Recently a coworker went to Chipotle Mexican Grill for lunch. She came back with some righteous fury to go along with her burrito. “How can a company that advertises they do everything the right way put out a bag like this?!” she wondered. So I took a picture of that bag with my phone. (Here’s where you marvel at how well I framed a shot of a paper sack on my desk: You can’t even see the piles upon piles of paper work!)

What about customers with OCD?

Chipotle claims to use “naturally raised” meat, meaning the animals that will become our lunch and dinner are fed vegetarian diets and are never given antibiotics. Raising them this way makes for “happier, healthier” livestock that produces the BEST MEAT EVER. The healthier I’ll buy, but happier? I’m not so sure about that: 1) I’m pretty sure a pig’s mindset has nothing to do with the way my bacon tastes in the morning and 2) I’m pretty sure that they way their lives end is anything but happy.

Where’s the “advertising with integrity?”

But I digress. My point is Chipotle thinks that it actually means something when they advertise “Food with Integrity.” But what about the people who eat that food? Shouldn’t Chipotle care about them at least as much the livestock slaughtered to serve the company’s goals?

Well, according to Chipotle, it’s perfectly OK to make fun of them if they have a mental illness. Look at that bag again. It seems to be written from the viewpoint of a Chipotle employee because it talks about making sure the onions are perfectly diced. I’m all for that, I guess, but I’m not a huge fan of what else is on the bag:

“So maybe I’m a little bit of a perfectionist, but I don’t think it qualifies me as obsessive. It’s not like I’m spending all day counting beans & washing my hands with steel wool.“

Did that bag just say what I think it said? Surely it didn’t just make light of a serious mental illness, one that can have debilitating effects. Let me read it again.

Nope, I was right the first time. The bottom of the bag reads, “So maybe I am a little obsessive.  But if being certifiably crazy about the way I make food makes it taste as good as it does, I don’t wanna be sane.” Just…wow. Maybe Chipotle should think twice before disparaging the good people who patronize their restaurants. Unless, of course, insulting patrons by using “obsessive” and “crazy” so flippantly is a big part of their corporate culture.

Just the facts

Folks, let me drop some knowledge on you. I know, I know, you don’t read my posts to learn anything. I’m right there with you. But I think this issue needs some context.

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by recurrent, unwanted thoughts, obsessions or repetitive behaviors (compulsions). Typical obsessions include fear of dirt or contamination, fear of acting on violent or aggressive impulses and concern with order or symmetry. Repetitive behaviors such as hand washing, counting, checking or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away.

Read that again: People with OCD keep performing the same tasks, over and over and over again, in the vain hope that they won’t have to keep performing them. They’re looking for peace, for a way to quiet a mind that won’t let them move on, not the perfect way to chop onions.

Imagine spending hours organizing your desk or kitchen or garage or any place in your everyday life that is usually cluttered. You step back to admire your handiwork, only to see a few places where items aren’t in a perfect row or that your tools aren’t organized by size quite as perfectly as you thought they were. So you start the process all over again, even though you want nothing more than to stop and eat or drink or use the restroom. Sounds hilarious, doesn’t it?

OCD is the fourth most common neuropsychiatric illness in the United States, affecting nearly five million people in the U.S. each year. One in 40 adults and one in 200 children suffer from OCD at some point in their lives. Up to 30 percent of patients treated in outpatient settings fail to respond to treatment. A structured inpatient setting is often necessary for the individual to progress and effectively learn to manage their OCD.

These numbers should tell you how serious OCD is. We see the disorder used in humorous ways quite a bit, but that doesn’t mean the condition is a joke. Sure, Tony Shaloub is great on Monk and that show is supposed to be funny, but I recall there are quite a few instances in which the character’s OCD gets in the way of living his life.

Seriously, folks

Should you be upset? Would you find it offensive if the bag said something like “If I can’t dice those onions perfectly, I may just have to kill myself?” Would “I’m retarded about putting together the perfect salsa” bother you?  How about “I wouldn’t say my obsession with perfectionism qualifies me for the short bus?”

In one silly, inconsequential promotional item, Chipotle has made a joke of a disease that many people struggle with everyday, one that will sometimes lead them to be hospitalized.  Chipotle’s turned Jack Nicholson’s nuanced character from As Good As It Gets into two lines on a brown paper bag, and they should be ashamed.

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.