A night out anywhere in the world holds with it a marvel of interesting sights and experiences. These experiences allow one the opportunity to observe with ease whether a man has a great degree of integrity or not.
The definition of integrity is the quality of being honest and having strong moral principles. A beautiful phrase to hold in mind is “a gentleman of complete integrity”. Although this is a simple enough definition the words honest and moral are two words, which need to have a conscious and purposeful striving towards before we can get remotely close to its true essence.
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A noted trend in teenage girls from the age of 14-17: Self Harm
A trend that seems to be developing among teenage girls between the ages of 14 – 17 is an inability to process their emotions, which leads them to use self-harm as a means of emotion regulation. What has been noticed is a distinct inability to digest anger and frustration, which needs a much-required outlet.
Society appears to be more focused on the mindfulness revolution, which aims at pacifying one’s over-thinking and tumultuous emotional states.
We are all for mindfulness practice and we benefit greatly from this practice. However, concern is raised when it seems that every problem we have is referred to a dose of mindfulness as a cure. It is clear that we all have the capacity to sit with uncomfortable feelings and emotions and because mindfulness is a practice, its effectiveness is in the practice. It does take some time before a sure level of tranquility is reached, but one does eventually reach this tranquil state when due diligence is applied.
There is a slight contradiction here, as becoming more mindful does allow us to regain a sense of control in life in general, however few of us have the patience to do so.
Moving off at a tangent, reference is made to the movie “Fight Club”. There is one scene in particular that is intriguing. The protagonist in the movie has had his first fight with Brad Pitt outside a bar. This scene depicts his internal sense of relief and tranquility. Obviously in physical pain from being punched in the face and doing the same to his imaginary friend (Brad Pitt), they sit together to discuss the chain of events just happened. We get an immediate sense that Edward Norton (Protagonist) needed to find an outlet for his anger. Grossly unorthodox in the manner in which it arises, he recognizes the immensity of his internal relief by being able to simply let this anger out in a fashion that general society would not condone.
By no means is this suggesting that young 14 – 17 year old girls go out and create a fight club. However this does suggest that alternate ways of embracing anger towards others needs to be considered before there is the inevitable shift towards self-blame and loathing.
Due to the process of conditioning through repetition, these young girls find themselves in a difficult cycle to break out of. On one level they have convinced themselves that it is easier to cut and self harm because the effect is almost immediate, in comparison to using traditional psychological tools. You will often hear the phrase that “it is easier to cut than to do a mindfulness exercise or an alternative method of distraction”.
Let me explain the anatomy of this type of belief system. At onset, you have an individual who is trying to make sense of the world. From social conditioning she establishes that it is inappropriate to display anger or to share this with peers and parents due to the inevitable reaction that there is no point in getting angry. So she feels dismissed and the emotions she feels are squashed. The girl therefore begins to internalize her anger instead of finding an external release. This is where the mind/body conflict begins to take a turn for the worse. Due to the immense emotional pressure and buildup she feels, there are two paths in which this can follow.
- The use of self-harming techniques, which induce a different yet distracting pain, which deters from her centering her focus on the emotional pain. With a bit of consistency, reinforced by a changing core belief system that she actually deserves this, convinces her to see this as a successful means of processing the underlying rage and emotional pain.
- The second path follows a more unconscious process based on the research of Dr Sano. Here the emotional buildup and rage needs to find some type of release but instead imbeds itself into the creation of a bodily ailment eg: lower back pain. The protection mechanism of the unconscious mind forces the body to embody this rage, which causes bodily pain instead of the body having to face emotional pain. This suggests that it is more excruciating to face emotional pain than the physical cutting.
You will find that avoidance and resistance to facing emotional pain is a common human condition, yet a source of great relief and healing. Part of the problem is allowing oneself the luxury of being guided to the site of pain. Secondly, when you are there, having the courage to sit and process and digest the range of pain behind the rage at the self and others.
