Facing Our Fears

We humans have an innate desire to avoid emotional pain. After all, who wants to feel pain? Ironically, however, the more we try to avoid emotional pain, the more painful the situation becomes. Stated more simply, avoiding pain leads to increased pain.  Facing our fears diminishes pain.

You’re a student with a final exam approaching. You are anxious about the exam, afraid you might not pass.  To avoid the fear, you spend the week before the final doing everything but studying, telling yourself “I won’t see my friends until the fall.”  The night before the exam you start studying at 10 pm after a quick beer with friends.  You are overwhelmed with fear when you start reviewing your notes.  How will you learn all this material before the exam at 9 am?  You stay up all night studying but get a D on the exam.  You’re angry at yourself for not studying earlier in the week.  You feel guilty and ashamed because you promised your parents you’d bring your grades up.  You wonder if you might have gotten a D even if you had studied early.  You vow that you will study early for the next final but you are so obsessed with fear of failure, you make other commitments to distract yourself from the fear.  The same thing happens with the same result.  This pattern will occur over and over until you face your fear of failure. 

Cycle of Avoidance

As the diagram below illustrates, the final exam triggered negative emotions (fear), which leads to finding things to do to avoid the fear (avoidance). Spending time with friends (problem behavior) brings temporary relief.  But investing all of your time in social activities leaves no opportunity to develop good study habits.  Not knowing how to study efficiently or effectively makes you even more vulnerable when the next exam comes up.  Your negative emotions expand and escalate from fear to guilt and self-judgment to shame.   Now you fear that even if you study you might not be able to pass.  And the cycle begins again, escalating each time you avoid studying.  Bottom line is avoiding pain leads to more pain.

Think of other situations that may trigger this cycle of escalating avoidance —fear of flying or driving a car or learning a new skill, fear of failure (or even success), fear you’re not good enough or worth the effort – to name a few.

 

 

avoidance-cycle3

Start with Beginner’s Mind

If you decide to face your fears, you will need to tolerate the distress. The longer you have avoided the situation, the harder it will be.  It helps to let go of your expectations.  If you have unrealistic expectations, you may reinforce the very habitual cycle you are trying to break.  Adopt a beginner’s mind – no expectations.  Whatever the result, it’s okay.  Figure out what skills you lack, learn from the experience and move on.  The next time you face the situation, adopt beginner’s mind again.  Sometimes the outcomes may improve; other times they may not.  The only “mistake” is not learning from the experience.

As you become more skillful, your fear and vulnerability will diminish. Your urge to engage in the problem behavior will become easier to overcome.   There may even come a time when you forget you ever avoided the situation (or not).

So next time you have the urge to avoid a feared task face your fear, master new skills and feel better about yourself for not avoiding.

Sandra Miller, MSW, LCSW and sometimes blogger, sees clients at St. Louis DBT, LLC.

Those Pesky “…ing” Words

The lady doth protest too much, methinks is a quotation from the 1599 play Hamlet by William Shakespeare.  Over the centuries, it has come to describe an individual’s frequent and vehement attempts to convince others of their version of events when the opposite is true.

Venting

Frequent and vehement attempts sounds like venting to me, “to give often vigorous or emotional expression to.” Venting comes on a continuum from a thoughtful airing of thoughts and emotions with a trusted confidante to a self-vindicating verbal barrage on the unwitting listener. The thoughtful sharing can be cathartic; hours of verbal barrage are not. Healthy sharing with a trusted confidante yields assistance in reinterpreting what you may either have taken too personally or perceived erroneously.

Frequently venting frustration or anger  is a form of practice — the more you do it the more skilled you become at it. Being more skilled at venting makes you more likely to get upset by future disappointments, even small ones. If venting becomes a pattern as automatic as it is self-reinforcing—it heightens stress and leads to misery.

”Talking out an emotion doesn’t reduce it, it rehearses it,” wrote Dr. Carol Tavris, a social psychologist and researcher. ”People who are most prone to give vent to their rage get angrier, not less angry.”  Dr. Willard Gaylin, a New York psychiatrist, calls venting “a form of public littering.”

Have you ever noticed the longer and more vehemently someone vents the more agitated they become?  They get louder and their pitch gets higher. They speak faster.  They may clench their jaw or make a fist.  They breathe faster and shallower.  It’s as though they are re-experiencing the situation, not necessarily as it happened but as they have reconstructed it in their minds.

Helping clients recognize that in retelling the story again and again they risk escalating themselves requires helping them accept that the situation is not happening in this moment. To help them see they are escalating themselves in the re-telling takes the repeated gentle observation. “I see you’re escalating.”  When they learn to recognize they are escalating, then the question becomes “What about the re-telling is escalating you?”  Only then is it possible to begin talking about the means and function of the venting.

