But Why?

Elisa A. Escalante/ LCSW/ 4-20-2025

Our mind will go to places that defy the laws of radical acceptance, & life itself. The reason that I ‘why’ my patients, and sometimes my friends to death, is because the mind is reaching for every answer to every possible scenario. Or the mind is fixated on sticking with the rules that the mind believes are ‘cemented in stone’. The mind may not stop until it get’s to the conclusion it needs, or when it wills the body to do the action it needs. This is especially common with anxiety, OCD & PTSD patients. I conclude almost every radical acceptance intervention with the question of: “Why do you want to predict the future?” The answers include: “I want to be able to plan and be prepared…” or “If I know for sure what will happen, then I will not be nervous about it or confused”. These answers indicate an underlying avoidance of helplessness, suspense or confusion. The opposite of helplessness is control. Attempts to control what can’t be controlled perpetuates… more helplessness. The ultimate goal would be to surrender.

Patient A: Pt- I have to have a training partner when I go to the gym… I can’t go alone because I have panic attacks. Me- Why? Pt- Because when I’m alone I am more afraid of people at the gym staring at me and judging me… Me- Mind reading? Why do you believe they are for sure staring at you and judging you? Pt- I was made fun of a lot growing up, I was bullied for being overweight. Me- Let’s paint your worst case scenario then. You are at the gym, one of the women is giving you judgmental looks. Pt- (Face clearly in distress already) Even worse if it’s a woman… omg! If she tells me I have an ugly outfit, and I’m out of shape and I’m not doing the workout correctly!” Me- Okay so this fit lady comes up to you, she tells you “You are fat, your outfit sucks, and you are not doing the workout correctly. Then what?? Pt- I would either punch her in the throat and run away. Or cry and run away. Me- Are you thinking about consequences? And are you thinking about what it means about her to say such a cruel thing to you? Pt- Yea I would not actually punch her I don’t want to get in trouble. I’ll cry and run and be mortified. But… if she does judge me then yeah, maybe she’s…. Me- Judgmental? Envious? Projecting some type of envy back onto you? Maybe even jealous and trying to put you down….? And… would you hide again? Pt- I might… Me- So in order to avoid judgment all together you decided you would hide away? (Agoraphobia) Pt- Yes.

I wrote out Pt A’s survival program: “I am terrified of continued judgement therefore I will hide away”. Pt agreed that she believes in this sentence entirely. (A survival program is often created by our mind in childhood to protect us from physical or mental danger and when it is reinforced it will become the control center for our thoughts, emotions and behaviors) I wrote out a Pro/ con list for pt to identify ways in which her survival program helps her and harms her. Pros: I was less judged overall because I hid in my home with my pets/ I bonded a lot with my pets and they received a lot of attention Cons: I don’t take many risks due to my social anxiety/ I am more sedentary & getting less sunlight; bad for health/ I have so many regrets due to not going after my goals; shame & poor self esteem.

Patient B: Pt- I am failing science class. Me- Why have you been failing? Any idea what can be done so that you can pass? Pt- I am just really confused and not sure what to do. Me- Have you been asking the teacher questions or inquiring about make up work you can do to catch up? Pt- No, I am afraid to… Me- Why? Pt- I worry that the teacher or other kid’s will think I am stupid… Me- What’s a teachers job as a teacher? Pt-…. to teach…. Me- And what is your job as a student? Pt- to learn…. Me- And to paint your worst case scenario… what if a student happens to come up to you and tell you “Hey I can’t believe you asked questions, you are stupid!” What would you do?? Pt- (Laughs out loud) I guess I would just say something back to them or maybe ignore them. Me- Is this common for you to not speak up or ask questions due to a fear of being criticized? Pt- Yes…

I wrote out pt B’s survival program: “I must not speak up or ask questions, or I will be criticized.” I also inquired about the root cause of this survival programming. Pt identified being judged a lot for asking questions from both parents and teachers throughout her childhood. Pt was also agreeable to a pro and con list regarding her survival program. Pros: When I am quiet no one even looks in my direction/ I was less critiqued overall Cons: I rarely asked questions and I remain confused/ I did not learn to express myself or self advocate/ I am failing a class and sabotaging my progress out of fear/ I am future predicting & overthinking.

Patient C: Pt- I have been having more arguments with my husband. Me- Why? Pt- They never do chores unless I ask, and if they do chores, they do them wrong. Me- Any specific examples you can give me? Pt- Well for example if he does the dishes, maybe he only does half of them. Or he does not clean them thoroughly. I also hate how he loads up the dishwasher. Me- Why does the dishwasher have to be loaded a specific way? Pt- It just makes sense to, I was raised to do it that way and I have to do it that way. Me- Why? Pt- Well because if it isn’t done the way I am used to doing it, it will drive me crazy. Me- Why? Pt- (Pauses to really think about this answer) I just can’t relax unless the chores are done immediately and correctly. If they pile up, I cannot relax. Me- How long has this been an issue for you? Pt- As long as I can remember, I had strict parents and they had high standards on cleaning. It’s how I learned to be. Me- What happened if you did not clean to their standards? Pt- I would get in a lot of trouble, spanked, yelled at and grounded.

I wrote out Pt C’s survival program: “I must clean immediately and perfectly, or else I will be severely punished” The patient also acknowledges that not only does this impact her life, but she has projected the same expectations onto her spouse. Because, well, she lives with him and his messy behaviors impact her mental health too. Pros: I have great work ethic/ I get compliments on how beautiful my home looks when guests come over/ I temporarily relieve my anxiety after I clean up. Cons: I burnout and experience a lot of fatigue/ When I try to relax I feel tense and anxious instead/ Me and my spouse have ongoing arguments because he cannot live up to my standards of cleanliness/ I am a perfectionist which leads to shame if I can’t be perfect.

After patients walk through their deep seated fears, explore their survival programs and make their pro/ con lists, I tend to have follow up questions. “Is this an outdated survival program? Does this survival program now harm you more than it helps you? Can you abandon it or modify it? Is it hard to let go of? Can you recognize that it was built out of fear due to toxic environments?”

Conclusion: An effective therapist does not tell a patient what to do. They will ask why? And why? And why again. We use the curiosity approach to ask the right questions. There are many stuck points that people remain in because they rarely have the opportunity to sit down and unpack their thoughts/ emotions/ behaviors. How many times have they been told the right answer but they do not have the tools to execute what they need to do? Or, their brain paralyzes them to a point they feel incapable of doing what they truly want? Therapist or not, before giving someone an answer or a solution, ask why first. Ask them why it’s hard. Then you will find out that it’s not a matter of them being physically incapable, it’s a matter of them being mentally frozen.