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Process oriented psychology differs from more popular ‘process psychologies’ in its differentiated method of observation. Thus, a frequent misunderstanding derived from popular conceptions of the term ‘process’ is that clients can get dangerously or uselessly wrapped up in their ‘process,’ that is, get too involved in themselves. Would it not be more useful and valuable at times to simply give direct and clear instructions which a client could follow?Encouraging clients to follow only one part of themselves is always less useful then helping them contact all their parts. Only the total process is really healing. Following a client in process oriented psychology means not only following the part which the client identifies with in the moment, but following the total process, that is, with both primary and secondary signals.Thus, encouraging a client to be God when he is proclaiming that he is God and that the ‘authorities’ are evil would be less useful than enabling him to get in contact with his own inner authorities. Once this is done, he will be able to take simple and helpful directions from others and will even be able to give them to himself. As long as he is identified with God, it is not likely he will be able to hear or follow such instructions.Until recently, contacting the other side of a polarization during an acute episode has been difficult to achieve with patience and psychological interventions alone, that is, without drugs. *27\227\8*

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OCS AND D the dsm-iv diagnostic manual used by mental health professionals in the United States contains a set of diagnoses called personality disorders that are applied to people with long-term maladaptive patterns of thinking and behaving. Many of the labels are well known: paranoid, hysterical, psychopathic, narcissistic, and, yes, obsessive-compulsive.You probably recognize what obsessive-compulsive personality disorder is like. It represents the extreme of what in general parlance is referred to as obsessive-compulsive behavior. It describes the person who is perfectionistic, punctual, aloof, and inflexible, when severe obsessive-compulsive personality results in a sort of malignant fussiness. One patient of mine timed family members every time they showered, yelled when anyone put a fork in the dishwasher with the prongs facing down, and insisted on saving the carpet by having family members walk up and down the stairs on newspapers.Until recently, the unquestioned assumption among mental health professionals has been that obsessive-compulsive personality leads directly to obsessive-compulsive disorder. That is why, of course, they were both referred to as obsessive-compulsive in the first place. The two disorders were thought simply to represent different levels of seventy of the same basic problem; the rigidity and inflexibility of obsessive-compulsive personality was thought to cause by unconscious mechanisms the obsessions and compulsions of OCD. When I was in training there was no doubt about this link. Yet, although this theory is still cited in newspapers and magazines, the fact is that experts in the field no longer believe it.First of all, researchers have found that obsessive-compulsive personality is not, after all, a necessary condition for the development of OCD. Recent studies suggest that obsessive-compulsive personality disorder is not even the most common personality disorder that is found among people who have OCD. A 1993 study by Russell Noyes and colleagues at the University of Iowa, for instance, found that although 80 percent of OCD patients suffer from personality disorders, it is dependent personality disorder—fear of decisions, under-assertiveness, excessive leaning on others—that is present in more than half of patients. This finding agrees with what is found in clinical practice. Instead of being detached and emotionally cool, as are people with obsessive-compulsive personality disorder, OCD patients are nervous and clinging.Secondly, the idea that OCD is caused by any personality disorder has been called into question. In a 1992 study at Harvard, Michael Jenike and his colleagues looked at seventeen patients who were diagnosed as having both OCD and personality disorders. Ten of these patients responded well to medications and behavioral therapy for their obsessions, and when tested again after treatment, nine of the ten no longer had their personality disorders. What these findings suggest is that when people with OCD have personality disorders, it may well be the obsessions and compulsions that are causing the personality problems, not the other way around.Studies such as these cause mental health professionals to question whether the diagnoses referred to as personality disorders are truly valid and reliable. Other approaches to personality may be better. One well-researched new scheme for describing personality is that introduced in 1987 by Dr. Robert Cloninger, chairman of the Department of Psychiatry at Washington University in St. Louis. I like Dr. Cloninger’s approach and so do my patients. It’s easy to understand, and it doesn’t involve negative labels, such as “hysteric” or “paranoid.”*22/338/2*

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Once the physician recognizes delirium, the patient must be protected from its dangers. The measures needed to accomplish this end will vary from case to case, but all are based on the knowledge that a delirious individual is confused, that he may experience frightening hallucinations and delusions, and that his condition can fluctuate throughout the day and worsen during the night.
Observation is the key to protection. If a patient is monitored, his needs can be known and appropriate care can be given. A major goal of observation is to deal with minor problems before they become behavioral crises. Timely reassurance, for example, may convince a patient that an intravenous line, not a snake, is attached to his arm.
With mild delirium of the hypoactive-hypoalert type, frequent checks by nursing staff may be sufficient to protect the patient, especially if family members are also in attendance. With severe delirium of the hyper-active-hyperalert type, constant observation by nursing staff is required. The level of monitoring should be determined by clinical, rather than budgetary, considerations.
At times, the patient and others cannot be protected unless he is restrained. Although there are good arguments against the use of restraints (e.g., an agitated patient can become even more agitated), there may be no other way to prevent serious injury (e.g., fracture, laceration, or wound dehiscence) and to guarantee the continuation of needed treatment (e.g., assisted ventilation, intravenous antibiotics). Restraint is not an alternative to constant observation and treatment of symptoms; it is a temporary measure in a dangerous situation.
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