someone for whom everything related to matters of honor was very important. She carried with her several experiences of humiliation throughout her life and saw herself as a victim and a tortured saint.

It turned out during the conversation that her daughter Leah, too, adopted exactly the same attitude and the episode with the workers became for her an event that could not by any means be ignored and she had no choice but to react with depression.

A therapeutic intervention that allowed her to move further away from those attitudes of her mother gave her new energies to continue and her condition improved already after the first intervention.

After several days Leah called again and asked for an urgent appointment because the situation was "not good".

As she recounted at the meeting, she had visited a fortune teller the day before and she was told that there was an older woman in control of her.

"I understood from what she told me that the demon had taken over me …. and that scared me a lot"

Only her treatment of the father's character, who was a man of life wisdom and was a rather rational person, allowed Leah to disengage from the influence of that character who was "empowered" by a fortune teller.

What actually happened to Leah?

Her whole story, as we see here, revolves around the theme of honor being hurt. We usually call "respect" a form of reference to a person that is of importance to that person and recognition of his or her worth.

From this it is also possible to infer the main reason why respect is so important to us – since there is a close connection between respect and self-esteem. This fact has opened the door to a problem: in cases where our self-worth is nourished by the respect we receive from "outside", from the environment, we become "hostages" of that environment. Our self-worth depends on it – if society "gives respect" – we are in heaven, but if not …… in hell!

Once we learn to feed our self-esteem out of ourselves and less of those around us – something that happened to Leah during therapy – we become freer and less vulnerable …

D] The Striving for Perfection

Imagine someone who tries to take into account all the details required to make decisions, does not shy away from difficulties and obstacles, mobilizes the energy needed to persevere in achieving the important and complex goals and always makes sure that everything is "perfect". Sounds wonderful, doesn't it? But, there is also a second side to the coin. Striving for perfection can come at a pretty heavy price: delaying things that are not sure will be done perfectly, doubting one's own abilities, constantly seeking support and attention from others, focusing on small and unimportant details and thus hindering the performance of a task. The tendency to constantly criticize others can even lead to complications in professional and social life. And in quite a few cases it is even possible to develop depression or chronic fatigue.

Many psychotherapeutic approaches attempt to treat this syndrome, including dynamic therapy (based on a psychoanalytic approach), cognitive-behavioral therapy, and other therapies.

Here we present an intervention according to the RGFT approach. The intervention is based on the assumption that perfectionist attitudes develop as a result of internalizing the characters (from meaningful for us reference groups – like family, school, workplace, etc.) that motivate us to run a crazy run towards endless goals and feed us the illusion that only then we can win a place under the sun. The problem is, once the goal is reached, we will again feel we have no place and start running towards the next goal. These effects are revealed during the therapeutic intervention so that a path is paved for less perfectionist alternative attitudes with a significant improvement in the quality of life. Of course the details of the patient's life were changed in a way that did not allow for any identification.

Gadi, pseudonym, 21, a student at the conservatory,, came to treatment with complaints of feelings of exhaustion and persistent depression,

"I do not understand what has been happening to me lately. I am fighting like a lion with life but I am not doing so well. I feel lacking in energy, barely able to do a quarter of what I plan …"

In the conversation, it became clear that Gadi, after finishing a long school day, sits on the study material every day and plays until the late night hours. He sleeps barely 4-5 hours before returning to his studies at the conservatory.

"I am a strong man, there is nothing I can’t handle… the world is cruel and only the strongest survive."

Gadi turned out to be a very competitive person who spared no effort to reach his goal, on the other hand he demonstrated a lack of self-confidence, to be a person who needed constant encouragement and admiration in order to feel "equal".

According to the method, the RGFT, the therapist looked for the figures within Gadi that express the same rigid attitudes with which he is so identified. The character of Gadi's father came into play as the main character.

It turned out that the root of Gadi's urge to be the best in the field he was involved in, was related to the severe sense of frustration felt by his father, a musician himself, who did not achieve his goals in the music, the most important thing in his life. It turned out that his father put tremendous pressure, not always consciously, on Gadi, as an attempt to correct his own failure. The expectations of Gadi’s father figure were unequivocal – a complete success in the field of music. Any deviation from this maximum goal would be interpreted as a complete failure of Gadi, just like his father's own experience of failure.

