Category: Anxiety

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The Buddy Bench

“Play makes us nimble — neurobiologically, mentally, behaviorally — capable of adapting to a rapidly evolving world.”
~Hara Estroff Marano: A Nation of Wimps
     I’ve heard discussions about something called the Buddy Bench. These are benches for children to sit on when they don’t have any friends to play with. Sitting on this bench is a cue for other children to invite this child to play. There are probably some nuances to the Buddy Bench I’m missing, but this is the basic principle. For more information, please check out the Buddy Bench website. The vision around the Buddy Bench is fantastic. Growing up, I experienced severe bullying and exclusion. Inclusion and friendship are great goals and we should be intentionally providing ways to encourage these behaviors in children. We should also be teaching them to adults! However, I believe the Buddy Bench potentially does more harm than good. Existentially, there are a few reasons this is a bad idea, and I’d like to recommend some alternatives.
     In A Nation of Wimps, Marano claims that parental over-involvement serves to undermine children’s confidence by weakening their psychological resiliency. Maranos’ research based book illustrates the risk of removing reciprocity from relationship (Buber). I will suggest why the Buddy Bench may inadvertently subvert the very ideals it seeks to encourage. Then, I will suggest a more difficult and authentic response to encourage children, and adults, to engage in healthy social relationship.

The Problem

    The primary issue I have with this idea is that it puts the onus of relationship almost entirely on the “other”. It does so through passive, rather than active/assertive communication. Sitting on the bench is making a statement without making a request. This is passive-aggressive communication 101. For example: if someone comes to your house, is sitting down to dinner with everyone, and made the statement, “It sure is hot in here…”, it may be a natural response to turn on a fan, open a window, turn down the AC, apologize for the unseasonably warm weather, or simply agree with them! However, the person making that statement has avoided vulnerability by making a request. Instead of asking if they could turn the AC cooler and risk being told, “No” (a rejection), they can use manipulative statements in an attempt to elicit a behavioral response from someone else.
     The more adept someone is at reading body language, subtle context clues, and implications, the better they will be at accidentally enabling others to continue using passive-aggressive speech. This prevents people from creating actual trust in others, because there’s no vulnerability. Without risking rejection, there can be no trust because no one has had the opportunity to let you down or hurt you!
     You may be saying, “Hey, Nathan! You don’t think sitting on a Buddy Bench is an act of vulnerability? You’re crazy!” Well, you may not be wrong about that last part, but here’s the issue: Sitting on a Buddy Bench automatically shifts the responsibility of connection from self, to others. It is a clear signal of needing support or relationship, but it is a request without risk. Even when the bench works, it doesn’t work, because the child will not know if they have a relationship with another child out of social obligation or due to their own personality, choices, and skills.

The Alternative

     Bullying is not acceptable. Bullying is meaningless, destructive, hurtful, and unhelpful. Anything I suggest from here on out should, in no way, be construed to imply that bullying is useful or healthy. And, just because a child is struggling with friendships/relationship, does not necessarily mean they are being bullied. It’s important to look at the context within which the isolation is occurring. If it’s primarily one or two children, then it’s likely bullying. If the child has almost no friends and is conflict with most other children, then it’s likely the child themselves is the issue.
     The response should not be to request the rest of the world to change to accommodate a lack of social skills/social understanding in one child. If this was the expectation, then it would stand to reason that we should all change in order to acquiesce to the requests of bullies! There are societal expectations and norms. They are not always fair, but they exist. Children are particularly skilled at punishing undesirable social behaviors. There are healthy ways for children (and adults) to learn to adjust their behavior to be more acceptable.
     I am not suggesting we should “go with the crowd”. There should be a sense of self that modulates all interpersonal and intrapersonal behavioral choices. But it is difficult to establish a sense of self by externalizing the locus of control in relationship creation. The better alternative would be to teach social skills in schools. Provide training to educators and administrators about how they can foster resilience in children. Resilience does not come without a certain amount of stress and discomfort. Having faith that our children are capable of learning new and better ways to interact and express themselves is a more difficult and time consuming route, but it is far healthier than a buddy bench.


