Retrieved from Issue 346 of Institute Inbrief 20/01/2021

Paranoia: Definition and levels

When a person believes that others are “out to get them”, trying to stalk or harm them, or paying excessive attention to them for no reason, they may be experiencing paranoia. Occurring in many mental health conditions, paranoia is most often present in psychotic disorders. It involves intense anxious or fearful feelings and thoughts, most often related to persecution, threat, or conspiracy (Mental Health America, n.d.). It can be a symptom of illnesses such as schizophrenia, brief psychosis, paranoid personality, psychotic depression, mania with psychotic features, delusional disorders, or substance abuse (chronic or momentary) (Barron, 2016).

Mental health experts have identified three levels of paranoia:

1. Paranoid personality disorder (PPD): Characterised by odd or eccentric ways of thinking, PPD involves an unrelenting mistrust and suspicion of others when there is no reason to be suspicious. It is one of the personality disorders in the DSM-5’s Cluster A, along with schizoid and schizotypal personality disorders. Thought to be the mildest form of paranoia, a person with PPD may still be able to function in relationships, employment, and social activities. The onset is typically in early adulthood and is more common in men than in women.
    
2. Delusional (paranoid) disorder: Found in the DSM-5 chapter, “Schizophrenia spectrum and other psychotic disorders”, this is a condition in which an individual holds one major false belief or delusion; it will often be an implausible but not bizarre delusion. A delusional disorder typically occurs without any other signs of mental illness. So a person might think that others are talking behind their back if they have a persecutory delusion, or believe that they need immediate medical attention for a (non-existent) medical problem if they have a somatic delusion. This condition is slightly more common in women than men.
    
3. Schizophrenia with bizarre delusions: People with this condition do not function well in society and need consistent treatment (Sunrise House, 2018; WebMD, 2018).This is the most severe form of paranoia, involving bizarre delusions without basis, such as that aliens are trying to abduct them, or that an unseen enemy is removing their internal organs and replacing them with others’ organs.

This article is about Levels (1) and (2), the paranoid personality disorder (PPD) and delusional disorder, which you may encounter more commonly, either in your client or the client’s partner.

Identifying paranoia

We have several options for finding out what characteristics should be called “paranoid”: we can assess how we experience the person — how we describe them and what they evoke in us — and/or we can run with DSM-5 descriptions, which outline the clinical symptoms we can observe specifically with the paranoid personality disorder and delusional disorder. Let’s do both.

Descriptions of the paranoid person

Joe Navarro, who has written extensively about mental disorders, asked those who had either lived with or been victimised by paranoid personality types to describe this personality type from their experiences. Here is the list of some of their words:

“Angry, anxious, apprehensive, combative, complainer, contrarian, critical, delusional, demanding, difficult, distrustful, disturbed, eccentric, fanatic, fearful, fixated, fussy, guarded, hard-headed, inhospitable, intense, irrational, know-it-all, menacing, mentally rigid, moralistic, obsessed, odd, offensive, opinionated, sensitive, peculiar, pedantic, quarrelsome, questioning, rigid, scary, strict, stubborn, suspicious, tense, threatening, tightly-wound, touchy, unforgiving, unhappy, vindictive, wary, watchful, withdrawn” (Navarro, 2016).

What they evoke in us:

Experiencing a relationship with someone described by such intense words as those above cannot fail to bring forth a reaction in us. Laurel Nowak (2018) outlines the common feelings evoked by paranoid individuals in those with whom they are in relationship. She talks about: “feeling weighed down, negative, stressed, isolated from the people and activities you used to enjoy, and like you’re walking on eggshells”. Some have noted that it can feel to the other person like they are not being seen — ever — for who they truly are. The exaggerated negative spin on events or in response to statements occurs in the context of relating which lacks tenderness, humour, or comfort (Navarro, 2016). While these authors are describing feelings evoked in intimate relationships with paranoid individuals, they could have been talking about how therapists feel when faced with a client with this condition. Dealing with such a person eats away at the most robust sense of happiness and self-esteem. Here are the DSM-5 symptoms.

Paranoid Personality Disorder: DSM-5 symptoms description

According to the DSM-5, there are two primary diagnostic criteria for Paranoid Personality Disorder, of which Criterion A has seven sub-features. Four of these must be present to warrant a diagnosis of PPD:

Criterion A is: Global mistrust and suspicion of others’ motives which commences in adulthood. The seven sub-features of Criterion A are:

1. Belief others are using, lying to, or harming them, without apparent evidence thereof
2. Doubts about the loyalty and trustworthiness of friends and associates
3. Inability to confide in others due to the belief that their confidence will be betrayed
4. Interpretation of ambiguous or benign remarks as hurtful or threatening
5. Holding grudges (being unforgiving of insults, injuries, or slights)
6. In the absence of objective evidence, belief that their reputation or character are being assailed by others; retaliation in some manner
7. Being jealous and suspicious without cause that intimate partners are being unfaithful.

Criterion B is that the above symptoms will not be during a psychotic episode in schizophrenia, bipolar disorder, or depressive disorder with psychotic features (American Psychiatric Association, 2013).

Delusional Disorder: DSM-5 definition and types

According to the DSM-5, this condition is characterised by at least one month of delusions but no other psychotic symptoms. Delusions are false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary; these beliefs are not ordinarily accepted by other members of the person’s culture or subculture. In delusional disorder (a moderate level of paranoia), a person experiences non-schizophrenic (i.e., not bizarre) delusions, such as that they are that they are being spied on. Because only thoughts are affected, a person with a delusional disorder can act normal and function in everyday life, although they may display paranoia or other symptoms related to their delusion. The five types of delusions people with this disorder have are:

1. Erotomanic, where there is a belief that a person with higher social or financial standing (such as the president or a movie star) is in love with them; it can lead to stalking and obsession.
    
