Treating a Chronic Tendency to Self-Sabotage

In Monday's New York Times Dr. Richard Friedman wrote a column about patients who suffer chronically self-defeating behavior. Link here.

For the record, Dr. Friedman is a distinguished psychiatrist at a distinguished psychiatric facility. He represents the best that the profession has to offer. If you, as did many of the Times commenters, find his approach lacking, you can draw a conclusion from that fact. You might even want to muse over the fact that many of the masters of the Wall Street universe are treated by psychiatrists who think like Dr. Friedman.

I am not alone in finding his article disappointing. Many commenters expressed frustration and annoyance at his condescending attitude toward his patients. I haven't read all the comments, but I would recommend #24, #35, and #55. Link here.

If you read through the comments you will get a very good sense of the debate surrounding psychotherapy today.

One commenter noted that Dr. Friedman's article centers around an epiphany he had. Dr. Friedman saw the light when he discovered that patients who are invested in failure will usually be compelled to fail at therapy too.

In the not-too-distant past case studies used to contain patient epiphanies where the suffering individual discovered a truth about his childhood, recovered the memory of a trauma, and felt liberated to march off into the sunset. Now, we have a psychiatrist having an epiphany telling him that it's not his fault that his patients do not get better.

Having labelled these patients as masochists-- with some commenters taking vigorous exception-- Dr. Friedman despairs of not having a pill to erase their now-eroticized impulse toward self-defeatism. Beyond that, as the commenters note, he is unsympathetic, condescending, and defeatist himself.

Dr. Friedman's approach seems to involve telling the patients that they are themselves responsible for their failures-- in itself, unobjectionable-- and that they are doing it for a reason-- in itself, objectionable. Telling people that they are failing because they want to and because they are deriving a perverse sexual enjoyment from it is not likely to help them to improve their condition.

Since patients who fail at love or work are failing in public, Dr. Friedman is telling them that a certain group of the enlightened sees through their mask and knows that they are repressed masochists who have sublimated their deviant sexual impulses into self-sabotage. How would you feel if your psychiatrist told you that the world knows something about you that is deeply humiliating, only you do not know it yourself?

If that is the interpretation, then treatment would consist in persuading the patient that that his repressed masochistic impulses are directing his behavior. Do you think that once he accepts the interpretation and embraces his inner masochist, he will feel motivated to succeed.

I have no intention of leaving things in such a morass. Surely, there are better ways of treating people who engage in repeated self-sabotaging behavior.

Cognitive therapy is one step in the right direction because it will challenge the patient's basic assumption, namely that he always fails. At best, it will help him to marshal evidence of his basic competence and successes. It is easier to build on success than to imagine that you are destined to fail.

Dr. Friedman seems to accept his patients' all-or-nothing thinking, even though I am sure he knows that it expresses depressive thought patterns.

Another approach, more in line with good coaching practice, would also ignore all reference to past history or to the behavior's hidden meaning. It would would see him as having become mired in bad habits, not knowing how to succeed. Coaching would then help him to develop good habits to replace the bad ones, roughly as Aristotle would have recommended.

Teaching him how to succeed would seem to be preferable than telling him that he is destined to fail at everything.