Post Dramatic Stress Disorder

748Today I counseled an inmate who was upset because he had been diagnosed with what he called Post Dramatic Stress Disorder (PDSD). What he meant and I quickly corrected him, was Post Traumatic Stress Disorder.

Initially my colleagues and I had a good laugh at the fact that he mistakenly called Post Traumatic Stress Disorder, Post Dramatic Stress Disorder, but then I thought about it. Can exposure to too much drama create a milder form of stress that can have a negative effect on an individual’s life?

Every day most of us are exposed to some type of drama, either in our personal lives or through the media where we are bombarded with images of war, devastation and danger just from watching the  news. We are faced with even more murder, betrayals and violence from the television shows, books and magazine articles we consume.

Most of us don’t give a second thought to these images that slip into our brains, but for some of us, prolonged exposure to drama can create anxiety, difficulty sleeping, a sense of helplessness and agitation.

Think about it. How many times have you watched or read something that was provocative, suspenseful or violent and then found yourself dreaming about it that night, perhaps even having a nightmare that the dramatic even was happening to you?  Many of us will push this aside as we wake up and get back to our realities, but for a few, they will remain hyper vigilant and uneasy for days.

My oldest sister had to stop watching one of her favorite movies because it would cause her to go back to work the next day angry. Why? The dramatic events in the movie didn’t happen to her, yet they affected her on multiple levels triggering an agitated response.

What’s the solution? Certainly I am not advocating boycotting television or books filled with drama, but instead to take a break from it every now and then. Go for a walk, take up yoga, spend time with someone you love, try to avoid real life drama, do anything relaxing that can help bring you centered. Also, try to pay attention to how dramatic events affect you, which ones and how. Most of us are much more affected by the dramatic events in our real lives than in the media, but maybe watching a suspenseful movie before bed isn’t the best idea if they generally give you nightmares and poor sleep quality.

What started off this morning as a good laugh (with the seriousness we deal with every day we are always looking for a good laugh), a real topic was brought up. Post Dramatic Stress Disorder may not be a real disorder, but the effects of being dramatized are. The less drama (real or fictional) we have in our lives, the healthier we will be both mentally and physically.

Too Scared To Talk: Children with Selective Mutism

142005745The other day I was speaking to a mother who was describing her son’s symptoms to me. She reported that he had difficultly and sometimes just couldn’t speak at all in various social situations, especially at school and around strangers. He had been tested for Autism and that was ruled out. She was very frustrated with her son, but also felt bad for him because she could tell that he was also in distress. She just couldn’t understand why her son would suddenly become mute in social situations when he was such a funny, outgoing and talkative kid at home.

After listening some more, I realized that her son did not have an autistic spectrum disorder as she still believed, but that he had what is called Selective Mutism.

Selective Mutism is the inability to speak and communicate in social settings, but the ability to speak in settings where the child feels comfortable, relaxed and secure.  Many parents think their child has absolute control over this, hence their frustration, but Selective Mutism is an anxiety related disorder .

90% of children with Selective Mutism also have social anxiety or social phobia. While many parents initially think their child is faking or playing games, Selective Mutism is very painful and debilitating to the child.

Children with Selective Mutism have a real, paralyzing fear about speaking and therefore this totally impairs their ability to develop social relationships or to participate in social situations.

Not every child expresses Selective Mutism in the same way. While some children are totally mute in social situations, others can only manage to whisper while some will remain perfectlu still, seemingly unable to speak or move, while less severe children can manage to speak totally normal to a select few individuals in social situations.  This type of anxiety goes well beyond the normal range of shyness seen in other children.

A very select few children with Selective Mutism don’t appear to be shy at all. They actually do a very good job trying to mime their way through social situations.  In these children, Selective Mutism may be a symptom of something else, such as the child initially being mute and never grasping communication and are basically stuck in the nonverbal stage of communication.

Why Does A Child Develop Selective Mutism?

Most children who have Selective Mutism have a genetic predisposition to anxiety. This means that it is inherited. Almost from infancy on, these children may show severe separation anxiety, moodiness, frequent tantrums, inflexibility, show extreme shyness and have sleep problems.