2. Grandiose, involving the false belief that the person has a special power or ability not shared by anyone else (such as that they are extremely lucky and will always win at the casino).
    
3. Jealous: a mistaken belief that a current or former loved one is unfaithful or even harmful. Paranoia about the loved one’s words or actions can be a symptom of these delusions.
    
4. Persecutory, in which the common sense of the paranoia is that someone is out to get the individual, because the person believes they are being threatened, mistreated, or that they will be harmed in the future.
    
5. Somatic: a delusion in which the individual believes that they have an illness, disability or physical defect (Sunrise House, 2018; Mental Health America, n.d.; Bourgeois, 2017).

Treating and coping with paranoia

For the therapist

First, we must note the common advice: a person suffering from either PPD or a delusional disorder needs to seek professional help, although most such individuals do not believe that they are paranoid; rather, they think they are perceptive, noticing things that no one else sees. In this sense, it can be difficult to get such a person to therapy, as the condition tends to be ego syntonic. If such an individual turns up in your therapy rooms, however, note that a referral to a medical doctor is in order to determine if medication is needed.

Medication generally is not a major focus of treatment for PPD; therapy is. However, medications, such as anti-anxiety, antidepressant, or anti-psychotic drugs, might be prescribed if the person’s symptoms are extreme, or if he or she also suffers from an associated psychological problem, such as anxiety or depression (WebMD, 2018).

With delusional disorders, the diagnosed individual begins a combination of medication and psychotherapy. The anti-psychotic medication helps the individual improve enough to be able to understand reality and the need for therapeutic help. In milder cases, the individual may receive anti-anxiety medications or anti-depressants, which allows them to undergo therapy, where they learn coping skills, how to recognise delusions as false, and how to manage stress or difficult feelings. Hospitalisation may sometimes be indicated to stop the person from harming themselves or others during violent delusions (Sunrise House, 2018).

As the condition affects the client’s thought patterns and beliefs, it can be worked with effectively using cognitive behavioural therapy, which transforms the unrealistic, maladaptive thoughts by replacing them with more helpful, realistic adaptive thoughts. In addition, some therapists have observed that psychodynamic work, such as object relations, can help paranoid clients look into reasons for becoming mistrustful and suspicious which arise from early childhood relationships (Everyday Health, n.d.).

You might be asking, “Wait a minute; chief symptoms are a tendency to be suspicious and an inability to trust. How, then, can a therapist make any reasonable headway with such a client, given that trust is the basis for any solid therapeutic alliance?” If you twigged to this issue, congratulations; you have nailed the problem: how to keep the paranoid client in therapy long enough for enough trust to be built so that real progress can be made. Building trust is where the challenge is, no matter what modality is being used with the client.

To help a client in relationship with a person living with paranoia

You are likely to see the partner of a person acting paranoid. Once it is established that some form of paranoia is indeed the diagnosis, some clear guidelines exist for helping the partner. Some of the following tips also hold true for therapists working with this client population.

Setting boundaries. The paranoid person needs compassion and understanding, true, but that does not equate to acceptance of poor treatment on the grounds that the person has a disorder and is frustrated. Clear lines of what is acceptable and what is not must be drawn; those expectations for decent treatment must be communicated clearly, including around the issue of refusing to collude with delusional thinking (compromising one’s own needs) because of the person’s paranoia or fear.

Practicing self-care. For therapists and partners alike, this one is paramount! Dealing with this disorder is exhausting and sometimes heart-breaking. Those in close relationships (whether intimate or therapeutic) with paranoid individuals must have regular, solid habits of self-care. All the usual practices go into this category: relaxation/meditation, exercise, decent diet, support systems activated, and perhaps journalling or creative work to vent frustrations. Particularly for partners of those with PPD or a delusional disorder, maintaining a healthy social life — not allowing oneself to become isolated — is important.

Don’t abandon own stance, but empathise with their fear. If either the partner of the paranoid person or you, as therapist, hear an accusation that seems really “off” — totally unfounded — you can employ the tactic of empathising with the feeling, but not necessarily agreeing with the facts (though outright disagreeing doesn’t work, either). Carrie Baron, M.D., and Director of the Resilience Program at Dell Medical School in Texas, explains that consoling the person and refuting what they have said will not likely alter any paranoid convictions or delusions. What works better is “observation, reflection, curiosity and openness without judgment”, which lead to better understanding (Barron, 2016). Thus, the partner could say to the paranoid person, “I can imagine you’re worried if you think that the inheritance you counted on for your retirement might be taken away through your dad marrying. Have you observed any behaviour that made you question her motives?” (curiosity). However they do it, partners of people with any form of paranoia must look beneath the surface before getting swept up in the partner’s claims (Barron, 2016).

Recognise that the paranoid person can still contribute to life. Because of the fact that mild or moderate forms of paranoia are circumscribed, showing up only in particular thoughts and delusions, only those involved or accused may be aware of the psychopathology of the condition. The person can thus contribute to family life, work, and aspects of social life in positive ways, which you as therapist can help highlight for the partner.

Having either a client or a client’s partner who is paranoid is not easy, but the worst heartbreak and chaos can be avoided if the person can engage treatment, including medication when necessary.

References:

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders.(5th Edition). Washington, DC.: APA.
2. Barron, C. (2016). 7 Tips for coping with a paranoid partner. Psychology Today. Retrieved on 4 December, 2018, from: Website.
3. Bourgeois, J. (2017). Delusional disorder. Medscape. Retrieved on 9 December, 2018, from: Website.
4. Everyday Health. (n.d.) Coping with paranoia in a loved one. Everyday Health. Retrieved on 4 December, 2018, from: Website.
5. Mental Health America. (n.d.). Paranoia and delusional disorders. Mental Health America. Retrieved on 6 December, 2018, from: Website.
6. Navarrro, J. (2016). The paranoid partner: Identifying the paranoid personality in relationships. Psychology Today. Retrieved on 4 December, 2018, from: Website.
7. Nowak, L. (2018). Paranoid personality disorder and relationships: Moving past fear, together. Bridges to Recovery. Retrieved on 4 December, 2018, from: Website.
8. Sunrise House. (2018). Is there a difference between paranoia and delusional disorders? American Addiction Centers. Retrieved on 9 December, 2018, from: Website.
9. WebMD. (2018). Paranoid personality disorder. WebMD LLC. Retrieved on 9 December, 2018, from: Website.