Buddy Bench
Buddy Bench
(C) Nathan D. Croy, 2016
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Hope.

Fear and hope are alike beneath it.
~Ralph Waldo Emerson
     Usually, the illustrations that accompany my posts are my own. I have written about this in the FAQ’s section, but to summarize; my drawings are awful. I know it, you know it. However, art was once a big part of my life. There were experiences and thoughts I would not have been able to express in another way without it. As I grew older, I lost touch of that part of myself. That artistic aspect, without so much of a yelp or whine, simply faded away without my awareness or intent.
     Then I read Rollo May’s The Courage to Create. This work was a challenge to reclaim a part of myself long abandoned. Every time I publish a post with one of my illustrations, it is a stretch. There is an element of shame and embarrassment with each one! And that is precisely the point of publishing them. 
     However, on this rare occasion, I’m off the hook. I recently had the privilege to dialogue with an incredible artist named Nicola Samori regarding his piece: L’Occhio Occidentale (The Occidental Eye). To me, it is a fascinating study in hope. A man, shrouded in shadow, reaching up and out with hard-worked hands, looks to the sky with a stone face; not fully formed. Or not yet carved. As one hand reaches out, another reaches in. There is fear. There is also hope.

     When working with clients and discussing hope, therapists must be sensitive to the reality that hope can be a burden. Sometimes, it is too heavy a burden. In those times, the healthy response of the therapist must be the placeholder for hope and then provide it in small doses to families and individuals as they come to us. We must always have hope.

     Hope is never fully formed. Like the man in shadow, it sits reaching out, and in, waiting to come to fruition. There is no certainty where hope exists. This is the dialectic tension which exists in the relationship between hope and certainty. Where there is certainty there is no need for hope. Where there is hope, there is also fear. If we hope for one outcome, in the same breath we are stating we are fearful the alternative may occur. But in this very tension there exists a positivity!

     Within every fear there is a positive hope. There is a distinct difference between a negative hope (“I hope something bad does NOT happen.”) and a positive hope (“I hope something good DOES happen!”). A negative hope does not instill peace. Instead, it encourages nearly non-stop avoidance. A negative hope does not facilitate calm, but creates anxiety. Positive hope is a meaningful goal or practical dream! Goals, when they are congruent with our values, can be a boon to any individual or family, when they are ready to create them.

Negative hope says, “I’ll never let that happen again”.

Positive hope says, “I’ll do better next time”.

     A special thank you to Nicola Samori for taking time to discuss his painting with me and providing permission to use it in this post. 

 L’Occhio Occidentale (The Occidental Eye), 2013, Oil on copper. by Nicola Samori
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Subtypes of BPD, Part II

“Your perspective on life comes from the cage you were held captive in.”
― Shannon L. Alder
Introduction
        The first post provided a brief overview of BPD by way of metaphor. Now, I would like to suggest an original way of viewing BPD from an existential viewpoint. This is not based on any research, but professional experience and observation over time.
Subtypes of BPD
    
      From professional experience and observation, there tend to be three types of BPD. BPD shares a similar pathology with diabetes: Type I, Type II, and Gestational. Not only does the pathology tend to match, the treatments are similar as well: Maintenance/Life changes, Life changes, and Monitoring; respectively.