Some children with Selective Mutism may have Sensory Processing Disorder (DSI), which basically means they may be sensitive to sounds and lights, and that they may perceive environmental and social cues differently than most people. They become easily frustrated, angry, confused, withdrawn or act out because the signals they are receiving from their brain are alerting them to danger and fear causing them to have anxiety.

Up to 30% of children with Selective Mutism also have a speech, language, processing or learning disorder which can increase their anxiety and inability to communicate effectively in social situations.

There is no evidence that abuse or trauma causes Selective Mutism, which is different from Traumatic Mutism.

In Selective Mutism the child can usually speak normally at least in situations where they are comfortable. In Traumatic Mustism, a child witnesses or experiences a tragedy so devastating that they can’t comprehend it, they stop speaking altogether in every situation suddenly.

Selective Mutism can progress to the point where the child stops speaking and becomes totally mute, but that is usually gradual and when negative reinforcements cause the child to slowly start limiting the places and people he/she feels comfortable talking to.

Diagnosing Selective Mustism

Most children are diagnosed with Selective Mutism between the ages of 3 and 8. Most of these children have already exhibited severe symptoms of anxiety. If a child stops speaking for more than a month than the parents need to take the child to a doctor.

Here is the diagnostic criteria for diagnosing Selective Mutism. Note that this criteria shouldn’t be the only criteria used to diagnose or rule out Selective Mutism since each child and case is different:

DSM-IV-TR (2000):
1. Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.
2. The disturbance interferes with educational or occupational achievement or with social communication.
3. The duration of the disturbance is at least 1 month (not limited to the first month of school).
4. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
5. The disturbance is not better accounted for by a Communication Disorder (e.g., stuttering) and does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.
Associated features of Selective Mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home. There may be severe impairment in social and school functioning. Teasing or goading by peers is common. Although children with this disorder generally have normal language skills, there may occasionally be an associated Communication Disorder (e.g., Phonological Disorder, Expressive Language Disorder, or Mixed Receptive- Expressive Language Disorder) or a general medical condition that causes abnormalities of articulation. Mental Retardation, hospitalization or extreme psychosocial stressors may be associated with the disorder. In addition, in clinical settings children with Selective Mutism are almost always given an additional diagnosis of Anxiety Disorder, especially Social Phobia is common.

Many parents, teachers and even professionals do not understand Selective Mutism because research is so limited. Many think the child is being defiant, controlling, that they are just shy and will grow out of it, or that they have some other disability such as autism.

Children with Selective Mutism tend to want friends, they are just too anxious to develop friendships easily while children with autism tend to not care to have any friends at all.

When considering seeking treatment for a child with Selective Mutism, parents should be careful not to find a professional who believes that Selective Mutism is behavioral and about the child being defiant or controlling. These type of professionals tend to try to use punishment and forcing the child to speak as treatment, which consequently increases the anxiety of the child and worsens the condition.

Good professionals who understand Selective Mutism will focus on making the child feel comfortable, decreasing anxiety and helping the child learn coping skills to deal with anxious feelings. This is often done with a combination of therapy and medication and as a collaborative approach with the professional, parents and the school.

Dealing with a child with Selective Mutism can be frustrating, but understanding what Selective Mutism is and is not helps decrease the frustration.

For more information and help, go to http://www.childmind.org

Working Around Your Abyss

SONY DSCI’m always amazed at the lengths some people will go through to hide their pain. All of us have pain, disappointments, regrets, wounds, and parts of us we wish we could hide forever, but many times those very issues are the things we need to address in order to move on and live truly fulfilled and happy lives.

The other night I was watching Beyond Scared Straight on A&E and there was a kid on there whose father committed suicide when he was younger and it looked like the kid had never really talked to anyone about it or dealt with it in any sort of healthy way. Instead he turned to drugs, violence and other petty criminal behaviors as a way of acting out and dealing with what I believe must be anger towards his dad coupled with immense depression.

Most people would look at this kid and see a juvenile delinquent, but all I saw was a kid crying out for someone to see past the walls he had erected around his pain and help him navigate his way around it.