As I always like to say, there are as many reasons why people self-sabotage as there are people. A common theme is to protect the self from failure, feeling things we don’t want to feel, and to control our experiences.

One of the hidden culprits behind self-sabotage is the need for perfection and control. Self-sabotage has a strange way of helping us maintain the illusion that if only we had put in more effort or had better circumstances, everything would have worked out as it should. Social psychologists call this counter-intuitive strategy of regulating self-esteem ‘self-handicapping.’ It’s very seductive to engage in self-sabotage because the hidden payoff is high. It’s often easier to be a perfect whole rather than a real part. It’s a short-term solution that sidesteps the more arduous but ultimately more fulfilling work of individuation and self-realization. It takes risk, patience, suffering, and ultimately wisdom to come to the place where you can let go of self-sabotage and learn how to be real.

Behaviour is said to be self-sabotaging when it creates problems in daily life and interferes with long-standing goals. The most common self-sabotaging behaviors include procrastination, self-medication with alcohol and other drugs, comfort eating, and forms of self-injury such as cutting.

Self-sabotage originates in the internal critic we all have, the side that has been internalized by the undermining and negative voices we’ve encountered in our lives. This critic and ‘internal sabotuer,’ functions to keep the person from risking being hurt, shamed, or traumatized in the ways they had been in the past. While it keeps the individual safe, it does so at a very high cost, foreclosing the possibility of new, creative, and three-dimensional experiences. Like an addiction, self-sabotage insidiously lulls and deludes us into thinking that it has the answer. In fact, it is the problem masquerading as the solution. Nothing stops self-sabotage faster in its tracks than shining this particular light on it. Consciousness is true power. We need to let go of our illusions of omnipotence and perfection and see that it is only when we are real and imperfect that we can create a true work of art. Then and only then we can enjoy the gifts of being Real.

– Michael Alcée, Ph.D., Relational therapist/ Clinical psychologistArt: Bawa Manjit, Acrobat

– Self-Sabotage | Psychology Today Australia

People living with obsessive-compulsive disorder are encouraged to follow three general tips for effective self-management. They are: challenge the obsessive thoughts and compulsive behaviours (this includes use of distraction skills, and resisting the compulsion), maintain high self-care (you may need to put your needs first a lot – this is NOT selfishness or self-centredness), and reaching out for support. I want to clarify that I am not trained or qualified in OCD treatment – this is an extract from an article posted on the Australian Institute of Professional Counselling website.

The following information has been retrieved from AIPC Article Library | Self-help Strategies for OCD and OCPD. I think it’s also important to reinforce that if you have been living with OCD for years, you’re probably the expert on what is already most effective for you, and some of the following suggestions may make you roll your eyes. It can be very helpful/useful to talk to other people who live with OCD. They may understand your experience better than health workers, and this can be comforting, validating and healing.

Challenge the obsessive thoughts and compulsive behaviours. In addition to refocusing, the OCD client can learn to recognise and reduce stress. Some of the strategies here are counter-intuitive. You can urge clients to “go with the flow” by writing down obsessive thoughts, anticipating OCD urges, and creating “legitimate” worry periods. Tell them to:

Write down your obsessive thoughts or worries. Keep a pen and pad, laptop, tablet, or smartphone nearby. When the obsessive thoughts come, simply write them down. Keep writing as the urges continue, even if all you are doing is repeating the same phrases over and over. Writing helps you see how repetitive the obsessions are and also causes them to lose their power. As writing is harder than thinking, the obsessive thoughts will disappear sooner.

Anticipate OCD urges. You can help ease compulsive urges before they arise by anticipating them. For example, if you are a “checker” subtype, you can pay extra attention the first time you lock the window or turn off the jug, combining the action with creating a solid mental picture of yourself doing the action, and simultaneously telling yourself, “I can see that the window is now locked.” Later urges to check can then be more easily re-labelled as “just an obsessive thought”.

Create an OCD worry period. Rather than suppressing obsessions or compulsions, reschedule them. Give yourself one or two 10-minute “worry periods” each day, times you are allowed to freely devote to obsessing. During the periods, you are to focus only on negative thoughts or urges, without correcting them. At the end of the period, let the obsessive thoughts go and return to normal activities. The rest of the day is to be free of obsessions and compulsions. When the urges come during non-worry periods, write them down and agree to postpone dealing with them until the worry period. During the worry time, read the list and assess whether you still want to obsess on the items in it or not.

Create a tape of your OCD obsessions. Choose a specific worry or obsession and record it into a voice recorder, laptop or smartphone, recounting it exactly as it comes into your mind. Play the recording back to yourself over and over for a 45-minute period each day, until listening to it no longer causes you to feel highly distressed. This continuous confrontation of the obsession helps you to gradually become less anxious. When the anxiety of one worry has decreased significantly, you can repeat the exercise for a different obsession (Robinson et al, 2013).