Coming back to the trend first mentioned. I have identified that part of the problem is the lack of psycho-education in this age range. The harsh reality that they are being placed under more stress and demands from school, which detracts them from actually having a childhood. Moreover, schools teaching them little of value which could be used in the outside world i.e: how to realize one’s full potential and knowing how to achieve it; what is your meaning and purpose and how to instill and cultivate the necessary values to acquire greatness; how to deal with negative thinking and emotions.
Another part of the problem is related to the effects of the media and social contagion. Drawing on social contagion, awareness of self-harm has increased significantly over the years, partly through reference to self-harm in the media and popular culture. Related to the notion of social contagion, the internet is a social and cultural resource which can have a powerful impact on young people, and particularly vulnerable young people at risk of self-harm. For example, research conducted recently indicated that young people at risk of self-harm tended to be online for longer periods of time than other teenagers (Daine et al., 2013).
Although the internet may represent a preferred way of communicating with others for isolated adolescents, and the anonymous e-communication may be particularly appealing for those experiencing psychological difficulties and emotional distress, and for those who do not feel comfortable discussing their experiences of self harm offline, research has indicated there are several risks associated with this particular form of content and communication. For example, a recent review (Daine et al., 2013) indicated that one study reviewed highlighted that young people using internet forums appeared to normalise self-harm, and rather than talking about how to reduce self-harming behaviour, the study indicated the forums were used a way to swap tips on how to hide the problem and did not make the users feel any better. Therefore this suggests that some internet forums may actually reinforce self harming behaviour for some individuals, especially when the material is repeatedly accessed.
In addition, the review also indicated that one study highlighted that some users showed increased distress following a visit to an internet forum. Whilst some studies suggested that young people who went online to find out more about self-harm were exposed to violent imagery and then went on to self-harm themselves. Worryingly, the review concluded that internet use is linked with more violent methods of self-harm. Therefore, is it clearly important for the media to support vulnerable individuals, rather than promote the use of self-harm.
Related to the difficulties surrounding adolescence, identity formation is an extremely important development task during adolescence, and self-harming behaviour has been indicated to be a means of dealing with identity confusion (Claes, Luyckx, & Bijttebier, 2014). Related to the notion of identity and drawing on social identity theory (Brown, Eicher, & Petrie, 1986), a small minority of adolescents have been indicated to self harm in order to reinforce their group identity e.g. feel more like they are a part of the group (Young, Sproeber, Groschwitz, Preiss, & Plener, 2014). Moreover, drawing on the difficulties surrounding adolescence and fitting in with peers, and gaining acceptance from those around us, another part of the problem relates to invalidation or lack of acceptance. For example, a recent study indicated a high degree of peer invalidation predicted engagement in self harming behaviours in girls (Yen et al., 2014). This highlights a clear need to assess adolescents’ feelings of invalidation or lack of acceptance.
Furthermore, in line with the risk factors of other negative coping mechanisms, there are also various other risk factors for self-harm including a history of child abuse or trauma, adverse life events, bullying, family and peer conflict, low self-esteem and a persistent sense of hopelessness and poverty (Hawton & James, 2005). For example, bullying has been linked to a propensity to self harm during adolescence. One study found that children who were exposed to chronic bullying over a number of years at primary school were nearly five times more likely to self harm six to seven years later in adolescence (Lereya et al., 2013). This indicates bullying should also be considered as an important potential risk factor and that children should be provided with support to speak out about bullying and to not suffer in silence.
Given that self-harming behaviour is a serious public health concern which is increasing, particularly among younger girls aged 14-18, and since it is a risk factor for suicide attempts, there is a clear need for appropriate assessment and management of self-harm in young girls.
It is important for us to gain a greater understanding into the problems which are contributing to this trend, and to gain a greater understanding of the key risk factors of self-harm in order to inform existing interventions, and to develop new and effective treatment interventions which are both accessible and acceptable for girls engaging in self-harm. In addition, in order to reduce the risk of suicide, there should be good management of the care pathway of vulnerable individuals as they move from child and adolescent to adult services in order to ensure continuity of care.
