Coping with Overwhelming Emotions

So it's been a while, but I'm back!  In my absence I have been working on my doodles and thinking about how best to create useful content.

This week I have been immensely frustrated by a courier returning a parcel I desperately needed to the sender after just one attempt to deliver.  Since my special interest is working with people who struggle to manage their emotions when such things happen, I decided to take inspiration from my anger and write a brief post about a Dialectical Behavior Therapy (DBT) skill which might help in such circumstances.

DBT aims to equip people with a range of skills to help them manage emotions and relationships.  This skill is a Distress Tolerance skill, and is therefore used to help survive potential crisis situations without making them worse or getting stuck on the injustice or painful feelings in a way that adds more suffering to the natural angst generated by the situation.

THE "STOP" SKILL

Marsha Linehan, the creator of DBT is rather fond of an acronym (even if they are sometimes a bit of  stretch).  In this case, STOP stands for Stop, Take a step back, Observe, and Proceed Mindfully.  Here's how.

Let's break it down a bit.

First up, we STOP.  Freeze.  Do not move a muscle.  When you are in a highly emotional state (e.g. furious!) you may be driven to act on your emotions.  It may be extremely difficult to think clearly, and as a result, the action you take may not be in your best interests.  Stop to enable yourself to regain control.

Next up, we Take a step back.  Take a break.  Step away from the situation and take deep breaths.  Try to let go of the thoughts and feelings and get yourself back towards that calm baseline as best you can.  Do not let your feelings make you behave impulsively; you may regret it later.

Now we Observe what is going on inside and outside of us.  What is the situation?  What are you thinking and feeling?  What are other people saying or doing?  What are the facts of the situation?

 

The final stage of this skill is to Proceed Mindfully.  Your job now is to act with awareness of the facts, your thoughts and feelings, and other people's thoughts, feelings, and actions.  Keep in mind what your goals are (longer-term).  Will the action you take get you closer to or further away from your goals?  If it will make things harder, is there a better option? 

It really is important at this point to remember that you may need to repeat these stages.  If you have taken a step back and the other person or situation has wound you back up immediately, start again from the beginning.  You cannot proceed mindfully until you are able to think again, and you cannot think when you are too distressed and in "survival" or "fight/flight/freeze" mode.

I hope this brief post has been helpful!

Thanks for reading =)

The Bear xXx

What is a Personality Disorder?

***Please be warned that some of this post might be triggering.***

This is Steve.

Steve has decided to seek help with his mental health.  He really struggles with some things everyone else seems to find easy and it's making his life really hard.  He often feels very distressed and people around him get hurt or angry.  Steve isn't really sure what's going on; he just feels like something is wrong, and has been wrong for most of his life.  He doesn't remember things ever being different but is desperate for them to change.

People often comment on the way Steve thinks about things.  They tell him he is getting it wrong.  He is really hard on himself, and seems to jump to extreme conclusions very quickly.  He often thinks people are doing things deliberately to upset him or the world is against him.  Steve experiences his emotions as loud and tidal.  His mood changes often and he isn't really sure why.  He quickly becomes overwhelmed and other people tell him he's being dramatic or seeking attention.  Sometimes he manages his distress by being impulsive; hurting himself, drinking a lot, gambling, or sleeping with someone he doesn't even fancy.

Steve really struggles to maintain relationships.  His family have washed their hands of him because they say he is "too much" and "too needy".  He gets into arguments with his friends and they don't ever seem to make up.  He lost his last job after he got into an argument with the manager.

When Steve just stops and tries to relax, he becomes aware of how empty he feels.  It's a horrible feeling and one he tries to avoid wherever possible.  

Steve often feels intensely distressed, and his difficulties upset, worry, and anger people around him.  His mental health and behaviour have a significant impact on his ability to function day-to-day and prevent him from achieving the things he would like to achieve in his life. 

Steve is showing symptoms of Personality Disorder.

What is a Personality Disorder?

A Personality Disorder is an enduring mental health problem, the onset of which is usually in at least early adulthood if not adolescence, and which is stable, pervasive, and present across a wide range of situations (DSM-5, American Psychiatric Association, 2013).  Symptoms include an enduring tendency to think and behave in a way which is markedly different than other people of the same culture and age group; intense, changeable, and sometimes inappropriate emotional responses; difficulties in relationships; and impulse control problems.  These symptoms cause distress and affect the person's ability to function.