After working on his father’s figure as well as on other relevant figures, Gadi clarified the connection between the influences of the inner figures within him and his self-perception. He significantly flexed his expectations of himself and entered a path unknown to him so far – the ability to accept himself as he is – this time already without conditioning on the incessant achievements …

E] The Mine named Self-Esteem

Alona, ​​a pseudonym, a 12th grade student, came to the clinic with a complaint of ongoing frustration, a feeling that she was not worth it and difficulty developing satisfying relationships with the opposite sex.

However, Alona turned out to be a beautiful-looking young woman, an outstanding student, who successfully participates in dance and singing classes.

"I always felt that I was not doing well, that I was not good for anything …. even if others told me I was successful, I was sure they just wanted to encourage me. … I am a complete failure."

"Who in particular, do you think, has negatively affected your self-confidence in your life?" Asked the therapist.

"My mother was never really interested in anything about me. She was always late for parents' meetings and always left first …. she transferred money to classes I attended at the last minute, it made me ashamed and feel poor …. she dressed me in my big sister’s clothes , While in class everyone wore fashionable and beautiful things, only I was dressed in "raggs" .. All these things conveyed to me that she did not really care about me and that I was probably in the last place …. ".

When the therapist uploaded the character of Alona's mother and interviewed her, the character said:

"My daughter's claims are factually correct but my motive in the way she perceives it – is not entirely true. I am a mess from birth … late everywhere … late also in payments of all my bills … how many times have I had electricity and water cut off because of it. .. it was not at all related to Alona, ​​the same thing happened to me with my other children … As for the clothes – it's true, I wore it in the big sister’s clothes, but that was the way it was in my childhood … I also wore my sister’s old clothes. I was not aware that now they look at it differently … "

In the encounter between the two mother’s figures that exist in Alona's soul – one figure as perceived in childhood and another, more realistic and from a more mature period – the upheaval began. Contributing to this was also working with other characters, some of whom worked to strengthen Alona's self-confidence. The feeling of insecurity receded and Alona discovered a new world in which she stands on her two feet firmly and in full authority.

E] Root Canal Treatment

Dental care is a nightmare for many of us. Deafening noise from the drill, smells of antiseptic substances, lying in a chair that is comfortable but hardly allows you to move – it all comes to mind when we remember the last visit to the dentist. People who develop a fear of dental care – dental phobia – avoid going to routine treatment at the dentist, neglect the issue and when they are eventually forced to come – their dental condition is already so shaky that particularly large interventions are in need. Then the fears, of course, intensify even more. Where do the fears come from? There are many answers to this. Some people had a particularly traumatic encounter with a dentist in the past, an injection of anesthesia that was particularly painful, anesthesia that did not work to the end that made up for the pain to appear, sometimes even an unsympathetic attitude of the dentist himself. All of these are able to create a conditioning between the unpleasant experience and the place where it was created – a dentist's clinic. In other people the problem developed quite differently – they "learned" to fear through the example of someone of importance to them who himself was afraid of such treatment.

This is exactly what happened to Ephraim, a successful businessman, an assertive and brave man, a heavy motorcycle rider and engaged in all kinds of dangerous sports.

"Friends can not believe that a person like me who is not afraid of anything, can not even dare to think about the needle touch of the injection at the dentist on my skin …" – Ephraim said in his first meeting.

During a short interview, it became clear that Ephraim has two relatives who also suffer from a fear of injections. One of them is his father, the most significant person in Ephraim's life.

Ephraim seemed quite manned and said he did not believe at all that he would ever be allowed to overcome the problem. He also said that due to fear of injections he neglects not only dental treatments but also periodic checkups at the HMO and thus harms his health.

"When I was in my twenties, I went to extract a tooth where I was given an anesthetic beforehand. It did not affect me at all because I had a tooth infection as it turned out later. When the doctor started extracting the tooth I felt terrible pain and ran away. Since I can not get close to a needle and it to me "- said Ephraim.

Paradoxically, so to speak, Ephraim developed a fear of the needle and not of the dentist’s interventions themselves.