Brown, B. B., Eicher, S. A., & Petrie, S. (1986). The importance of peer group (“crowd”) affiliation in adolescence. Journal of Adolescence, 9 (1), 73-96.
Claes, L., Luyckx, K., & Bijttebier, P. (2014). Non-suicidal self-injury in adolescents: Prevalence and associations with identity formation above and beyond depression. Personality and Individual Differences, 61-62, 101-104.
Daine, K., Hawton, K., Singaravelu, V., Stewart, A., Simkin, S., & Montgomery, P. (2013). The Power of the Web: A Systematic Review of Studies of the Influence of the Internet on Self-Harm and Suicide in Young People. PloS ONE, 8 (10), 1-6.
Hawton, K., & James, A. (2005). Suicide and deliberate self harm in young people. British Medical Journal, 330 (7496), 891-894
Lereya, S. T., Winsper, C., Heron, J., Lewis, G., Gunnell, D., Fisher, H. L., Wolke, D. (2013). Being bullied during childhood and the prospective pathways to self-harm in late adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 52 (6), 608-618.
Yen, S., Kuehn, K., Tezanos, K., Weinstock, L. M., Solomon, K., & Spirito, A. Perceived family and peer invalidation as predictors of adolescent suicidal behaviors and self-mutilation. [published online ahead of print September, 29, 2014]. Journal of Child and Adolescent Psychopharmacology.
Young, R., Sproeber, N., Groschwitz, R. C., Preiss, M., & Plener, P. L. (2014). Why alternative teenagers self-harm: exploring the link between non-suicidal self-injury, attempted suicide and adolescent identity. Biomedcentral Psychiatry, 14 (137), 1-14.
The Faces of Borderline Personality Disorder: A Misunderstood and Crippling Disorder
Borderline Personality Disorder
Borderline Personality Disorder (BPD) according to the DSMIV (Diagnostic tool to diagnose mental disorders) is characterized by a pervasive pattern of instability of interpersonal relationships and self-image. It is characteristic of marked impulsivity beginning by early adulthood and presents in a variety of contexts. We at Harley Street Psychology have been working with sufferers of BPD since the start of the clinic and it is always fascinating how many therapists stay well clear of dealing with BPD. BPD is one of the most difficult of disorders within the personality disordered spectrum to treat, because once it has developed (and we don’t know the primary causes) it becomes engrained in the individual usually from a very early age and becomes further reconditioned for many years where it feels near impossible to get rid of the symptoms.
At Harley Street Psychology we view BPD as a “relational disorder” rather than following the specific criteria in diagnostic manuals. Many people don’t realize that in therapy the therapeutic relationship is key to assisting the individual through any difficult process and is vital in the overall effectiveness of the therapy. Think about it this way… if you didn’t like someone you wouldn’t want to open up to them right? The same applies to the therapeutic relationship. However, like any relationship there will always be issues that arise and these need to be ironed out with the therapist. By doing so a greater understanding of BPD can be achieved which is a transferable quality to other relationships.
Here is a list of some of the pervasive difficulties that someone with BPD may experience. The reason for which is to highlight the lived experience of such an individual to explain the severity of what one goes through-largely without assistance, unless privately funded.
There are extreme and frantic efforts to avoid real or imagined abandonment. Individuals with BPD have an acute fear of abandonment-this can develop in various forms, such as fear of rejection, not being good enough, real abandonment, and even playing the potential abandonment out in ones head.
Having Borderline Personality Disorder Can be Extremely Isolating
There is a historic pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation-this suggests that one second you may be idealized and the next second you may be rejected and devalued, and often made to feel devalued. This process of devaluation is often a good indicator of how devastated the BPD sufferer is on an emotional level and is a very extreme way of illustrating what it feels like to be them. Think about this as a means for the BPD sufferer to transfer their feelings onto you so you can get a glimpse of their suffering.
A debilitating experience in itself is developing an identity disturbance, such as the significant and persistent unstable self-image or sense of self. This forms a core to BPD, in that there is a drastic instability in self-image or sense of self that this may come across as being a severe experience of insecurity or sensitivity. However on an internal level, there is a sense of constant self-denigration and disgust with the self, where the person may desperately need reassurance but yet be suspicious of its deliverer.