Maintain good self-care. A healthy, balanced lifestyle plays an important role in managing OCD and the attendant anxiety (generally present with OCD, even though the disorder is no longer classified as an “anxiety disorder” per se), so the helpfulness of the following practices – truly not rocket science – cannot be underscored. Encourage OCD clients to:

• Practice relaxation techniques, for at least 30 minutes a day, to avoid triggering symptoms.
• Adopt healthy eating habits, beginning with a good breakfast followed by frequent small meals – with much whole grain, fruit and vegetable – throughout the day to avoid blood sugar lows and to boost serotonin.
• Exercise regularly; it’s a natural anti-anxiety treatment. Get 30 minutes plus of aerobic activity most days.
• Avoid alcohol and nicotine, as these increase anxiety after the initial effects wear off.
• Get enough sleep; a lack of it exacerbates anxious thoughts and feelings (Robinson et al, 2013).

Reach out for support. Staying connected to family and friends is the best defense an OCD client can muster against intrusive obsessions and compulsive urges, because social isolation exacerbates symptoms. Talking about worries and urges makes them seem less threatening. Also, involving others in one’s treatment can help maintain motivation and guard against setbacks. To help remind the client that s/he is not alone in the struggle with OCD, ask him or her to consider joining a support group, where personal experiences are shared and attendees also learn from others facing similar problems.

OCPD: Self-help strategies for survival

For both the person diagnosed with OCPD and also for his family and friends, dealing with this disorder requires patience, compassion, and fortitude. To start with, the ego-syntonic nature of OCPD means that the person does not necessarily agree that he has anything wrong at all. For those who staunchly continue to insist that their relational problems arise because of others’ faults, treatment is complicated. Given the OCPD’s general world view of “I am correct; you are wrong”, the prognosis for change is often poor. Transformation is likely to occur only when the OCPD’s relational skills and outlook are shifted. This is not a job for medication (at least not for long and not alone), and yet psychotherapy is not always available. When it is, the OCPD is not always willing to avail himself of it.

Regardless of this less-than-ideal context for managing OCPD, there are some things that the client himself and also friends and family can do to alleviate some of the tension and conflict that goes with living with the disorder. As a therapist, you can encourage the client and those around him to utilise some of these strategies.

Bibliotherapy. It’s a good idea to read up on OCPD, not only in order to know what to expect, but also for tips in dealing with it. Your client may also come upon writings that link some behaviours and lifestyle choices to the disorder in ways not understood before. When comprehension deepens, so, too, does the prospect of compassion.

Gentle confrontation (agreed beforehand). While we agree that OCPD clients have a mammoth need to be right, those clients who truly seek to feel better may be willing to make agreements with family and friends in which OCPD behaviours, when noticed, are gently challenged; the operative word here is gently.

Self-insight through journalling or tape-recording. We noted above that many OCPD clients are intelligent, sensitive people. Thus, keeping a diary or making voice recordings to note anything upsetting, anxiety-provoking, overwhelming, or depressing is a step toward the self-insight that will eventually help to manage the disorder. Too, family and friends may agree to note their observations and share them in a constructive, non-confrontational manner.

Good self-care. OCPD is a disorder about exaggerated need for control, so keeping on an emotional even keel can help reduce the unconscious need to micro-manage all of life. Strategies to achieve this are listed above under Tip 2 for maintaining self-care with OCD. They revolve around the basic life efforts of practicing relaxation techniques, adopting healthy eating and exercise regimens, getting decent sleep, and avoiding excessive alcohol/drug consumption (the last is not hard for the OCPD).

Reaching out for help. OCPD individuals tend to be loners, and relationships are hard for them to build and maintain. Nevertheless, it is helpful to the ultimate reduction of OCPD-engendered tension to go for support. This can be in the form of self-help groups, informal support from partner, family, and friends, or even from joining online communities of people dealing with the disorder. Whatever the form of the support, it may be helpful for OCPD clients to own their places of dysfunction when they see others owning their imperfect humanness – and surviving (Robinson et al, 2013)!

References

• Long, P. (2011). Obsessive-Compulsive Personality Disorder. Internet mental health. Retrieved on 18 April, 2013, from: hyperlink.
• Robinson, L., Smith, M., & Segal, J. (2013). Obsessive-Compulsive Disorder: Symptoms and treatment of compulsive behaviour and obsessive thoughts. Helpguide.org. Retrieved on 24 April, 2013, from: hyperlink.

In the 1960s, American neuroscientist Paul MacLean formulated the ‘Triune Brain’ model, which is based on the division of the human brain into three distinct regions. MacLean’s model suggests the human brain is organized into a hierarchy, which itself is based on an evolutionary view of brain development. The three regions are as follows:

1. Reptilian or Primal Brain (Basal Ganglia)
2. Paleomammalian or Emotional Brain (Limbic System)
3. Neomammalian or Rational Brain (Neocortex)

At the most basic level, the brainstem (Primal Brain) helps us identify familiar and unfamiliar things. Familiar things are usually seen as safe and preferable, while unfamiliar things are treated with suspicion until we have assessed them and the context in which they appear. For this reason, designers, advertisers, and anyone else involved in selling products tend to use familiarity as a means of evoking pleasant emotions.

Inattentional Blindness is the failure to notice an unexpected object in a visual display.

Cognitive Psychology is an approach to understanding human cognition by observing behaviour of people performing cognitive tasks. It is concerned with the internal processes involved in making sense of our environment, and deciding what behaviour to be appropriate. These processes include attention, perception, learning, memory, language, problem-solving, reasoning, and thinking.

The most famous experiment that shows evidence for inattentional blindness is the Simons and Chabris (1999) experiment where an audience or viewer watches a group of people pass a ball to one another wearing either black or white, and a woman dressed as a gorilla enters the frame for 9 seconds, then walks off. Results reported that 50% of the observers did not notice the gorilla enter the frame. In all honesty, when I saw the video for the first time at university, I did not see the gorilla enter the frame either.