The Means of Venting:  The Pesky “…ing” Words

So what’s really going on when someone feels the need to vent? That’s where the pesky “…ing” words come in.  The “…ing” words describe some of the means people employ in their venting.   My running list of means includes:.

Accusing
Arguing (their point of view)
Ascribing (motive)
Blaming
Complaining
Convincing
Defending
Exaggerating
Excusing
(Over) Explaining
Interpreting (the facts)
Judging
Jumping to conclusions
Justifying
Mindreading
Persuading
Rationalizing
Story-telling

Five Quick Examples

Example #1: A wife is having an affair.  Despite that her spouse has had a series of affairs, he blames his wife and her lover, makes excuses for his own bad choices and spends hours trying to explain why he is the victim.  He is blaming, excusing and over-explaining.

Example #2:  A woman hates her job.  She complains to her supervisors and co-workers about the injustices she has to endure.  She defends her performance and accuses her supervisors of not recognizing or appreciating her efforts.  She is complaining, defending and accusing.

Example #3:  A stay-at-home mom believes her husband should do more around the house.  She blames him and he blames her for their teenager’s defiant behavior.  He argues he works all day.  She says she works all day too.  Both do everything within their power to convince the other of the rightness of their argument to no avail.  He vents to his golf buddies and she vents to her girlfriends.  They are blaming, convincing, arguing, complaining and rationalizing.

Example #4. A man is often in crisis, generally as a result of one relationship or another that’s gone awry.  He vents to his brother.  He blames others but takes no responsibility himself. He rationalizes and excuses his own behavior while blaming others no matter what went awry.  It’s not clear whether he is trying to convince his brother or himself that others are responsible (or perhaps both).

Example #5:  A wife is late coming home from work.  When she gets home, her spouse accuses her of having an affair.  No matter what she says he is unconvinced.  The next day he vents to a co-worker.  As he vents, his interpretations of her coming home late become increasingly exaggerated.  When one of his co-workers asks what evidence he has.  He rationalizes his interpretation and tries to persuade her that any reasonable person would know that his wife is having an affair.  He complains about being the victim of his wife’s infidelity.

The Function of Unhealthy Venting

The function of unhealthy venting is more complicated.  Some people vent because they feel powerless. Venting gives them a sense of empowerment. They are doing something about the problem. In reality, their venting may keep them from actually solving the problem.

Some people vent because their true emotions frighten them too much to even acknowledge.  Venting masks the underlying emotions (e.g., shame, guilt, hurt) with anger and self-righteousness.

Other people vent to validate themselves. These people generally have low self-esteem. When they blame or accuse someone else, they feel validated in their own righteousness.  They are trying to feel better about themselves.

Some people feel invisible and want to be seen and heard. Others fear if they take any responsibility they will be blamed for all. For many people, however, venting anger and frustration becomes a powerful urge that requires an equally powerful act of willpower to ignore.

So Why Does It Matter?

As therapists, we often complain about the client who comes to sessions wanting to vent week after week. We get frustrated when we can’t redirect them.

In some cases, our frustration may reflect a missed opportunity to help clients identify and explore the means and function of their venting. Identifying and exploring creates the opportunity to discuss cognitive distortions, present (or reinforce) skills, practice mindful awareness and chain problem behaviors (or analyze missing links).  Researcher Jennifer Parlamis at the University of San Francisco says, “What is said in response to venting matters. Respondents should be aware of the attributions they use when responding to venting.”

Chain analysis can be an effective response. There are so many things to chain, starting with the venting but then moving on to each one of the relevant “…ing” words. In my experience, clients become mindful of their venting fairly quickly when it leads to identifying and analyzing its means and functions each week.

Redirecting the Venting

Of course, the challenge is how to interrupt the venting in a way that doesn’t invalidate, especially when the client has escalated to the point of nearly being out of his window of tolerance. Here are some ideas:

“I can see you are upset. You were calm when you came in.  Let’s figure out what just happened.” (Chain the venting)

“Sounds like you had a hard week. I’m noticing that the more you talk about it the more upset you’re getting.  Let’s figure out what’s going on.” (Chain the venting)

“I hear you but who are you really trying to convince – me or you?” (Chain the convincing)

“That situation caused you a lot of pain. I’m confused though.  How do you know that’s what she was thinking?” (Chain the mindreading)

“Sounds like a difficult situation. How do you think he would interpret what happened?” (Chain the interpreting)