According to diagnostic methods, impulsivity is noted in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). These experiences need to be seen as brief methods of self-soothing for the individual, however to the outsider, this is seen as erratic behavior which can be criticized rendering the BPD sufferer even more ashamed as a result.
In many cases of BPD, there is recurrent suicidal behavior, ideation, gestures, or threats, or self-mutilating behavior. The level of emotional pain and turmoil experienced is often transferred to such feelings, behaviors and thought processes as there is a desperation for some sense of soothing. Even the thought of suicide may be soothing but not necessarily wanting to be achieved ‘forever’, but often feeling that there is no other way out.
Emotional instability becomes a cornerstone to BPD; this is due to a significant reactivity of mood (i.e., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). The emotional element of BPD is often a primary factor that may trigger various episodes and cause a great deal of distress for the individual. A tool I often use is to draw up a mood chart, and do this for a minimum of two months to see the relevant patterns within ones mood. By doing this, there is a preemptive response to mood, which may help in remaining one step ahead at all times.
Chronic feelings of emptiness shroud BPD. This is rooted in childhood development and the lack of a secure base to understand the process of self-soothing and emotional connectedness. Words like love, containments, happiness and emotional connectedness may all seem far removed from the mind of the individual with BPD. Largely this is because they do not trust that the person delivering these actions and words are genuine. This is one aspect within the therapeutic relationship that is addressed immediately and it is vital to look at the sabotages that the individual will create out of being uncomfortable when they experience the above wonderful emotions.
Inappropriate intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights). Anger, has become a particularly anti-social method of expressing oneself in society. Unfortunately, societal reactions are often focused on the individuals with “anger problems” seeking out assistance, whereas I believe that general society should also learn how to deal with anger and assisting the individual in diffusing the experience.
Anger provides us insight into the depth of pain an individual is experiencing at the point of eruption. The second we can identify with the depth of pain, within ourselves we are able to rationalize and feel less burdened by the person experiencing the angry outburst. In these situations, our fight or flight response is triggered and we tend to either react by mirroring the angry response, or running away from the acute confrontation. Learn to endure someone who displays angry outbursts and no doubt they will appreciate your attempts at doing so.
Transient, stress related paranoid thoughts or severe dissociative symptoms. Unfortunately, due to the high level of sensitivity the BPD sufferer experiences, these dissociative symptoms may at many times cause the individual to cut off from the extreme emotional pain and resemble someone that has “switched off” the ignition and may become unaware of what is happening in their body and mind. This is why it is vital that Mindfulness practice is used as often as possible to maintain a centeredness and presentness.
Causes of BPD:
Although we have a diagnostic tool to diagnose someone with BPD, there is no substantial research into what causes BPD. There are a number of theories about what the causes may be, however many professionals subscribe to the biopsychosocial model of causation, in which they see the causes of BPD to be closely tied to biological, genetic, and social factors, and psychological factors. This suggests that there is no direct cause from any of the above mentioned factors, instead it is a complex and intertwined amalgam of all three factors.
BPD in our experience has often been misdiagnosed. We have had patients I’ve worked with arriving with a diagnosis of schizophrenia, Bipolar disorder all the way through to suggesting nothing was wrong.
Nonetheless, we have found that the greatest difficulty for people with BPD to overcome is creating a new relationship with themselves, where they do not sabotage every new good thing that comes into their lives because there is a deep-set core belief that they don’t deserve anything good in their lives.
This core belief can change, but what we have noticed is that there is a constant sense of not being good enough and fearing failure, and because they have been in this cycle of constant destruction, pain and heartache grow to become common sense and in a strange way a safety net of certainty. Many of us develop such strategies of coping with the uncertainty of life, but for people with BPD, uncertainty is filled with terror and panic and such high levels of anxiety that they can either crash into periods of depression or severe anxiety and panic attacks.