In reality, we are often aware of changes in our visual environment because we detect motion cues accompanying the change. This information suggests that our ability to detect visual changes is not only due to the detection of movement. An obvious explanation of the gorilla experiment findings is that the visual representations we form in our mind are sparse and incomplete because they depend on our limited attentional focus. Simons and Rensick (2005) point out that there are other explanations, such as: detailed and complete representations may exist initially but may either decay rapidly or be overwritten by a subsequent stimulus. It needs to be said that in the gorilla experiment, the observers are instructed to count how many times the ball passes, so really, our attention is deliberately compromised. The real-life implications of inattentional blindness reveals the role of selective attention in human perception. Inattentional blindness represents a consequence of this critical process that allows us to remain focused on important aspects of our world without distraction from seemingly irrelevant objects and events.

Being present, in the moment (mindfulness) can help aid our attention. Distractions such as using our mobile phones, advertising material, other people, “multi-tasking” and internal emotional states all contribute to our lack of focus and attention. Think of a magician’s ability to manipulate their audiences attention in order to prevent them from seeing how a trick is performed. There are also safety implications, as you would know … if you’ve been paying attention, haha.

Just food for thought, my readers, and friends 🙂

What is meant by self-harm?

Self-harm is any behaviour that involves the deliberate causing of pain or injury to oneself without the intention to end your life. Self-harm can include behaviours such as cutting, burning or hitting oneself, binge-eating or starvation, or repeatedly putting oneself in dangerous situations. It can also involve abuse of drugs or alcohol, including overdosing on prescription medications. Self-harm is usually a response to distress, whether it be from mental illness, trauma, or psychological pain. Some people find that the physical pain of self-harm helps provide temporary relief from emotional pain (extract from Self harm (lifeline.org.au)).

People who engage in self-harm will profess that they have no intention of dying and that their self-harming behaviour is a coping strategy, however, there are incidents of accidental suicide. The act of self-harm can develop into an obsessive-compulsion experience which can be very difficult to stop, like addiction, without outside intervention. This can result in feelings of hopelessness and possible suicidal thinking. Like building a tolerance to a drug, when self-injury does not relieve the tension or help control negative thoughts and feelings, the person may injure themselves more severely or may start to believe they can no longer control their pain and may consider suicide.

The following extract by Tracy Alderman Ph.D explains the physiological response to physical pain:

“Physiologically, endorphins are released when we are injured or stressed. Endorphins are neurotransmitters that act similarly to morphine and reduce the amount of pain we experience when we are hurt. Joggers often report experiencing a “runners high” when reaching a physically stressful period. This “high” is the physiological reaction to the release of endorphins – the masking of pain by a substance that mimics morphine. When people self-injure, the same process takes place. Endorphins are released which limit or block the amount of physical pain that’s experienced. Sometimes people who intentionally hurt themselves will even say that they felt a “rush” or “high” from the act. Given the role of endorphins, this makes perfect sense” (Oct 22, 2009).

Please click on the link for the full article Myths and Misconceptions of Self-Injury: Part II | Psychology Today Australia

The first step is to distinguish between self-harming and suicidal behaviour by paying attention to a person’s underlying motivation. When working with self-harming behaviour it is important to remember that this behaviour serves a purpose. In collaboration with the client, try to identify what problem self-harm solves for the client. For example, from the client’s perspective:

• To make me feel real (counteracts dissociation)
• To punish me (temporarily lessens guilt or shame)
• To stop me from feeling (when strong feelings are too dangerous)
• To mark the body (to show externally the internal scars)
• To let something bad out (symbolic way to try to get rid of shame, pain, etc.)
• To remember
• To keep from hurting someone else (to control my behaviour and my anger)
• To communicate (to let someone know how bad the pain is)
• To express anger indirectly (to punish someone without getting them angry at me)
• To reclaim control of the body (this time I’m in charge)
• To feel better

Tips for helping yourself in the moment
It can be hard for people who self-harm to stop it by themselves. That’s why it’s important to get further help if needed; however, the ideas below may be helpful to start relieving some distress:

• Intense exercise for 30 seconds, 30 second break, repeat, up to 15 minutes – Exercising intensely will help your body mitigate unpleasant energy that can sometimes be stored from strong emotions. Transfer this energy by running, walking at a fast pace, doing jumping jacks, etc. Exercise naturally releases endorphins which will help combat any negative emotions like anger, anxiety, or sadness.
• Delay — put off self-harming behaviours until you have spoken to someone.
• Distract — do some exercise, go for a walk, play a game, do something kind for yourself, play loud music or use positive coping strategies.
• Deep breathing — or other relaxation methods.
• Cool your body temperature – Cooler temperatures decrease your heart rate (which is usually faster when we are emotionally overwhelmed). You can either splash your face with cold water, take a cold (but not too cold) shower, or if the weather outside is chilly you can go outside for a walk. Another idea is to take an ice cube and hold it in your hand or rub your face with it.
• Listen to loud music
• Call someone you trust or one of the services available like LifeLine 13 11 14, MensLine Australia 1300 78 99 78 and BeyondBlue 1300 22 4636 [see below].
• You could write an email to yourself to express your emotions, or journal your feelings, if that’s something that might be effective for you.
• Watch humorous Youtube clips

New, healthier coping strategies may not be as effective as the one you’re trying to replace so it may take practice. Bring lots of compassion to yourself, okay.

You may find that some of these strategies work in some situations but not others, or you may find that you need to use a combination of these. It’s important to find what works for you. Also, remember that these are not long-term solutions to self-harm but rather, useful short-term alternatives for relieving distress.

Stephen Porges, psychiatry professor and researcher, on the polyvagal theory he developed to understand our reactions to trauma:

[Paraphrased] Polyvagal theory articulates three branches of the autonomic nervous system (ANS) that evolved from primitive vertebrates to mammals. First, there is a system known as ‘freeze’, which involves death feigning or immobilisation. Second, the ANS has a ‘fight or flight’ system, which is a mobilisation system. And third, with mammals, there is what Porges calls, a social engagement system (SES), which can detect features of safety, and actually communicate them to another. The SES may also be referred to by some as ‘rest and digest’, which Porges theory suggests is a function of the Vagus Nerve – the tenth cranial nerve, a very long and wandering nerve that begins at the medulla oblongata. When an individual experiences feelings of safety (within an SES state), the autonomic nervous system can support health restoration. In terms of dealing with a life threat, an ordinary person will most likely go into a feigning death, dissociative state of ‘freeze’.