This young kid wasn’t unlike many of the high school kids I dealt with that teachers thought were just bad apples, but they were really acting out because of the pain they were holding on to, such as coming from poverty stricken, sometimes violent and unstable broken homes. Especially the boys who would hold on to their pain so tight, not wanting to show any weaknesses, and yet the pain was literally destroying them by causing them to constantly get in their own way by fighting, failing out of school or getting involved in illegal activities that were sure to lead to incarceration.

We all have stuff. We all have issues. That is something I say all the time when people open up to me, no matter if they are clients or friends. I always encourage talking about those pains because I believe that talking about them, even just a little bit, helps ease some of the tension, stigma, shame, and fear people attach to their pain.

While some people try drastic measures to consciously or unconsciously hide from, ignore, deny or cover up their pain (sex, drugs, alcohol, cutting, eating disorders, continued bad relationships, etc.), some people are so absorbed in their pain that can’t even enjoy moments of happiness when they happen. They can’t see anything except for their pain. They live in constant depression, anxiety, suspicion, and pessimism.

It may be something that happened a long time ago, yet they are never living in the moment, they are constantly living in the past and their pain. They are constantly unconsciously telling themselves stories which for the most part are untrue. Stories about themselves, their pain and their lives. Stories that hold them hostage to turmoil and they will hold on to those stories with a death grip even in the face of evidence that their stories are at least partially untrue.

The stories we tell ourselves include things such as, “My dad left because I was a bad kid”, or “My husband cheated because I wasn’t enough for him” and “I fail at everything I try”. The list goes on and on, but you can imagine how someone who is telling themselves these stories will live their lives in the present and future if they continue to believe these stories about themselves.

They will hold on to those stories, sometimes because it is the only story that they know and it’s much easier to believe in the story that you know than to try to create a better story where there may be unexpected surprises even if some of the surprises include very pleasant ones.

One of my favorite books is entitled The Inner Voice of Love: A Journey Through Anguish To Freedom by Henri Nouwen. It was given to me as a gift several years ago and I have since given it away, brought it again and given it away again no less than eight times.

The first passage in that book is called Work Around Your Abyss and it says:

There is a deep hole in your being, like an abyss. You
will never succeed in filling that hole, because your
needs are inexhaustible. You have to work around it
so that gradually the abyss closes.
Since the hole is so enormous and your anguish
so deep, you will always be tempted to flee from it.
There are two extremes to avoid: being completely
absorbed in your pain and being distracted by so
many things that you stay far away from the wound
you want to heal.

When I first read that passage about six years ago, I almost cried because I felt like it was talking directly to me. I was holding on to a lot of pain and not doing anything about it. Pain about my fathers death, pain about our relationship, pain about the romantic relationship I was in and fear of not being completely loved and fear of failure.

Holding on to and not addressing those pains was leading to anxiety, depression, low self-esteem and agitation. It was until I read this passage that I started to address and work around my abyss which slowly, but surely started to close and this passage is probably the #1 reason I have shared this book so many times with people who have shared some of their pain with me.

All of us have issues, or what I like to call “stuff”, but it doesn’t have to define us and we don’t have to wear it like a scarlet letter nor pretend like it’s not there. We define ourselves and our situations, our situations do not define us. Let’s all make a commitment to start working around our abyss so that we can start living fully and completely, the way we were all meant to live.

Change And Inertia: Embarking On A New Adventure

6a00d8341d537753ef00e55133a7c08833-800wiI hate change, which I know is probably strange for me to say because during my therapy sessions I do a lot of what is called change talk, which is talking about and encouraging change. I generally consider myself to be an agent of change as I guide my clients through the stages of change, but I myself have always had issues with change. I don’t like it.

Some people love change and I always admire those people. They love new adventures, they adapt quickly, and never seem to get stuck in a rut or dead end job. They seem to just be wired differently and indeed, the ease to which people accept or don’t accept change is a personality trait known as the Openness trait and some people are naturally more open than others to change.

My fear of change over the years has cost me a lot. It has kept me at jobs I should have moved on from for far too long and in relationships I should have left for far too long. It has also kept me from experiencing many pleasures and probably some pains and failures, otherwise known as learning experiences and opportunities to grow.

I, like a lot of people, like being comfortable, playing it safe, even when that inertia isn’t all that great and sometimes downright unpleasant. There’s a popular quote by a late, great female therapist, I couldn’t find it or her name, but it basically says that we prefer the familiar negative to the potential unfamiliar positive, except of course she said it more beautifully.