"Personality Disorder" is an umbrella term covering ten types of Personality Disorder.  It is not unusual for people to have a mixed diagnosis, meeting criteria for more than one disorder, or presenting with bits of several but not meeting the full criteria for any one in particular.  Sometimes, people have some milder qualities of Personality Disorder, but function well for the most part.  In these situations they might be said to have some "traits" of Personality Disorder which they may wish to seek help for, but they will not be given a full diagnosis.

As with all mental health problems, Personality Disorders can vary in terms of severity.  At one end, people might have quite mild difficulties and function well with structure and supportive people around them, only ever coming to the attention of mental health services if something very stressful has happened; for example, the end of a long-term relationship, or redundancy.  At the other end of the spectrum, people with severe Personality Disorder might be very disabled by their problems and require a high level of support from mental health services as well as supported housing.

This diagnosis is not uncommon, with an estimated 1 in 20 people in England having a Personality Disorder.


Why do people develop Personality Disorders?

This is a good question, and as with any mental health problem, there is not a definitive answer.  However, our best theory at present is that there is an interplay between nature and nurture.

Think back to that earlier post about attachment.  Attachments are likely to play a major role in the development of Personality Disorder.  Adults with this diagnosis present with insecure attachment types.  For Borderline Personality Disorder, this is most often a disorganised attachment style.  (Here's a quick reminder of what that looks like in an infant.)




They really struggle in relationships with others, and those around them notice a push/pull phenomenon whereby the person wants to be close but then seems unable to tolerate it and pushes the other away.  The other person might respect this and give them space, but the person with Personality Disorder then feels abandoned, neglected, or rejected, and responds with anger and distress.  This pattern can be very difficult for others to manage, and difficult for the person with Personality Disorder to recognise and understand.  It is a major contributor to their difficult relationships and is most likely to have originated from a difficult early attachment which taught them that caregivers are unpredictable and sometimes harmful, scary, or unresponsive or neglectful.  Relationships activate the attachment system and the adult finds themselves playing out something very difficult from their early life.

We all have different temperaments when we are born.

Some babies sleep easily whilst others keep their parents awake all night.  Some babies are placid and content whilst others are anxious or grizzly.  It is likely that people who go on to develop Personality Disorders were more sensitive than the average bear to begin with.  They were attuned to the emotions of others and might feel sad or worried more quickly than their peers.  If life had been plain-sailing for them, they might have been the sort of adults who cried at films and preferred not to watch the news.  However, it wasn't all plain-sailing after that, unfortunately.  Somehow or another, their experiences got invalidated and they learned that their emotions were wrong, bad, attention-seeking, or harmful.  They learned that their needs would not be easily met, and this made the world a confusing, scary place, in which they experienced extreme distress and there seemed to be no resolution.

This invalidation could have happened in a number of ways.  On the less sinister end of it, it might have been that the child was just poorly matched with their parent/s in terms of temperament.  Whilst the child was sensitive and felt things deeply, mum was a "stiff upper lip" type and the sort to just shrug things off.  When presented with a child who cried easily she told them they couldn't possibly be as upset as they thought, because she couldn't conceive of this herself.  It was alien to her.  So every time her child became distressed by something she thought was ridiculous she assumed they were being dramatic or attention seeking, and told them so.  And she didn't respond to that need, because as far as she was concerned, it wasn't real.  She didn't mean any harm, but the child learned that their emotions weren't valid, and their need wouldn't be met.  They were left with not only the initial distress, but now the additional emotion/s arising from knowing they were in the wrong - perhaps shame, anger, hurt, or fear that the distress would last forever.

On the nastier end of the scale, a child's feelings and experiences might be intentionally invalidated.  In the case of child abuse, an abuser might tell the child they like something they do not, or that their distress is not real. Tragically, they might also be disbelieved when making disclosures about their experiences.

Somewhere in the middle of the two are parents whose own mental health or extreme social stressors limit their ability to be available to their children, resulting in emotional neglect, whether intentional or not.  People with Personality Disorders often report early experiences of abuse or neglect, or parents with mental health or substance use problems which were poorly managed.