Polyvagal theory in psychotherapy offers emotional co-regulation as an interactive process between therapist and client which engages the social engagement system of both therapist and client. Social engagement provides experiences of safety, trust, mutuality and reciprocity in which we are open to receiving another person, just as they are.

The following extract has been retrived from https://www.theguardian.com/society/2019/jun/02/stephen-porges-interview-survivors-are-blamed-polyvagal-theory-fight-flight-psychiatry-ace

Polyvagal theory has made inroads into medical and psycho-therapeutic treatment, but how should it inform how people treat each other?

“When we become a polyvagal-informed society, we’re functionally capable of listening to and witnessing other people’s experiences, we don’t evaluate them. Listening is part of co-regulation: we become connected to others and this is what I call our biological imperative. So when you become polyvagal-informed you have a better understanding of your evolutionary heritage as a mammal. We become aware of how our physiological state is manifested, in people’s voices and in their facial expression, posture and basic muscle tone. If there’s exuberance coming from the upper part of a person’s face, and their voice has intonation modulation or what’s called prosody, we become attracted to the person. We like to talk to them – it’s part of our co-regulation.

So when we become polyvagal-informed, we start understanding not only the other person’s response but also our responsibility to smile and have inflection in our voice, to help the person we’re talking to help their body feel safe.”

Clink on the link below to hear Dr. Bessel van der Kolk, one of the world’s leading experts on developmental trauma, explain how our long-term health and happiness can be compromised by prior exposure to violence, emotional abuse, and other forms of traumatic stress.

https://youtu.be/53RX2ESIqsM

In our previous article (read it here), we asked why men do not seem to express emotion as easily as women do. Was there some pathology, or should we just put the differences down to male-female tendencies? We identified Dr Ron Levant’s notion of “normative male alexithymia” as representative of one side of the controversy: namely, that, yes, men do have a restricted range of emotional expression compared to women, but it’s so pervasive in society that it’s normal (Schexnayder, 2019).

On the other side of the debate were researchers such as James Thompson (2010), who – while acknowledging men’s relatively greater “stoicism” or restriction emotionally – nevertheless insisted that it’s invalid to conflate alexithymia with maleness, especially given that men’s holding back from emotional expression is largely culturally induced. Yet we observed that the issue should be dealt with, given the male-female suicide ratio in Australia, the U.K., and the United States of about 3:1 – and the fact that suicide is on the rise in all three countries.

We concluded that therapy might be able to help, and that is where we go with this article: to a discussion of just how we as mental health professionals might be able to help men deal with an outdated but strongly held socialisation pattern which has impacted their emotional expression, and through that, their capacity for growth, satisfying friendships, and intimate relationships. 

We tackle the question in two parts. First, we share psychologist Barbara Markway’s (2014) take on how to help men out of the double bind that leads to their emotional repression. Then we suggest therapies which might be able to assist.

Deciphering the code

Markway (2014) insists that dismissing men as “the feelingless gender” is not only unhelpful, but also wrong. They just, she says, express their feelings using a secret code: one which even they themselves cannot decipher. Let’s do some translation.

Men convert one feeling into another

Let’s say you’re a guy, and you’ve just found out that a good friend of yours has been cheated in business by her business partner: a business you yourself helped them set up. The cheating transactions will cost your friend thousands, and maybe her whole business. You may erupt volcanically, vowing to help your friend sue the partner for all they are worth, or maybe go threaten the partner within an inch of their life. If you react this way, you are showing anger and not a little pride, which are acceptable “male” emotions to express. Hiding underneath them could be sadness for your friend, and even a shared sense of vulnerability, but these are more “feminine” emotions, which by socialisation you are not “allowed” to express. So you convert them into “male” emotions of anger and pride.

Men may shift their feelings into another domain

Are you male, and basically an exuberant, affectionate sort? Markway claims you may not necessarily let this show in your personal relationships, but on the sports field, lookout; you’ll be hugging, high-fiving, and butt-slapping with the best of them. It’s ok in that domain, she says, for men to express strong feelings of delight (over a goal made, say) and affection.

Men may somatise their feelings

Let’s say now that you’re female, and in an intimate partnership with a guy. You make plans to get away for a holiday, but no sooner have you checked into the five-star hotel at the fabulous beach than he gets a migraine and is out of action for that day at least. What’s going on? Markway observes that, with the structure of work, many men are able to squash down feelings, but when they are away from that structure, such as on weekends or holidays, their emotions and needs surface. Not wanting to acknowledge them, many men will convert strong emotions into physical symptoms, such as headaches or back aches. If asked about it, some men would have the conscious belief that women do want them to show their emotions, but only certain ones, and only in amounts they (the women) can handle. Men who deviate from this are, as we have noted, judged to be poorly adjusted or not “manly enough”, because – at the root of it – they are bucking their whole socialisation model.

Men’s emotional expression can put us all off balance

When men do get in touch with emotions, the result can catch everyone off guard, as it may seem to come “out of the blue” and be overwhelming. In fact, for any of us, when we chronically stuff down feelings, we don’t get the practice of handling strong emotion. When it does come up, then, we are ill-prepared to deal with it. Think, for example, of the person stoically putting up with an in-law criticising their partner, probably repeatedly. At some stage, there will be “the straw that breaks the camel’s back” – just one criticism too many – and the person may unleash a massive emotional response, consisting in part of stored-up feeling from previous violations (adapted from Markway, 2014). 