And this tends to be true, at least for me and the majority of my clients who struggle to make changes in their thinking and interpersonal lives because they are afraid of what the new change will bring, good or bad, but they know exactly what the old thinking and behavior will continue to bring them, both good and bad. This is one of many reasons people resist change.

This is why I think I was so successful at helping people make changes they found difficult to make, because I understood their ambivalence towards change, their desire to both want to change and not want to change at the same time because I’ve experienced it so many times myself, even in ways that bordered being neurotic.

It’s easier to stay the same. Inertia is much easier than movement, especially when that movement has to be sustained, yet inertia robs us of so many experiences, opportunity and growth. A fellow therapist recently old me that if you are comfortable, then you are not growing. You should always be challenging yourself.

It’s that comfort zone I try to push my clients out of because sometimes you have to become a little uncomfortable to truly grow and realize your full potential and the same applies to me.

Some of you who follow my blog may know that the grant that pays for me to serve the students at the inner-city school I work at is coming to an end this Friday. The school has been working really hard to find funding to keep me and they may be close to working something out, but I couldn’t count on that to come through so reluctantly I started looking for another job.

Well an opportunity came up for me to apply for a job as a supervisor at the mental hospital I used to work at fresh out of grad school as a supervisor over the crisis unit I used to work at. I loved working in the mental hospital, I enjoyed dealing with people in various stages of a crisis from emotional and mental break downs to substance withdrawals.

This opportunity would force me to grow, push me out of my comfort zone, pay better and definitely be an upward climb in my professional career, so I applied for the job and got the news Friday that I got it. I should be excited right? But remember, I don’t like change and I do love working at the inner-city school I currently work at even though I potentially won’t be there next school year anyway because of funding.

image
One of my first students and myself.

I love working with the teenagers I work with, helping mold young lives and by taking this job at the mental hospital, I would miss that although in my private practice I would still see a very small number of teenagers. Although I would be taking a pay cut to stay at the school, potentially not have a job this year or next year AND still be stagnant career wise, I seriously thought about turning down the supervisor job to stay where I was comfortable, in a place that would require no effort (inertia) although I know I would love doing my job (compared to the unknown level of satisfaction of a new job).

I’ve had similar opportunities twice in the past two years to make more money and move up professionally and both times I turned it down to stay comfortable. Of course I said I did it because the kids need me, and while I felt like that was true, I also know that a large reason I stayed was fear of change.

Now however, I am pushing myself into change just as I talk to my clients about pushing themselves out of their comfort zones.

It’s with a heavy heart that I took this new job, something I should be extremely happy I got because the chances seemed so slim when I first applied and went through two interviews. After all, I have no real supervisor experience, but I have experience working in a crisis unit and my love and dedication to the mental health field and those who suffer from mental illness is unparalleled.

And it’s with a heavier heart that I have to tell the school tomorrow that I will not be returning for another school year. It’s a tough decision and one I made ultimately not out of where the money was, or where I felt most comfortable, but where I needed to be for both professional and personal growth.

I am pretty sure it won’t feel as rewarding and life changing as working with the high school students I work with, but I think it will allow me to serve people in another way while learning more about myself and the mental health system altogether.

My passion will always be teens and adolescences, and I’ll continue to write a lot about issues that effect that population, but I am sure that naturally I’ll write more and more about issues and situations I encounter working in the mental hospital.

So while I am still anxious and uncomfortable  I’m pushing myself towards this change, trying to welcome it and all of the new possibilities that come along with change. After all, how can I promote change in others if I am unwilling to go through the uncomfortableness of change myself?

Making Peace With The Worst Case Scenario

istock-peaceFear is a powerful emotion that keeps many of us from living life fully. It holds many of us hostage, too afraid to leave relationships, to start new careers or simply to try something new. Many people stay stagnant in life because they are afraid that if they reach for something different than what what they have, and fail, then they will lose more than they already have.

Maybe you are in a relationship that is emotionally abusive and you want to leave, but are afraid that by leaving you will be lonely and alone forever, so instead you stay in this relationship that is killing you emotionally.