If the parenting a child receives does not involve them being taught to label their emotions or learning how to manage them, e.g. by a parent noticing they are sad and comforting them, they will struggle to understand their own emotions or know how to manage them in later life.  Adults with Personality Disorder frequently feel like their emotions change without any real cause, have difficulty labelling their feelings, and feel unable to soothe themselves when distressed.

Keeping in mind the kinds of difficulties people with Personality Disorder have and just how understandable this is given their early experiences is helpful in ensuring a compassionate, thoughtful response to people whose behaviour and distress can be challenging and upsetting to those around them.

Check back for posts about specific Personality Disorders!

The Bear xXx

Core Childhood Needs (Part 2)

Whilst Part 1 of this post looked at the protective factors which might help keep a person well, Part 2 considers childhood risk factors, which may increase the likelihood of an individual developing mental health problems; be it in childhood or later in their lives.

Adverse Childhood Experiences

"Adverse childhood experiences" are those which may cause high levels of distress, disruption, or harm to a young person.  These may include:

- Physical, psychological, or sexual abuse.
- Physical or emotional neglect.
- Criminal behaviour in the household.
- Substance abuse.
- Parental domestic violence.
- Parental mental illness.
- Parental incarceration.
- Parental conflict, separation, or divorce.

Whilst many children may experience one of these at some point in their childhood, the effects appear to be cumulative, with worse outcomes for those who experience several of the above.  For example, one study found that the risk of suicide attempts, alcoholism, drug abuse, and depression in adults who had experienced four or more categories of adverse childhood experience were increased 4 to 12-fold. 

Similarly, an accumulation of less 'dramatic' risk factors in a child's life can have a severe impact on their development and well-being.

Let's look at some examples.


Isaiah

Isaiah's early life was happy and fairly uneventful.  He lived with his mum, dad, and older sister, Sasha.  They didn't have a lot of money, but they got by, and his parents spent a lot of time with their children, reading, playing games, and taking them to the park, the cinema, and museums.

But that all changed when Isaiah's mum got arrested and sent to prison.

Since then, his dad has been feeling very depressed and has struggled to motivate himself to even get out of bed.  Though he loves his children, he is caught up in what has happened and can't seem to find the energy to spend time with them.


Isaiah has not had anyone to read with him or help him do his homework.  No-one is doing jigsaws with him or ensuring he knows how to tie his laces.  Each day, Isaiah notices he is a little further behind his peers.  He's starting to feel very bad about himself as he suspects he must be stupid if he can't do what everyone else can.  And with no-one for him to tell about these feelings or anything else that is happening in his life, Isaiah's language and ability to express his needs are also being affected.  This emotional neglect is teaching Isaiah that him and his needs are not very important to anyone else.

With Mum in prison and Dad spending a lot of time in bed, Isaiah's sister Sasha has started to spend more and more time away from home.  She has made friends with a group of older teenagers and is staying out late drinking in the park with them sometimes.  Since no-one is reinforcing the rules at home, Sasha is no longer doing her homework, and her behaviour at school has become increasingly challenging.

In the absence of his parents, Isaiah looks to Sasha to be a role-model, and is learning from her what is acceptable and what is not.  Over time, Isaiah too might seek a sense of belonging and acceptance in a peer group, and is thus at higher risk of joining a gang.   His sense of himself as unimportant, and of others as being unavailable might increase his risk of developing mental health problems, and using unhealthy coping mechanisms such as substances or self-harm to manage these.  In this way, one major event in Isaiah's childhood may have a domino effect with long-term consequences for his future.

David

David is the son of a doctor and a lawyer.  His parents are both very successful, and very busy.  Their jobs are demanding and they work long hours.  The stress they experience often rolls over into their home life, and they frequently argue.  

With so much going on, David's parents need him to behave well.  Their parenting style is authoritarian and demands unquestioning obedience, whilst offering little warmth. As a result of following such regimented rules and regulations, David is timid and unsure of his own mind.  With little freedom to express himself or experiment, he rarely takes initiative, and feels anxious when he is expected to do things independently at school or with friends.

David's anxiety is also triggered by his parents' arguments. He fears being abandoned by one of his parents, or being forced to choose between them.  Sometimes David worries that he is responsible for his parents' arguments.

Although David has a lovely home and all the books he could ever need, his parents' stress and demands may place him at higher risk of developing mental health problems; particularly anxiety or eating disorders.