Type I
     The first, and most severe, type of BPD is Type I. Many adults with BPD have a history of trauma and abuse. Often times, a history of trauma is evidenced as a previous or current diagnosis of PTSD, RAD, or Disinhibited Social Engagement Disorder (DSED). Nearly 75 percent of clients with BPD report sexual abuse or trauma (Aguirre, 2007, p. 104). This statistic can be somewhat misleading, as many BPD symptoms involve antisocial, impulsive, and risky behaviors. These behaviors can expose people to situations where sexual abuse/trauma is more likely to occur. In addition, research has shown that people with BPD are more susceptible to developing PTSD (Golier, 2003). Etiology research has identified multiple factors involved in the development of BPD, but early trauma is one of the most common factors for people with BPD (Bandelow, 2003). However, meta-analytic study suggests that anywhere from 20-40 percent of people diagnosed with BPD do not report a history of childhood sexual abuse (CSA) (Fossati, 1999).
     Similar to Type I Diabetes, Type I BPD manifests early in life, will impact multiple systems, and requires medical treatment in addition to lifestyle changes. Type I BPD would be present in the 80-60 percent of cases where CSA, trauma, or neglect are reported. These instances will most likely have multiple diagnoses of PTSD, RAD, or DSED along with BPD (Binks, 2006). The proclivity of comorbidity of Type I BPD can muddy treatment goals and overwhelm resources, providers, and family/social supports.
     It is estimated that 90 percent of people with BPD attempt suicide at a 10 percent completion rate (Aguirre, 2007, p. 201). The rate of death due to diabetes is also 10 percent (National Diabetes Statistics Report, 2014). An additional commonality between Type I BPD and Diabetes is neuropathy. With diabetes, weakness, numbness, and pain from nerve damage, usually in extremities occurs. The resulting numbness can prevent people from noticing when they have a wound or injury. These injuries can then fester, become infected, and result in amputations. An emotional and relational equivalent also occurs in people with Type I BPD. They have experienced an emotional numbness that, when not addressed, can exacerbate relational wounds or injuries which fester to the extent the relationship requires amputation. This does not mean relationship repair is impossible. However, there are times when damage sustained from someone with BPD is so severe, the other person in the relationship is unwilling or unable to risk additional harm.

Initial Treatment
     To summarize, Type I BPD is evident in people who have a history of trauma, complex/compound trauma, unhealthy attachments, self-harm, likely multiple acute psychiatric hospitalizations, and symptoms have been pervasive since adolescents. Type I BPD will require long term treatment due to inherent distrust, emotional lability, and difficulty with attachment/joining. Emotional neuropathy may require multiple specialists to address specific symptoms while an overarching therapy is maintained. This could include EMDR, DBT, CBT, or IOP.

Type II
     In a minority of BPD cases, clients will present with no identifiable history of trauma, CSA, or familial trauma. Parents and family will state the client was a happy child with little to no mood lability, relational stability, and no history of hospitalizations, suicide attempts, or self-harm. Like Type II Diabetes, Type II BPD occurs when natural attempts to identify meaning and meet existential needs are frustrated. This exacerbation of the natural existential vacuum results in what Frankl identified as noogenic neurosis (Crumbaugh, 1964).
     An existential vacuum, a term created by Viktor Frankl, is defined as an emptiness and lack of meaning in our lives. “Frankl suggests that one of the most conspicuous signs of existential vacuum in our society is boredom” (Boeree, 2006). If this is not filled in a meaningful way, people will tend to settle for anything. People with Type II BPD often want for very few things. They tend to be wealthy with access to various supports and seemingly unlimited resources. This strength becomes the weakness which predisposes individuals to this existential form of BPD.
     When people reach out for meaning, belonging, and purpose, but are provided with resources, directions, and expectations, they end up meeting their “wants” without meeting their “needs”. This results in an existential version of “rabbit starvation“. This phenomenon occurs when rabbit meat, which is very lean, is the primary food. There are too few fats to make the meat truly beneficial in these circumstances and, though the hunter may be full from consuming massive amounts of rabbit meat, they starve to death.
     In clients with Type II BPD, they may have been “fed” a steady diet of resources, medications, and treatment, but they have been devoid of genuine relationships and meaning. Suddenly, out of relational desperation, these clients begin to panic. They become hypersensitive to abandonment, react strongly to any form of critique, and symptoms escalate rapidly. The crucial component then, is lack of authenticity and genuineness in relationships accompanied with an awareness of what is lacking. Van Deurzen (2007, p. 45) identifies inauthentic living as “a sense of imposed duty or the experience of discontentment with one’s fate”. The symptoms are exacerbated by a lack of sense of self (Buber, 1996, p. 126).
 