That fear of what may happen can be so real and intense, that it keeps you from ever reaching out and seeking something that could be much more fulfilling and fruitful.

Because fear can rob us of precious time and experiences, it’s important that we learn how to control it the best we can and one way of doing that is by making peace with the worst case scenario. By making peace with the worst case scenario, it’s possible to take much of the fear out of fear itself.

Going back to our example, let’s say that the worst case scenario is being alone. When you make peace with the worst case scenario, you take some of the bite out of that fear. So what if you are alone forever, that will give you plenty of time do whatever you want to do, to get to know who you are without the complexities of another person molding you into the person they want you to be. It gives you plenty of time to become a self-actualized person, to give back to the community, the world, to become a philanthropist, a leader, or whatever you want to be because you don’t have to answer to anyone. And, when given the opportunity, loneliness can give way to solitude (please see my post Loneliness versus Solitude for more information).

The thing is, the likelihood of never dating again after the break up is extremely low and most of the time, our fears are largely irrational or over exaggerated .

How many times have you feared something, and once you actually experienced that fearful thing, it wasn’t as bad as you thought it would be and you felt much better afterwards? Maybe you grew from the experienced in one way or the other. Making peace with the worst case scenario can help us realize that without having to go through the actual fearful situation.

On top of that, making peace with the worse case scenario can help bring clarity to a situation.

Just today I got an email from a student during the final minutes of school saying she was having dreams about killing herself and hasn’t been able to sleep. She ended her email “Please Help”. Immediately I responded to her email asking her where was she, and for her to come see me. I immediately contacted the class she was supposed to be in only to find out she hadn’t made it to class and had possibly left campus. It was the end of the school day and I wasn’t sure what else to do. This student has a history of suicide attempts and while she didn’t explicitly say she was thinking about killing herself in the email, the worst case scenario would be that she ended up committing suicide.

Looking at the worst case scenario in this way forces clarity. It made me ask myself, if that tragedy were to happen, can I say that I have done everything I was supposed to do in order to save this student. Did I do due diligence? Did I do the best I could to locate that student and make sure she was safe despite the fact classes were now over? Would I at least have some comfort in saying that I did everything I could have possibly done to save this child?

While processing this case with a coworker, I realized I hadn’t done all I could have done in the worst case scenario. I immediately went back and tried to contact both of her parents to no avail, then I called the sheriffs office and asked them to do a well-being check on her at home. It was only then that I felt I had done everything I could have reasonably have done, in the worst case scenario.

When you look at it this way, when you make peace with the worst case scenario, it is more likely that you have done everything in your power to prevent it, so that if it does come to pass, you can at least have solace in knowing that.

Fear doesn’t have to hold us hostage, it can actually free us if we learn how to embrace it and make it work for us, not against us.

Why Do We Like To Be Scared?

Today is Halloween and millions of people will spend millions of dollars to go to professional haunted houses where they hope to be “scared to death”.

Each year, millions of dollars are spent on Halloween, making it fall just below Christmas as the time of year Americans spend the most money, but why do we like to be scared so much that we’ll pay for it?

There are many different theories on why we like to be scared, but I tend to agree with the theory based on evolutionary psychology.

We all have inherited from our primal ancestors what’s called basic “fight or flight” instincts. When we are faced with a potential deadly situation, we instinctively either prepare to fight for our lives or to run for our lives.

Our ancestors needed this instinct to survive the plethora of dangers they faced on a daily basis, from wild animals to other clans/tribes invading their homes, killing, raping and enslaving them.

Today, most of us don’t live the type of lifestyle that requires daily use of our flight or fight instincts, yet they are still there, in our primal brain and they often need to be massaged.

During the time of flight or fight, our attention becomes more focused, our heart rate increases, breathing quickens, muscle tighten, all in preparation to defend ourselves from or to run away from a threat.

It is stressful, but this same rush of adrenaline, can be experienced when the brain knows there is no real threat and in turn, the brain translates this experience as enjoyable.

Most of us feel the need to scratch the itch of fight or flight our ancestors hard wired into us, yet for most of us, each day is relatively safe and mundane. That’s why many people say that being scared makes them feel alive?

