Re:CBT and Guilt

Unless he has been forced to see a psychological therapist, one suspects that, at some level, he has an ability to question his beliefs. This is something to build on.

One way to proceed is to outline different theories of the problem without advocating any one of these. There are at least two ways of viewing his problem. For example, here are two theories explaining his problem:

1) "It is morally wrong and a punishable offence to indulge oneself when there are people in the world suffering want and poverty. The "Evil Eye" really does exist. People are guided by powerful feelings of envy and revenge and have supernatural powers to act on these feelings and he is right to engage in the actions he does to ensure his safety".
This, or some version of it, seems to be the predominant theory in his mind (though not the exclusive one or he would not be seeing a psychological therapist!)

or

2)"This is a psychological problem arising from a difficulty deciding how to live a moral life and from excessive worry/ catastrophization of the consequences of failing to do so".

Therapy could proceed by exploring both perspectives. The therapist remains neutral as to which theory is correct. "Showing him" that his thoughts are distorted will, as you have found, have little effect. "Showing" people that their thoughts are distorted is not good cognitive therapy and will often fail to bring about cognitive change (indeed it may contribute to the strengthening of the very beliefs). Start by examining in detail his perspective and the evidence he believes support it. Avoid jumping in prematurely to challenge "distorted beliefs". Allow him to talk about his perspective. Initially work within his frame of reference. Listen and respond empathically to his story and the feelings expressed and unexpressed. At the end of this process you should have a deeper understanding of where he is coming from and he should feel listened to and his feelings validated (remember that part of the problem is his inability to validate his own feelings and needs so rather than seek to do more invalidating of him by challenging his "distortions" listen and convey to him that you have heard him). Based on this discussion present him with a written formulation of the problem in cognitive terms. Be collaborative. Seek his opinion on what you have presented.

It may be helpful to normalise his dilemma. How do other people deal with this moral question? How do you deal with it? Can you share this with him? It is not all-or-nothing. It is a great big grey area. Help him see this. Keep highlighting the dichotomous nature of his thinking.

Explore the evidence and get him to write it down. Are there people who he regards as living appropriately moral lives? Do they not permit themselves access to some of life's pleasures? Do they never enjoy themselves? Is it true that those who spend conspiciously suffer terribly from the "Evil eye"? Examine the experiences of famous and wealthy people. They may have their detractors but they also have their fans in large numbers. What do the statistics show about wealth (i.e. less depression, fewer health problems generally, greater longevity, etc - but not, of course, an absence of suffering which is part and parcel of living life for all). What is the evidence for/against the "Evil Eye"?

One of your central objectives is to help the client to get some distance from his current stance so he has some ability to reflect on his opinions. Hopefully the preceeding work will have achieved this to some degree.You could go on to look at the usefulness of his approach. Even if he tortures himself relentlessly what good will this do for those in need? How much self-torture would be enough?Maybe he could do more good by maximising his strengths and, from this position of strength, make decisions about the most effective ways to help the less well-off? Which position would ultimately produce the most good for those in need? Which would ultimately be the most moral position?Ask him if there are models for his position? What about the great religious figures - have they never permitted themselves to enjoy themselves? Jesus changed water into wine as I recall being taught. There are probaly many more of these examples. Challenge the all-or-nothing, dichotomous perspective at every opportunity. What is happiness? Some philosophical/religious approaches would argue that the pursuit of material wealth is not the answer to happiness anyway.

I wonder what behavioural change would be prescribed in this case. Maybe he needs to get out and meet more people and realise that most people find some pleasure some of the time? It is only people like him who do not! It would seem appropriate to do an analysis of his avoidant/safety behaviours. Try to negociate experiments that permit a testing out of his beliefs by exposing him to alternative information (etc, etc)

Do attentional work. Get him to deliberately look for evidence that counters his beliefs about the world and record such evidence.

It may be necessary early on to enable him to reduce his preoccupation with the problem. Help him to achieve cognitive/attentional control. Teach him detached mindfulness - this is the mind regulation strategy outlined by Adrian Wells (and similar in ways to that outlined by others like Marsha Linehan and John Teasdale). Just notice mental events as they emerge into consciousness but refuse to engage with them. Acknowledge their presence but then leave them alone to fade in their own time. Do not fight or struggle with such content just leave it. He does not have to spend all his waking hours thinking about this dilemma. Teach him to create limits to the amount of time he is permitted to think about it. Catch thoughts that emerge into consciousness but let them go again. He could allow himself a half hour per day to think about his problem but outside that time disengage from it whenever he experiences intrusions about it. Get him to try this for a period of weeks so that he can then judge the impact of it. Meanwhile, get him to build a life for himself by being more active and more involved in the world.

In your therapy with this person you will be helped by the realisation that his model of the world and his way of negotiating the world is not working for him (the fact of his being in therapy is evidence of this!). The more you can get him to question his position and enable him to disengage from it so that he can be exposed to new learning situations the better.

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