Initial Treatment
     This form of BPD, in my experience, responds remarkably well to existential psychotherapy, EFT, and the humanistic/experiential aspects of DBT. Like Type II Diabetes, Type II BPD can go into remission with lifestyle changes. Clinicians working with this population must be very intentional to avoid exacerbating symptoms. Preparing the client for successfully handling the necessary anxiety this treatment will produce is critical. Basic coping skills, psychoeducation, and planned gradual exposure, built on a solid foundation of the therapeutic relationship, can provide the necessary safety for someone to overtly and intentionally experience authentic relationship. Prognosis in these cases is very positive and could be completed within 12-20 family and individual sessions. Any hospitalizations should be normalized as part of treatment seeking stabilization. This will help clients avoid feeling shameful about their attempts at growth.
 
Summary

     This information is important to help understand and delineate types of BPD in order to specifically target forms of treatment in order to increase positive prognosis. As with any other diagnosis, knowing severity is important to assist in setting expectations and arranging necessary supports. If providers view every BPD case the same way, they may provide too many, or too few, resources. More research needs to be done to help clinically identify forms of BPD. Gestational BPD, a suggestion on how new research can be done, and how it may impact treatment will be covered in part III.

Phi
(C) 2016, Nathan D. Croy

Sources
 


     Aguirre, B. A., M.D. (2007). Borderline Personality Disorder in Adolescents: A complete guide to understanding and coping when your adolescent has BPD (1st ed.). Beverly, MA: Fair Winds Press.

 
     Bandelow, B., Krause, J., Wedekind, D., Broocks, A., Hajak, G., & Rüther, E. (2005). Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls. Psychiatry Research, 134(2), 169-179. Retrieved from http://www.fafich.ufmg.br/cogvila/criancaadolescente/bandelow2005.pdf
 
     Binks, C., Fenton, M., Mccarthy, L., Lee, T., Adams, C. E., & Duggan, C. (2006). Psychological therapies for people with borderline personality disorder. Protocols Cochrane Database of Systematic Reviews. Retrieved from LINK.

     Boeree, C. G. (2006). Viktor Frankl. Retrieved February 10, 2016, from http://webspace.ship.edu/cgboer/frankl.html

     Buber, M., & Kaufmann, W. A. (1996). I and Thou: Martin Buber; a new translation with a prologue “I and You” and notes. New York, NY: Simon & Schuster.

     Crumbaugh, J. C., & Maholick, L. T. (1964). An experimental study in existentialism: The psychometric approach to Frankl’s concept of noogenic neurosis. Journal of Clinical Psychology, 20(2), 200-207. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.505.6866&rep=rep1&type=pdf

    van Deurzen, E. (2012). Existential counselling & psychotherapy in practice. London: SAGE.
 

     Fossati, A., Madeddu, F., & Maffei, C. (1999). Borderline personality disorder and childhood sexual abuse: a meta-analytic study. Journal of personality disorders, 13(3), 268.
 
     Golier, J. A., Yehuda, R., Bierer, L. M., Mitropoulou, V., New, A. S., Schmeidler, J., . . . Siever, L. J. (2003). The Relationship of Borderline Personality Disorder to Posttraumatic Stress Disorder and Traumatic Events. American Journal of Psychiatry AJP, 160(11), 2018-2024. Retrieved from http://ils.unc.edu/bmh/neoref/nrschizophrenia/jsp/review/tmp/482.pdf

     National Diabetes Statistics Report. (2014). Retrieved from http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

 

 

 

 
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Overt Assumptions

“What makes earth feel like hell is our expectation that it should feel like heaven.”
― Chuck Palahniuk, Damned
 