A key ingredient to overcoming BPD is by firstly establishing a good relationship with a therapist. Our advice is to find someone who fits the way you are and get a good feel for them. They need to be able to contain you enough in any phase or mood you find yourself in.
This is the responsibility of your therapist to work through this process with you and to help you overcome feelings and fears of abandonment.
We have had the privilege of working with some of the severest forms of BPD at Harley Street Psychology and observe the immense changes that a person goes through when they want to change their behavior and thinking. This is very much possible even though many professionals believe that if you have BPD there is no way of maintaining a sense of control and live a full and enriching life.
Statements like that go against everything we believe in, and if I had to accept that as gospel then that is like suggesting that some headaches can be treated whereas others cannot. At the end of the day it is a headache and yes some headaches can be worse than others, but there is always a way to get to the root of the problem and address core beliefs and ways or relating and functioning.
Not only is BPD difficult for others to relate to, but first and foremost, it is incredibly difficult for the person diagnosed with BPD to fully accept that this is what is wrong with them. There is initially a phase of fighting against this diagnosis, especially if it has been adequately diagnosed and not misdiagnosed, as is the case in many other situations.
In saying this, that is why it vital to find someone who has expertise in dealing with BPD and who is strong enough to contain ruptures and outbursts so that a solid structure can be achieved and maintained.
Besides being terrified of the actual BPD diagnosis, we can only imagine how terrifying it must be to work with a professional who feels incapable of ‘holding’ the person while they’re going through such emotional and cognitive turmoil. Please bear in mind that the therapist you will be working with is still a human being and is one who has flaws, so it is essential to work through any ruptures that may occur within the therapeutic relationship.
Learning to be authentic with ones feelings and thinking is a vital combination in adapting oneself to having BPD and face up to the many faces it can have present.
Mindfulness, a philosophy or mode of living life arose during the beginning of the 21st century in western minds, and is derived from Zen Buddhism often found in most eastern philosophies dating back centuries.
The practice is simple. By allowing thoughts to enter the mind, not judging them, and allowing them to exit as quickly as they came in. However, still a practice, and a practice means PRACTICE! The only way this process can become beneficial for us is to embrace the teachings and techniques and apply them on a daily basis with consistency. At Harley Street Psychology, we always speak about conditioning the mind in the same fashion as we do our muscles, and if we don’t allow these new ways to become habit to us, we become complacent and revert to old ways of being.
There are a number of very helpful mindfulness practices that are available, however what we instruct anyone attempting at taking up mindfulness is find a technique that is suitable and helpful to you-don’t follow every guru that has “the cure it all solution”, instead build on your own philosophy in life and test out many. Additional approaches which are especially helpful are: Schema therapy, Acceptance and commitment therapy, Existential therapy.
Cognitive Analytic Therapy:
Cognitive Analytic Therapy (CAT) was first developed by Anthony Rile, and in my opinion is one of the most collaborative and embracing therapy models available to us. Founded on the given that everything in life has a beginning, middle and end, the structure of the therapy follows the same process.
CAT was primarily designed to deal with BPD and its challenges and besides there being a secure and agreed framework in which to practice it, it is very forgiving and collaborative with many other approaches.
A technique we use often and this can apply to anyone wanting to observe themselves closer is using a mood graph. The intention is noting twice a day (morning and evening) your mood and rating it (1-10) and identifying the precipitating event contributing to the mood. The intention of which is to be constantly checking in with yourself so that you are actively aware of your internal emotional state. This is often difficult for BPD sufferers, in that they often dissociate (almost like a day dream like state and feel detached from themselves) and are not conscious of their emotional and cognitive state.
Within BPD, there is often resentment towards a family member or someone close. In psychotherapy we call it the narcissistic wound carried by the individual. This is an emotional wound so painful that it is near impossible to reach the person on an emotional level, because when things become too painful the BPD sufferer will most often resort to deviating or avoiding the cause of emotional pain. In order for a beneficial relationship to develop for the patient there needs to be a close connection with explicit boundaries and clear expectations of ones needs and desires-this should be achieved and maintained on both