“I can see you’re in pain. My mother used to say ‘it takes two to tango’ when my brothers and I would argue.  What if we come at this from a different direction?  How would an observer who didn’t know either of you describe what happened?” (Chain the blaming)

“You must have been scared to death. That’s incredible.  I can’t imagine.  Please tell me it wasn’t quite that bad.  (If you’re lucky, client acknowledges a slight exaggeration.)  So tell me, what made you feel like you needed to exaggerate?” (Chain the exaggerating)

Avoiding Implied Judgment

If I chain the venting itself several times the “…ing” words seem to come up naturally over time. Even then, it is tricky to avoid coming off as an implied judgment.  It seems to be more comfortable for both the client and me to do an informal verbal chain rather than putting it in writing.

How I define the problem behavior also helps avoid implied judgment. The list includes a lot of synonyms. Finding just the “right” word to describe the problem behavior is critical. Different words have different connotations and meaning differs from person to person.  The client whose mother repeatedly blamed her for everything isn’t going to take kindly to chaining blaming.  In this situation, the problem behavior might be described as “ignoring my role in the situation.” You have to know your client well.

Chaining the “…ing” words assumes you have a strong therapeutic relationship with the client. It is important that the client trusts you have her best interests at heart, that you are only raising these issues to help her avoid escalating herself unnecessarily.

 

Sandra Miller, MSW, LCSW and sometimes blogger, sees clients at St. Louis DBT, LLC.

What Makes BPD So Challenging?

There are an estimated 40,000 adults in the St. Louis metro area with BPD. Research suggests 40 percent received no treatment while 50 percent were treated only by their PCP in the last 12 months. Just nine percent were in therapy.

Battle lines are drawn in her head each side ready to attack the other at a moment’s notice. On one side, her inner critic waits not-so-patiently to judge. Her inner critic judges harshly when she ridicules her best friend or takes a stranger home from the bar, when she cuts or quits yet another job after a month.  To the inner critic in her head, the list to be judged is seemingly endless.

On the other side, her impatient teenage part argues “you can’t tell me what to do” or “I’ll show you” or “I want what I want when I want it.” But underneath the bravado, the rebellious teen cowers at the criticism, wondering what’s wrong with me.  “Why can’t I do anything right?” or “Why am I so stupid?” or “Why am I unlovable?”

All the while, the wounded inner child deep in her being hides, trying to avoid getting caught in the middle of yet another argument.   Frequently, she checks out, dissociating to keep out reminders of past pain. More than anything, she fears abandonment.

She is frequently out of her window of tolerance with wild swings between the hyper-aroused rebellious teenager and the hypo-aroused, sometimes dissociated, wounded inner child. Her inner critic keeps the cycle going.  She has borderline personality disorder (BPD).

A Different Lens on BPD

An article on the website HelpGuide.org describes life with BPD. She lives on “shifting sands – the ground beneath her feet constantly changing and throwing her off balance, leaving her scared and defensive.” This same article explains she “probably feels like she’s on a rollercoaster—and not just with her emotions or relationships, but her sense of who she is.” She is “extremely sensitive.” Her emotions feel like an “exposed nerve ending … small things trigger intense reactions.” Once upset, she has a hard time calming herself. The emotional volatility and inability to self-soothe lead to relationship problems and impulsive, reckless behavior. Shame and guilt follow.

Finding the Middle Path Leads to Measurable Results

She has a nascent wise mind that has the potential to begin the healing process but doesn’t yet have the awareness and skills to tolerate distress, regulate emotions or interact effectively with others. DBT offers the opportunity to learn and practice healing awareness and practical skills.  Research on treating borderline personality disorder with DBT has shown dropout rates improve, hospitalizations and emergency room visits decrease, suicidal and self-harming behaviors decrease, substance abuse and other addictive behaviors decrease and quality of life indexes improve.  While DBT is not effective for all clients with BPD, it helps most participants move closer to a life worth living.

Estimates of BPD Prevalence in the St Louis Area

NAMI reports the prevalence of BPD is between 1.6 and 5.9 percent. At six percent, that’s an estimated 129,000 adults in the St. Louis metropolitan area with BPD. At two percent, more than 40,000 adults in the metro area are likely living with the misery of BPD.

BPD Under-Treated

At the 1st International Congress on Borderline Personality Disorder in 2010 in Berlin, it was reported 40 percent of clients with BPD received no treatment while 50 percent were treated only by their primary care physician in the last 12 months. Just nine percent were in therapy. Less than one percent were hospitalized.