While there are some people that enjoy actually putting themselves in real danger, most people enjoy being scared in relatively safe environments, where everything is in control, but they can still experience a sense that things are out of control, which is what is desired.

So much of what happens in our day to day life is controlled, that every now and then, most people instinctively want to feel a sense that things are out of control and that’s why many people spend money each year not only on haunted houses and scary movies, but on things such as roller coasters.

Halloween, All Hallow’s Eve, gives us a chance to confront and think about our fear of death. The same goes for most things we enjoy scaring ourselves with. We like to approach the edge of death without falling in, and then step back away from it.

One thing that makes humans different from all other animals is that we are aware of our existence and the fact that one day we will stop existing.

Being scared reminds us that we are vulnerable and that life is unpredictable and can change at any moment for the worst. It gives us a rush of adrenaline and makes us feel alive. It allows us to stop taking life for granted and appreciate that we are alive.

The Relationship Between Anger, Control and Fear

A lot of times when I am working with people with anger problems, I realize that two of the main sources of their anger come from either the need to control other people and fear.

Anger and fear are part of our natural flight or flight responses. The problem is, we are genetically geared to survive real threats that our ancestors who had to deal with threats to their lives on a daily basis were designed for. Today we don’t have to constantly worry about getting attacked by a leopard or the tribe across the river attacking us, and so our mind often generates fear and anger even when it is unnecessary or the threat is just imagined.

Anger in it’s self is not a bad emotion and can actually motivate people to make changes for themselves and their environment. The Civil Rights leaders in our recent history were angry and so they marched, protested and boycotted to make changes. Anger can make you write a letter voicing your disappointment in a company’s costumer service department or make you search for a new job instead of taking the abuse from a harsh boss. It can make you leave a bad situation, stand up for something you believe or protest against something you don’t.

However, anger can be destructive if it’s not dealt with in a healthy way which is when people run into problems.

Most of my clients with anger problems, once they get to the point where they can verbalize and dissect where their anger is coming from, are actually afraid. They are afraid of losing control, being taken advantage of, being ignored, etc. Take a client of mine who got into a fight while standing in line at a burger joint when he felt someone had blatantly skipped him. Does it make since for a grown man to get in a fight over a $5 hamburger because he had to wait an extra two minutes? Was it worth him going to jail and having to take anger management classes? Of course not, but to him at the time it was. He was eventually able to tell me that the reason he got so angry so quickly is because when he got skipped it made him afraid that he was invisible, that he would be seen as weak, and that he wouldn’t be respected. His fear is what made him so angry and caused him to act in an irrational way. At the same time, his need to be respected caused him to want to control the situation by making the other other person respect him and beating him up until he did.

Often times clients tell me, “She ignored me so I hit her”, “He came home late so I burnt his favorite shirt”, “He didn’t say excuse me when he brushed my shoulder so I had to push him”. All of these statements show both fear and control. Fear of being ignored, fear of being cheated on or left by a spouse and fear of being disrespected. They also show the desire to control the other person, to make them pay attention, come home on time and say “excuse me.” The problem is, we can’t control other people, just ourselves. The desire to control other people will always end up stressing us out, making us angry and causing us to act in irrational ways.

Another example is the constant wars that are waged across the world. People are afraid of losing their religion or xenophobia (the fear of people different from you), and will fight and kill out of that fear and the desire to control other people by either making them convert, conform or leave a region.

Lastly, a client of mine and her teenage daughter got into a very big fight after she found her daughters diary and read it. She didn’t like what she read in her daughter’s diary and decided to confront and punish her for the contents of her diary. Now nothing in that diary was life threatening or even “bad”, they were just her daughter expressing how she really felt about her mother and some of the things her mother did. I felt it was wrong 1) for the mother to have read the diary and 2) for her to try to punish her daughter for her private thoughts. Eventually the mother expressed to me that she felt like she had little control over anything in her life except her daughter, and she was terrified of losing control over her daughter. That need for control was actually pushing her daughter further away as well as causing the mother all kinds of anxiety and anger issues.

We have to understand that the only people we can control is ourselves and that if we can’t change a situation, we have to change the way we think about it. Wasting our time trying to change other people or change a situation instead of changing the way we think about it or removing ourselves from it, will only cause us to develop angry feelings as we try to control what we cant.