It’s not that these ways of directing emotion “sideways” are bad, but if a more direct emotional expression is desired, how can we help our male clients escape from the clutches of restrictive socialisation?

Re-setting the code

It’s a big job to help someone move past lifelong “training” in a given direction. In the case where the client is keen to make changes in his way of dealing with emotions (that is, his issues with emotional expression are ego-dystonic), psychodynamic therapies and the social constructionist narrative and solution-focused therapies may be hugely helpful; we briefly highlight these, while acknowledging that other therapies, such as motivational interviewing and CBT, may also have a role to play. In the case where the man is dragged into session because his partner is experiencing huge frustration but the man himself does not see that he has a problem (that is: his issues with emotional expression are ego-syntonic), we can look hopefully to emotionally focused therapy, although family therapy and other couples modes, such as imago therapy, likely have much to offer.

We put the psychodynamic therapies right up front in our discussion. Why? If, as is generally claimed, men’s emotional responses are because of socialisation and/or attachment processes, then that therapy may be most efficacious which can take the client back to the root of those processes: the early childhood years when all of us – for better or worse – began to be socialised into our respective “tribes”.

Jung’s psychoanalysis

Carl Jung espoused the essential wholeness of all human beings, but believed that most of us have lost touch with important parts of ourselves. Life’s goal of individuation demands that we give expression to the various components – often conflicted – of our psyche. These typically repressed components cause psychological disturbance until they are made conscious. Each person has a story and when mental illness occurs, it is because the personal story has been denied or rejected; healing comes when the person recovers and owns his or her own personal story (Sonoma.edu, n.d.).

The story will include symbolic archetypes. A man could, for example, be modelling after the archetype of the Invincible Warrior, which could express part of who he is, but he may have repressed the complementary Nurturing Earthmother part of himself (due to that part being discouraged culturally). The task in therapy, then, would be to help the man discover his Nurturing Earthmother side. The two sides, harmonised together, could transcend either archetype and help such a client come into greater wholeness (Geist, 2013).

Psychosynthesis

Similarly, Psychosynthesis, a transpersonal psychology, asks clients to work with body, feelings, and mind to synthesise, or integrate, the various “selves” inside them into a harmonious whole. Psychosynthesis postulates “subpersonalities”: parts of ourselves which constellate and act out in order to meet needs or to defend against needs which seem unable to be met (Assagioli, 1965). Thus, the same man – in angst because of being constrained from tender, loving expressions or emotional sentimentality – may discover an angry subpersonality within himself: one which, he later discovers, is in conflict with its opposite number, a “Sentimental Sally” subpersonality which, while weaker, nevertheless is driving the man’s behaviour from underground because it is not acknowledged; its needs for permission to express a softer side will continue to cause it to act out in some way until those needs are met.

Thus in this mode, therapy consists of finding out what conspired to prevent the man expressing his softer side and working out how it can find expression appropriately in the man’s life. Sentimental Sally also has to work in with the angry subpersonality (as the two will vie for dominance), and both must cooperate with the man’s greater, whole psyche. Somewhere along the way of this, the man is likely to recall early events which shaped his way of being: for example, leaning into his mother for a cuddle when upset and being pushed out and told, “Big boys don’t cry”.

Schema therapy

In some ways, schema therapy would seem to combine the best of several worlds. From its psychodynamic predecessors, it inherits its basic notions that mental health troubles arise from early needs not being met. Five areas of basic human needs are outlined, such as for secure attachment and autonomy/competence. Frustration of these engenders 18 domains of early maladaptive schemas (EMS), from mistrust and abandonment to emotional inhibition (Young, n.d.). The schemas are perpetuated in a person’s life, say practitioners, through cognitive distortions, self-defeating life patterns, and unhelpful schema coping styles, which cause others to respond negatively, thus reinforcing the schema(s) (Young, 2012a). 

In the psyche’s effort to heal, individuals set up relationships similar to the unsatisfying ones which originally engendered the EMS, and thus the unhealthy object relations which stultify growth are continued. The therapist can ask the “lonely child” or “angry child” in a person to set up dialogue with the “healthy adult” in order to heal the overcompensating, avoidance, or surrendering responses that perpetuate a given schema (Young, 2012b). From cognitive behavioural therapy (schema therapy’s other “parent”), there are therapeutic interventions to reframe the cognitive distortions: irrational thoughts are collected in journals/diaries, for example, which are then refuted through rational replacement thoughts.

Narrative

Narrative therapy assumes no single absolute reality, but that realities are constructed by individuals, families, and cultures, and then communicated through language. They are organised and maintained by stories. What is true for us may not be true for another person or even for ourselves at another point in time. In the narrative, social constructionist paradigm, there are no essential truths and we cannot know “reality”; we can only interpret experience. The narrative mind frame, unlike empirical work searching for facts, exhorts us to bring forth our novelist selves. This means that we can understand our client’s story from many perspectives. The work of narrative therapy is to elicit various experiences of the client’s whole self, determine which selves (parts of the client) are preferred in the new narrative, and then support the growth and development of those new selves and their accompanying stories (Ackerman, 2017; Archer & McCarthy, 2007). 

Thus, if a male client has experienced being emotionally stifled in the interest of becoming “manly”, he can be helped to understand how such definitions of masculinity are inherently constructed by society rather than being empirically true. He can be helped to, first, find “sparkling moments” when the issue of being emotionally constricted was not as much of a problem, and then to find ways to “grow” the self – and/or the moments – that were less restrained, more inclusive of perhaps a softer, more emotionally permissive self. In doing this, he is re-storying himself and re-constructing the “reality” that he and those around him will live about what constitutes appropriate masculinity. 