     For nearly 5 years, I grew up in Hendersonville, TN. Then, in my 4th grade year we moved to High Point, NC. Both states had many similarities. Food, family, and freedom were important to everyone. A few outsider, like ourselves, shared some insights into living in North Carolina: 1) “Yankees” are like hemorrhoids: If we come down and go back up, we’re alright. If we come down and stay down, we’re a real pain. And 2) Southern people are the nicest people you’ll never get to know. This isn’t to imply they’re inhospitable. Traditionally, and culturally, Southerners tend to have large and close-knit family systems. It can be difficult to get into the culture without a blood relative.
     Another slight difference was sports. When I lived in Tennessee, soccer was not even on the radar. If it was popular, I missed it. In North Carolina, it was unavoidable. Everyone played, watched, and lived soccer. Because the last 5 years had provided me very little exposure to soccer, I was not adequately prepared for this cultural shock. Still, I wanted to fit in, so I jumped in and tried to play whenever I could. I was awful.
     Part of my awfulness was due to the fact that I’m just not gifted in coordination. Some people are kinesthetically brilliant. I was kinesthetically blinded by that brilliance. To that, add a lack of general exposure to the sport. I never practiced the mechanics and fundamentals of the game. The physical act of kicking a soccer ball was a mystery to me! The ball may as well have been made out of cement. It didn’t seem to matter to anyone else that I was also completely unfamiliar with the rules of soccer! A game would be mid-half and suddenly, WHISTLE! Everyone, nearly in unison, would turn to look at me. Even the kids who didn’t know me looked! Took me three seasons to figure out what off-sides was.
     There had been a break down in communications. The other players began learning these things they were very young. The rules were taught alongside the mechanics. As they developed their mechanical skills through kinesthetic repetition, they strengthened their overall knowledge of the game. I missed these developmental milestones and was thrown into a game where nearly everyone knew all the rules; and they assumed I did, too.

     Blended (and blending) families often present to therapy seeking assistance in how to make two families into one. I’ve seen families adopt or foster children when they have had no children of their own. That’s one of the nice things about having kids: They (somewhat) ease you into the process of parenting. Slowly, they learn to roll, then crawl, then walk, then run like wild animals! It’s fine when we’ve been with them for literally every step of the way because our parenting skills have grown with them. Imagine having a 2 year old dropped off at your house if you’ve never had children before! What’s normal? Are their noses supposed to make so much snot? Do they really have no volume control? Do they really have no sense of privacy when I’m going to the bathroom?
     Sudden baptisms into parenting are incredibly difficult. A healthy response is to cut ourselves some slack and realize we’re going to be playing catch-up for a little while. But what happens when there are sudden shifts in family functioning? Isn’t that what therapy is supposed to provide? New insights, awareness, and skills which a family will implement and change their pattern of relating.
     Sometimes, therapists can make the mistake of assuming the family understands the rules of relationship. Instead, we need to make the new rules (and they ARE new) overt. This can be done through verbal or written contracts, reflecting current changes in the process, modeling/coaching, and even through paradoxical injunctions. Regardless of the means, we have to take time and make the assumptions clear. This way, we prepare the family for change and mistakes, accidents, and regression becomes part of the learning process instead of demoralizing failures. Communicating this can relieve a great deal of anxiety associated with change and encourage open discussion among struggling families.
     Have any suggestions on how your therapy or therapist has helped people adjust to change? Leave a comment below!

Fragile Soccer
Nathan D. Croy, (c) 2015
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Traps and Trauma

     The difference between children who have experienced trauma vs children who have not is the difference between a well-fed dog and a dog caught in a trap. Being bitten by a dog stuck in a trap will be interpreted differently than the same action by the well-fed dog. The pain and fear of the person bit may remain the same in each case, but the reason behind the bite is very different. The knowledge of this difference could lead us to quickly forgive the trapped animal while punishing the well-fed animal. Same behavior, same outcomes, different levels of acceptance.

     The reason it is more acceptable for the trapped dog to bite is because we expect it. We know they are acting out of fear and self-preservation. The rescuer may even fault themselves for not taking extra precautions when approaching a wounded animal. We do not fault the animal because we see the trauma. Some animals may need extra care and services before they are rehabilitated enough to join a family and be adopted. Some dogs that have been trapped are euthanized and deemed impossible to rehabilitate. Most often it could be possible, but the expense, time, and resources estimated to bring that change about are seen as too great in a cost-benefit analysis.

