Borderline personality disorder (BPD) is a severe mental health condition marked by symptoms such as…
Don’t Wash That Floor! ‘Holistic’ Treatment in Action
After many years of providing individual, family and group psychotherapy to people from all walks of life, certain cases still stand out as great “teachable moments” for therapists and clients alike in understanding how therapy can work and really make a difference. When the client is a parent, the positive changes may help prevent problems for the next generation as well.
Sometimes the approach a social worker might take in providing psychotherapy may be a little different from a psychologist or a psychiatrist. That’s where the “holistic” idea comes into play: social workers often use a “bio-psycho-social” approach to understanding a client, and that understanding extends to the client’s family, workplace and social circle. Sometimes we talk about understanding a client’s “system,” which means we try to see them in context, and understand how they fit in with all the others with whom they interact. A baby’s mobile with a number of dangling toys to bat around is a good analogy here: think of the client as the one toy in the center. If the client starts spinning or moving in the breeze, that movement will have an impact on all the other toys. Similarly, when you understand your client in context, and try to take into account all the ways in which he or she interacts with other people, you might be in a better position to design a treatment plan full of interventions that work.
Maria, a 28-year-old married woman, came to therapy complaining of symptoms of depression and anxiety. She was tearful, felt anxious much of the time, had trouble sleeping, and had gained weight. She also complained of troubled relationships with her husband and her mother who lived nearby and was also in therapy and on medication for depression. She told me that she entered therapy at her mom’s urging as her mom believed she was depressed and also had obsessive compulsive disorder.
Maria expressed concern that her depression was due to recent birth of her daughter, who was only several weeks old when Maria first called the clinic. She admitted that she had been experiencing low moods and tearfulness throughout the pregnancy and that after the birth of her daughter she wasn’t feeling any better. She expressed the hope that she could avoid “poisoning” her daughter’s childhood with her depression.
Beliefs and Behaviors
Maria admitted to feeling guilty for being in therapy—she talked about feeling like she should be able to handle pretty much “anything” on her own. To me, this meant that I would need to show her a great deal of respect and allow time for establishing a trusting relationship with Maria. Guilt and shame can make a client vulnerable to misinterpreting even innocent remarks and can lead to a client feeling judged and attacked.
As trust was established I learned more and more about Maria’s daily life, her relationships, and her routines. As she opened up about her beliefs around what it means to her to be a mother, and a wife, and how these beliefs influenced her behavior on a daily basis, I saw where to intervene first.
Maria had a routine of mopping her kitchen and bathroom floors before she went to bed every night. The more we discussed this behavior, the clearer it became that this action was extremely emotionally laden: she needed to engage in this cleaning almost like a ritual, but she also felt deeply angry and resentful about it. In addition, she was physically exhausted and it was simply too much for her. But her beliefs about mothering and homemaking led to a rigid “need” to continue to mop, sometimes as late as midnight, by the time she had finished laundry and dishes.
One possible path to take with this situation would be to diagnose obsessive compulsive disorder (if she did indeed meet criteria), and refer her to a doctor for a medication evaluation. Given all her symptoms, she probably would also have met criteria for a depressive disorder and possibly generalized anxiety disorder as well. But before sending her to someone else to discuss medications, I used the trust I had developed with her to develop behavioral interventions that would (I hoped) lead to real changes in her whole system.
Looking Beyond the Behavior
Looking at her cleaning behavior in isolation, it is natural to see a mental illness such as OCD. But the approach I used meant that I needed to look at her behavior in context—the context of her family and of her beliefs. These two approaches are not mutually exclusive either—she could certainly have a medication evaluation and continue to work behaviorally in therapy—but she preferred to wait on medication as she was breast-feeding her baby.
My intervention included instructing her to stop mopping the floors every night. Initially we could reduce to every other night—Maria was willing to try that, although it wasn’t easy for her. That was it: stop mopping the floor! But what would not washing the floor mean to Maria and her family? First, by helping Maria get to bed a little earlier, she might get more sleep which would help her mood and anxiety ease, even slightly. Getting her to bed before she was utterly spent also meant she had more potential time to enjoy intimacy with her husband when no children were awake. By getting her to redefine what was absolutely necessary and required of her as a wife and a mother, she could then question other beliefs she held (e.g., beliefs about spending money on herself versus spending for her children). The dirty floors were a springboard into questioning and redefining herself on a number of fronts.
Ultimately, Maria was able to stop attending therapy after about six months. She had made changes in her relationship with her mom, putting more boundaries in place and redefining herself as a mom based on her own opinions and needs. She realized that she was “over-functioning” and that this had created an imbalance in her marriage, which she was able to address by backing off and doing less, which made the space for her husband to pitch in and help more. That brought them closer and helped her husband bond more with the baby, which led to Maria having more time freed of childcare responsibilities. Maria found that with more sleep, less rigid beliefs about housekeeping and family obligations, and more independence, she actually felt less sad and anxious much of the time.
Understanding behaviors in context, supporting the strengths clients have, and gaining sufficient trust to make “crazy” suggestions—like stop washing your floor!—can add up to a truly successful therapy experience for all. Here I am, decades later, remembering Maria fondly. And celebrating her dirty floor!