All of us experience occasional confusion in our lives. Sometimes this is due to a particular set of circumstances, or sometimes it is due to a lack of, or change in, our psychological or behavioral resources. In such moments we may personally "feel" disorganized, and our interactions may appear disorganized to others. For the disorganized client, however, daily functioning and one's sense of self may be fraught with inconsistency, ineffectiveness, incompleteness and a sense of failure.
Disorganized clients come for treatment with all sorts of presenting problems. Common presentations include eating disorders, addictive disorders, abuse/trauma-related disorders, self-injury and personality disorders. Upon careful examination of their histories, these clients often tend to "rotate" through a variety of disorders or exhibit multiple disorders or symptoms simultaneously. Thus, it is not uncommon for them to have had a number of hospitalizations or intensive treatment experiences. In particular, the disorganized client often exhibits affectively charged memory information along with much distortion and failure to integrate the memory content. In addition, they exhibit a generally confused sense of efficacy, power, mastery and control in the world. Consequently, many of these clients possess a distorted sense of reality and describe considerable disturbances in their interpersonal relationships.
General interactional patterns commonly exhibited by disorganized clients include: interacting with the world through their symptoms such that they feel they are able to be effective, efficient, powerful and meaningful without directly interacting with those people, places and situations right in front of them; refusing to share or relinquish control when necessary; reserving the right to break their word while expecting you to keep yours; engaging in no-win patterns of interaction, such as when they tell you that "nothing will work," and yet come to therapy expecting success; and often demanding to make their own decisions but rarely following through with them.
Disorganization refers to the general ways clients experience or manage themselves and the ways they interact with others in their environment. In more specific terms, this refers to their general repertoire of skills, the types and patterns of interactions they exhibit with others, and the connections between the skills and interactions. For many clients, disorganization becomes a lifestyle. In fact, for many of these individuals self-defeating patterns of interaction are the expected; successful patterns are viewed as "flukes," and information from them is ignored. It is no wonder that many of these clients have tended not to respond effectively to different treatment experiences.
Many authors have described these clients from a variety of perspectives. Lansky and Levitt, for example, discussed the treatment of these types of clients who presented with severe eating disorders,1 Linehan described many of these traits in clients with borderline personality disorders2 and van der Kolk suggested that many of these symptoms may be the result of adaptation to trauma or abuse.3 For clinicians faced with treating this clientele, particularly in this era of scarce resources, it may be useful to view the client as disorganized versus some other pathological condition or symptom.
By understanding clients as managing themselves in a disorganized pattern, the clinician can focus on what client skills are necessary in order to resolve their presenting problem(s), what patterns of interaction occur that either maintain or are part of the problematic situation and how the client's skills and interactions fit together. This guides the clinician and makes improving the organization the focal point of treatment, rather than curing a pathology such as a personality disorder or a specific symptom (e.g. self-injury) when the symptom is either complicated by other symptoms or is apparently chronic in nature. By emphasizing the client's style of self-management in employing skills, focus can be placed on adding to or "learning" new skills, acquiring different resources, learning to use present resources more effectively or learning new management strategies.
Disorganized clients have survived in a conflicting and difficult world. Their symptom "system" has protected them in most powerful ways. That constellation of symptoms, skills and patterns of interaction have allowed these individuals to navigate through life and has given them the ability to withstand many traumas, conflicts and personal losses without becoming even more incapacitated. The art of therapy for these clients is to initiate, support and enhance their capacity to manage themselves and improve their life situation. Clinicians who work with disorganized clients will be tested and retested. Working with this population will require tensile strength, malleable hardness and kindness.
References
John Levitt is an approved supervisor of the American Association for Marriage and Family Therapy (AAMFT) and is a certified addiction counselor (CADC). Levitt is the author of a number of articles and has co-authored and edited two books.