Assuming two percent prevalence in the St. Louis metropolitan area, an estimated 17,000 adults with BPD likely had no treatment in the last 12 months. Some 21,000 adults were treated only by their primary care physician.  Adults with BPD most likely to seek therapy had significant co-morbidities. BPD accounts for about one in ten outpatient therapy clients and one in five inpatient hospitalizations.

Diagnostic Criteria for BPD

While significant changes were proposed, DSM-5 left diagnostic criteria for BPD essentially unchanged from DSM-IV-TR. People with BPD exhibit four types of behavioral disturbances: (1) poorly regulated and excessive emotional responses; (2) harmful impulsive actions; (3) distorted perceptions and impaired reasoning; and (4) markedly disturbed relationships.  To diagnose BPD, there must be a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. frantic efforts to avoid real or imagined abandonment
  2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  3. identity disturbance: markedly and persistently unstable self image or sense of self
  4. impulsivity in at least two areas that are potentially self-damaging (e.g., excessive spending, substances of abuse, sex, reckless driving, binge eating).
  5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  6. affective instability due to a marked reactivity of mood (e.g. intense episodic state of unease or generalized dissatisfaction with life, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. chronic feelings of emptiness
  8. inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper tantrums, constant anger and reoccurring fights).
  9. transient, stress-related paranoid ideation or severe dissociative symptoms

A Challenging Diagnosis

BPD is difficult to diagnose. BPD symptoms overlap with other illnesses and high rates of co-occurring disorders create challenges for proper diagnosis and treatment. According to data from the NIMH-funded National Comorbidity Survey Replication, about 85 percent of people with BPD also meet the diagnostic criteria for another mental disorder, including:

  • 61 percent also have at least one anxiety disorder, most commonly a specific phobia, or social phobia
  • 49 percent have an impulse-control disorder, most commonly intermittent explosive disorder
  • 38 percent have a substance abuse or dependence disorder, most commonly alcohol abuse or dependence
  • 34 percent have a mood disorder, most commonly mild chronic depression or major depression.

Men Under-Diagnosed

About three-quarters of adults diagnosed with BPD currently are women. There is growing evidence that men are under-diagnosed, most frequently misdiagnosed with PTSD or major depression.  Recent research suggests male and female late teens are diagnosed with BPD in roughly the same proportions.  Research is needed to determine if adult prevalence of BPD in men and women is similar.

Risk Factors for BPD

According to a 2010 blog by the director of the National Institute of Mental Health, the causes of BPD are not yet clear but research suggests genetic, brain disturbances and environmental factors are likely involved.

Genetics. BPD is about five times more likely to occur if a person has a close family member (first-degree biological relative) with the disorder.

Environmental and Social Factors. Many people with BPD report experiencing traumatic life events, such as abuse or abandonment during childhood. Others may have been exposed to unstable relationships and hostile conflicts. However, some people with BPD do not have a history of trauma. And, many people with a history of traumatic life events do not have BPD.

Brain Factors. Studies show that people with BPD have structural and functional changes in the brain, especially in the areas that control impulses and emotional regulation. However, some people with similar changes in the brain do not have BPD. More research is needed to understand the relationship between brain structure and function and BPD.

BPD Can Be Treated Effectively

Myths about people with BPD make it less likely people with BPD will seek treatment. Perhaps, most harmful is the myth that BPD can’t be treated and that emotional dysregulation is a life sentence.  This simply is not true.  It is true that brief treatments do not work. Rather, long term treatments are needed to help people with BPD create a life worth living.  Developed in the 1970s by Marsha Linehan and colleagues, evidence-based DBT is generally considered the “gold-standard” of BPD treatments but other treatments can also be effective.

There are other debilitating myths about people with BPD: For example, their manipulation is mean-spirited; they self-harm and makes suicidal gestures to get attention; and they don’t want to get better. While it can be challenging for family, friends and professionals to deal with the mood swings and volatility of someone with BPD, the following assumptions underpinning DBT can make the challenge easier.  These assumptions also make treatment more likely to succeed.

DBT Assumptions Make Treatment More Likely to Be Effective

People with BPD are doing the best they can.  When family, friends and professionals validate people with BPD are doing the best they can, they feel heard and understood.  If the person with BPD still makes poor choices, then helping them make better choices involves coaching them through the chain of events to identify more effective ways to achieve their goals and generate natural consequences without further stigmatizing them.

People with BPD want to improve. Assuming people with BPD want to improve makes it more likely they will be motivated to improve.  When family, friends and professionals assume they don’t want to improve, they invalidate their efforts to improve, sending the message that nothing they do is good enough.  An important way to reinforce their desire to improve is to validate what they do effectively rather than focusing on what they fail to do.  Validation motivates.  Validation also provides evidence of others’ willingness to see things from their perspective, thus strengthening trust.