     Unfortunately, even dogs that are well-fed and well cared for can still bite and are often “put down” for reasons citing temperament. As if “temperament” were an unchangeable aspect of the animal existing in isolation from the environment. This is not including elderly dogs who may be suffering from dementia. While there may be some truth to this, most healthy dogs can relearn how to behave appropriately in a family/pack unit.

     So it is with children who have experienced trauma. The scars are not always as visible as they are with dogs. Children can arrive at school or daycare, interact with children every day, and be caught in an invisible trap they have brought with them from their home. It is not clear we should approach them with caution or additional supports. Good intentions are greeted with snarls and threats. Well-meaning people are driven away, confident their loving actions will not be “wasted” on an ungrateful child.

     All the while, the traumatized child and the trapped dog know two things: 1) Someone more powerful than myself has done this to me, and 2) only someone more powerful than myself can help save me. Therein lies the fear that drives the bite. These victims have learned they cannot trust those who are more powerful than they are, yet they know they are dependent on them for safety. It is a dichotomy of terror with no hope. Realizing this, the dog chews off his paw and risks bleeding to death. Coming to a similar realization, the child cuts off their emotions (reactive attachment disorder, oppositional defiant disorder, conduct disorder, antisocial personality disorder, etc), their connection with reality (schizotypal personality disorder, schizophrenia, etc), both their emotions and reality (Bipolar disorder, schizoaffective disorder, PTSD, etc), or their own self (borderline personality disorder, dissociative identity disorder, etc). Ultimately, they may even choose to end their own life as a means of escaping what they perceive to be a world full of traps and void of help.

     There have been instances where people like this have been “put down”. It happens under the guise of justice and death penalties. It happens through social isolation and institutionalization. It happens socially and economically and religiously. Through these processes, humanity is enacting the age-old rite of self-preservation on a social level. “We” are protecting “Us” from “Them” because “They” are threatening. It makes complete sense and, evolutionarily, protects us from threats. However, too often we are in a rush to protect, to diagnose, to define, and to dispense. The onslaught of managed care has taught us to ignore the traumatic traps and treat the paw, the specific injury, and discharge the patient in under seven sessions.

     In the process of being so quick to protect ourselves from the threat, we have become the very thing we thought we were protecting ourselves from: Isolated. Isolation is a social tool of punishment designed to either alter behavior so “they” becomes more like “us” (a part of our pack), or else relegate “they” to alienation and almost certain death. This ensures homogeneity and easy identification of who “we” are. The United States claim not to be savage, to be moral, to be respectable. Yet, if we are judged by how we treat our sick, our young, and our old, we are incredibly cruel, immoral, and lack any modicum of respect. If the sick could heal themselves, we would not need doctors. If the traumatized could free themselves, we would not need therapists. If the elderly were cared for by family, they would not need retirement homes.

     This is not strictly about government policies, universal healthcare, or insurance companies. This is about a society becoming so consumed with living a safe life they have failed to live a life. Convenience, ease of use, and customer satisfaction has replaced effort, attentiveness, and prudence. Somewhere along the line, acquisition of material goods and resources became synonymous with safety and wellness.

     So we abandon the dog that threatens us. We forget the child that scares us. We ignore the parent that cannot remember us. We waste our lives on things, and are surprised when things dominate our lives. To quote Kierkegaard in The Sickness Unto Death:

     “What we call worldliness simply consists of such people who, if one may so express it, pawn themselves to the world… The greatest hazard of all, losing one’s self, can occur very quietly in the world, as if it were nothing at all. No other loss can occur so quietly; any other loss – an arm, a leg, five dollars, a wife, etc. – is sure to be noticed.”

     And this is just what has happened. We have become worldly at the expense of our own selves, at the expense of those smaller, weaker, poorer, or sicker than ourselves. This has happened without a sound, with no notice, and it silently continues on, perpetuated by greed, fear, and the unending pursuit of safety. Let me assure you of one thing: a safe life is no life at all. There will be traps and traumas for all of us. Each of us will require the aid of another who is greater than ourselves to free us from these traps through relationship with patience founded on deep love. Just as each of us will encounter a trap, each of us will encounter another in their own trap. Will we risk being bitten?

(C) Nathan D. Croy
Trap