Solution-focused therapy

Like its narrative cousin, solution-focused therapy emanates from a post-modernist, social constructionist paradigm, meaning that it shares with narrative therapy the understanding that there is no such thing as an objective, absolute reality. Rather, reality is co-constructed, so the “truth” of a client’s life is negotiable within a social context; fixed, objective “truths” are unattainable. Clients’ lives have many truths (O’Connell, 2006). Just as narrative therapy tries to elicit the “sparkling moments” in which the problem wasn’t as much of a problem, so too solution-focused therapy enquires into what a miracle would look like if the problem were to be “fixed” or to go away; in fact, much of the therapy has this present or future focus. 

The therapist thus elicits the client’s preferred future. Suggestions for change are based on clients’ conception of their lives without their symptoms (i.e., the healthiest, most empowering vision of themselves and their lives that clients can generate). Changes the client makes will have a ripple effect, generating behaviour to change the whole system (Seligman, 2006; Archer & McCarthy, 2007). Thus a solution-focused intervention could see a male client generating a vision of himself as a fully expressive man living in a community which accepts both his “traditional” male side and also his more emotionally liberated self. The therapy would be likely to search for times and places when this had already occurred.

Emotionally focused therapy (EFT)

Obviously in cases where it is the partner expressing angst and the man sees no problem in his flatter emotional demeanour, the therapies which may be more helpful are those which work with both partners to see how to accommodate both sets of needs and behaviours.

EFT is an empirically supported humanistic (couples) treatment that includes elements of experiential, person-centred, constructivist, and systems theory, but is firmly rooted in attachment theory. It is based on the concept that distress in intimate relationships is often related to deeply rooted fears of abandonment, as an individual’s emotional response to these fears may be harmful to relationship partners and put strain on a relationship. The insecurity may show up as partners asking questions such as, “Do you really love me?” “Am I important to you?” “Are you committed to our relationship?” “Can I trust you?” When intimate partners are not able to meet each other’s emotional needs, they may become stuck in negative patterns of interaction driven by ineffective attempts to get each other to understand their emotions and related needs. 

EFT reinforces positive bonds that already exist, and fosters the creation of a secure, loving bond between partners where there is not one. It does this through expanding and reorganising important emotional responses, which help to shift each partner’s position of interaction while initiating new cycles of interaction that are more beneficial for the relationship. In the non-judgmental environment of session, participants are able to contact and express deep emotions and experiences. In voicing their deepest concerns and conflicts without criticism, they are able to address them and move on to more collaborative, productive behaviours (GoodTherapy.org, 2018). 

Thus if the female partner is experiencing the despair of little emotional validation from a man who does not readily show emotion, he can be helped to see how, if he learns to do that in a way that is meaningful to her, it can benefit not only her but also the whole relationship. She can be assisted to recognise the ways in which he does show emotion – albeit “sideways”, such as Markway (2014) describes above – and to learn to accept how he is without criticism, asking directly at times for her needs to be met. EFT helps people learn to interact with their partners in more loving, responsive, and emotionally connected ways, which can result in a more secure attachment and – we say – greater freedom of emotional expression.

Summary

It’s easy to agree that men generally do not show as many emotions, or as intense of emotions, as their female counterparts. What we have seen to be more difficult is assessing whether a given man is pathological or not in the apparent emotional holding back. Without judging that, this article has demonstrated that there are several options for response if a man’s emotional expression seems greatly inhibited. One is to understand the ways in which men “convert” emotions: to other emotions, to other domains, or to their bodies. The other option is to encourage the man – either alone or with his frustrated partner – to attend therapeutically to the roots of the inhibition, which are likely to reside in insecure early attachments and/or socialisation against expression.

References

1. Ackerman, C. (2017). 19 narrative therapy techniques, exercises, & interventions (+ PDF worksheets). Positive Psychology Program. Retrieved on 10 October, 2017, from: Website.     
2. Archer, J., & McCarthy, C.J. (2007). Theories of counselling & psychotherapy: Contemporary applications. Upper Saddle River, N.J.: Pearson Education, Inc. 
3. Assagioli, R. (1965). Psychosynthesis: A manual of principles and techniques. New York and Buenos Aires: Hobbs, Dorman & Company.
4. Geist, M. (2013). Reflections on psychology, culture, and life: The Jung page. Cgjungpage.org. Retrieved on 22 July, 2019, from: Website.
5. GoodTherapy. (2018). Emotionally focused therapy. Goodtherapy.org. Retrieved on 22 July, 2019, from: Website.
6. Markway, B. (2014). How to crack the code of men’s feelings. Psychology Today. Retrieved on 17 July, 2019, from: Website.    
7. O’Connell, B. (2006). Solution-focused therapy. In Feltham, C., & Horton, I., Eds. (2006). The SAGE handbook of counselling and psychotherapy. London: SAGE Publications.
8. Schexnayder, C. (2019). The man who couldn’t feel. Brain World. Retrieved on 17 July, 2019, from: Website.
9. Seligman, L. (2006). Theories of counseling and psychotherapy: Systems, strategies, and skills, 2nd ed. Upper Saddle River, NJ: Pearson Education, Inc.
10. Sonoma.edu. (n.d.). Handout on Carl Gustav Jung. Sonoma University. Retrieved on 13 November, 2018, from: Website.
11. Thompson, J. (2010). Normative male alexithymia. In search of fatherhood. Retrieved on 18 July, 2019, from: Website.
12. Young, J.E. (2012a). Early maladaptive schemas. Schema therapy. Retrieved on 8 June, 2015, from: Website.    
13. Young, J.E. (2012b). Common maladaptive coping responses. Schema therapy. Retrieved on 8 June, 2016, from: Website.    
14. Young, J.E. (n.d.). Schema therapy: Conceptual model. Retrieved on 8 June, 2016, from:Website.

Please click on the link for the article by BY ERIC LANGSHUR AND NATE KLEMP PHD

Two Science-Backed Ways to Ease a Worried Mind