People with BPD need to do better, try harder and be more motivated to change. If people with BPD want to improve, then they want to become more effective over time, learning from their poor choices.  In this context, expecting people with BPD will learn from their poor choices and try harder, do better and be more motivated next time is only reasonable. That said, this is an area where it is important for others to follow the middle path, not pushing too hard or expecting too little.

People with BPD may not have caused all of their own problems, but they have to solve them anyway.  If the person with BPD was abused and abandoned as a child or there is a family history of BPD, it is understandable that they developed BPD. As an adult, however, the person with BPD is the only person who can solve his or her own problems.  Blaming the abuser or bad genes will not solve the problems even if it is unfair.

The lives of people with BPD are painful as they are currently being lived. Having BPD, often with serious co-morbidities, is not something anyone would choose.  When someone with BPD says they are miserable, they are not trying to manipulate you; they are in pain.  That’s not to say they can’t improve their situation with nurturance and guidance but change starts by addressing the pain that they are currently living.

People with BPD must learn new behaviors in all important situations in their lives. Without lifelong learning, humans stagnate.  To flourish, people with BPD must be encouraged to learn from every situation they encounter.

There is no absolute truth. There are at least two sides to every story.  When family, friends and professionals assume they are (always) right, there is no room for give and take in the relationship and no room for learning how to make good choices.

People with BPD and their families, friends and professionals should start with the assumption that most people are well-meaning rather than assuming the worst. It’s hard to have a productive discussion if you assume the worst about the person with BPD or they assume the worst about you.  Everyone will save themselves a lot of misery by assuming others are well meaning.

People with BPD cannot fail DBT. DBT is about being more or less effective, not right or wrong.  DBT doesn’t have any tests; it is a set of skills that require practice, practice, practice.  Even after practicing a lifetime, there will still be room for improvement.

Sandra Miller, MSW, LCSW and sometimes blogger, is one of four therapists who see clients at St. Louis DBT, LLC.  Learn more about St. Louis DBT

 

 

Tolerating Overwhelming Emotions

We see this confusion in our clients as well. Our clients (and some of us) confuse emotions with thoughts, rumination or even the facts of a situation.

In 1884, William James wrote an article, What is an Emotion? Scientists are still debating this question today.  As clinicians, however, most of us would describe an emotion as a natural instinctive state of mind triggered by circumstances, mood or relationships, or something similar.

Emotion is a relatively recent concept. The English word emotion derives from the 16th century French word émotion used to describe mental agitation. Before the word was introduced into the English language, people used words such as appetites, passions, affections or sentiments. Besides being a relatively recent concept, emotion is culturally-based and some languages do not have an equivalent word to this day.

We see this confusion in our clients as well. Our clients (and some of us) confuse emotions with thoughts, rumination or even the facts of a situation.  They say, “He made me angry” rather than seeing emotions as a natural instinctive state of mind.  They believe emotions are bad or a weakness.  They judge themselves for having emotions.  Saying someone is emotional is an epithet.

Continue reading “Tolerating Overwhelming Emotions”

Extending DBT To Couples

Why is it we sometimes say the nastiest things to the person we love the most? How is it that seemingly simple negotiations sometimes end up with partners screaming at each other?  How do we end up snapping and acting in ways we swore we would never do again? What makes people who love each other sometimes get really anxious when approaching each other, or leads us to avoid talking about important matters?  And more importantly, how can we learn to stop long-standing patterns of destructive conflict, develop the skills to manage our negative emotions and destructive urges, and learn how to talk and listen in ways that lead to understanding, validation, negotiation and closeness?

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Can’t “Fix” Teens Unless Parents Change Too

Parent’s inclination often is to seek help for their teen on the assumption that the teen has to do all the changing. The reality is both caregivers and teens will need to make changes …

Imagine — Tamara is 15 years old. She and her mother started arguing when Tamara was 12.  They argue about seemingly everything – clothes, curfews, chores, homework, friends – you name it and they’ve argued about it.  Their arguments have escalated over the last year.  Mom doesn’t trust Tamara to make good decisions, especially now that Tamara is dating a 16 year old who just got his driver’s license.  Tamara says her mother never listens and doesn’t trust her.  Tamara often storms out of the house when it gets too overwhelming.  Two times, she has stayed overnight with a girlfriend without calling.  Mom feels out of control and hopeless to change the situation. Mom decides to find help –- for Tamara.

Continue reading “Can’t “Fix” Teens Unless Parents Change Too”