Jessie

Jessie's home life is very different from David's, though her mum is also very stressed.  Jessie is one of five children, and her mother Kerry is a single parent.  The absence of a second parent in the home means less 1:1 time with a parent for each child, with associated consequences for their adjustment, self-esteem, and conduct.

Overwhelmed by the competing demands of her children, Kerry struggles to set firm rules.  It isn't really clear to Jessie what is expected of her at any one time and since the rules are inconsistently reinforced she often refuses to do as she is told.

Jessie and Kerry frequently butt heads and argue for extended periods of time.  Eventually, Kerry gives in for the sake of some peace and quiet, and Jessie gets what she wanted.  Over time, Jessie has learned that the best way to get what she wants is through opposition and aggression.  If this pattern is not broken, Jessie's conduct problems may extend outside of the home, and she may find herself in trouble at school or even with the law.  Communicating her needs in such a hostile way might also make it difficult for Jessie to form and maintain healthy relationships, leaving her isolated.  


Ahmed

Whilst Jessie has very little 1:1 time with her mother, Ahmed has lots!  Complications at birth left Ahmed very unwell for a short period at the beginning of his life, and his mother has never forgotten her terror at the prospect of losing him.

Aisha is a doting mother who showers Ahmed with love.  Her parenting style is permissive, and whilst it is very warm, it is lacking in discipline.  As a result, Ahmed is used to getting what he wants, when he wants it, and lacks impulse control.  

Aisha is over-involved in Ahmed's life, and he rarely does anything independently.  Though he is a happy child who enjoys spending time with his family, being away from them for even short periods of time can be quite distressing for him, and he experiences acute separation anxiety, complaining of stomach aches and headaches.  His mother's constant fussing may also teach Ahmed he is vulnerable to harm and illness, and cause him to worry excessively about his own safety.

As Ahmed grows older he may be at increased risk of anxiety disorders, including health anxiety.  


Elaheh

Elaheh's family are refugees who only recently arrived in the UK.  Her parents witnessed atrocities in their home country, and her father has post-traumatic stress disorder (PTSD) which can make him respond in scary, unpredictable ways at times.

None of Elaheh's family speak English fluently, and as such, they are quite isolated.  With no social support in the UK they have no-one to ask for help when things are difficult. Elaheh's limited English is also tricky for her at school where she struggles to follow the lessons and is shy with her peers, with whom she would like to make friends.  Sometimes she feels quite lonely.

Whilst both of Elaheh's parents would like to work, neither have a job as yet.  As such, they are living in a very rundown area with high levels of social disadvantage and crime.  The violence in the local area is particularly scary for Elaheh who remembers dangerous things happening before she came to the UK.

The family's financial situation means Elaheh has no internet access at home, and very few books.  Whilst her mother is happy to take her to the library, Elaheh's opportunities to learn at home are limited as compared to her peers.

Sometimes Elaheh witnesses strangers being racist to her parents, and her parents being scared.  If this persists, she might begin to believe they are less acceptable than other people, or that other people are largely hostile and to be feared.  

Elaheh's early experience of atrocity and fear, her father's mental health problems, and a move to a new country where her family are isolated and socially disadvantaged may place her at increased risk of mental health problems.


Paul

As a small child, Paul was the victim of physical and psychological abuse.  He was removed from the family home and placed in residential care.  

Though the people who work at the care home are nice enough, there are a lot of staff members and they all work shifts. Sometimes, Paul starts to form a good relationship with a staff member or another child only for them to leave soon after.  He therefore struggles to form a secure attachment to anyone, and may present as aloof in interpersonal relationships.  

As a child who has been abused, Paul is at higher risk of developing depression, anxiety, eating disorder, or a personality disorder later in life.  His experience of others as dangerous may lead him to respond with either excessive fear or aggression, or to avoid difficult memories using substances.

Paul is likely to need specialist help to process what has happened to him and to help him develop healthy beliefs about the world, and ways of coping with it.


Summary

Whilst we cannot be sure what causes mental illness, there is significant evidence to suggest life experiences and environment play a part, with those who have had multiple adverse experiences at highest risk.  For those who experience difficult times but do not develop mental illness, there are likely a number of protective factors in play.


Next time we will begin to look at mental illness.

The Bear xXx