"For me, they could implant me half a mouth, just don’t inject anything" – he said.

This reflected to the therapist, that the very traumatic event at the dentist’s strengthened the attitudes he copied from his father, in the context of injections, which helped develop the phobia of dentists.

During the treatment, a number of interventions were made in which the characters of people from Ephraim's past were raised, which negatively affected the fears he suffered from, and at the same time, the characters of people close to him were raised, that on the contrary, were not afraid of it at all.

Thus Ephraim managed to break away from his complete identification with the attitudes of the father and begin to overcome the problem.

Already after the first meeting he went to perform a blood test that had been required for a long time and was very surprised, just as the nurse who took his blood was also surprised that the fears had completely gone.

After a number of treatments the fears stopped dictating to him the lifestyle and he discovered that he had far more powers than he ever believed- the stair-wheel of his life was back in his hands!

G) A Control Freak

An emotional life is the foundation on which our whole personality is built. If from the first moment after we come into the world, we are surrounded by love, support and help, there is a great chance that we will develop into mature people with a rich and cohesive emotional life, become creative, open and sociable.

Unfortunately the environment does not always provide us with the support and love we so desperately need. When children become, God forbid, orphans at a young age without someone taking the place of the parents as significant figures then it is intuitively clear to us that they are in danger of developing emotional deprivations. The matter is much less understandable when the biological parents are alive and well, at least on the surface. The child eats well, is well dressed, and even has a fine playroom.

What is hidden from our view is the fact that the child's emotional needs are not addressed at all. The parents do not "feel" the child for their own emotional reasons and circumstances, they treat him only in a functional way without the ability to understand that their child is a separate entity that requires personal attention, especially in the area of ​​emotion.

When the parents treat the child only as a function, then that is the feeling he grew up with. He felt himself as a function, as a machine whose main function is to satisfy the will of the parents. He grows up unable to connect to his true feelings and also suffers from difficulty giving emotional response to others.

Gadi (pseudonym), 46, a successful CEO of a large high-tech enterprise and a father of three, came to me at the clinic after feeling that despite all his efforts, he was having difficulty raising his children and was going through a deep relationship crisis with his wife.

"I do everything that is required of the father and the husband and yet something does not work here. My family's train is very close to getting off rails" – Gadi declared at our first meeting. He came to a meeting with a laptop in his hand which he described as his "private CEO".

"I am a well-oiled machine and a freak of control" – that's how Gadi defined himself – "but here something happens that gets out of my control". And certainly, he gave me the impression of something robot-like, emotionally restrained, and went into the small technical details – even in a treatment room he was a "CEO".

In the treatment, it was possible to notice that the figures that came up, including significant figures like that of mother and father were very pale and schematic. They did not express any emotion but addressed only the functional aspect.

Admittedly, when emotion was nevertheless expressed, as in the context of his eldest son, for example, it was very difficult for him to relate to it.

When the therapist reflected this to him, he asked "Do you want to tell me I love my son?"

He needed legitimacy from the therapist to admit his love for his son!

During the sessions Gadi felt more and more relaxed, even his body language testified to this, he became less restrained, started smiling and talking about emotion-related things, like his feelings when his son came back beaten after meeting a group of "brats", his pain feeling after a fight with his wife or frustration when something went wrong for him at work.

His "emotional warehouses" that had been empty for so long began to fill up, he felt more and more connected to himself and no longer experienced himself as a "machine" anymore …

These examples highlight a number of points:

First, the cumulative experience shows that treatment with this method yields relatively quick results compared to other therapeutic approaches.

Second, in this treatment approach the dependence on the therapist is smaller than in a variety of other treatment methods because the therapist usually allows the patient to meet his inner figures influencing his inner world, his feelings, and attitudes, and thoughts, and behavior.

We’d also to note that in this method of treatment there is no place for the use of interpretations by the therapist, but the patient draws conclusions himself while witnessing the encounter with the internalized figure interviewed by the therapist.

We look forward to meeting you in the next conversation that will continue to expand and focus on RGFT treatment approach.

Dr. Igor Salganik & Prof. Joseph Levine

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