“Speak up! (Easier said than done)”

“The same thing happens again and again,” complained my friend. “I can’t get a word in edgewise at meetings and when I try, I just get talked over – like I’m not even there.” We commiserated about being talked over in meetings, and I offered all the usual well-intentioned platitudes about being assertive. The conversation nagged at me. How many clients, students, colleagues and friends have I urged to “be more assertive,” as if speaking up were ineluctably both a) easy and b) unfailingly effective. Obviously, neither is the case; I ought to know.

Some relevant personal disclosures: I am radically introverted. I detest unnecessary conflict. Many experiences have shown me the wisdom of saying very little when I feel attacked and while this is, at times, incredibly useful, at other times it just makes things worse. The “worse” that results from speaking up tends to come right away: schoolyard bullies, for example, delight in prey that “fight back,” like cats playing with still-living mice. The “worse” that grows from silence usually comes later, which makes it hard to know when to retreat into silence and wait it out, and when it is worth taking something to the mats.

Some months ago, at a meeting with colleagues, I attempted several times (in vain) to make a point about a problem in the plans for a mutual project. The particulars aren’t relevant here; what matters is that I was trying to point out that if A, B, C are to be combined into D, and the current volume of A, B and C are 2D…well, we need to plan for 2D and not just D. The person in charge of the meeting plowed cheerfully over my objections. Alas, I continued to have concerns about the arithmetic and this was treated as some sort of mutiny and personal betrayal (it wasn’t). No explanation that it was merely a math problem was helpful. I spoke up, I tried again to speak up, and it was, clearly, not effective. Despite efforts to move forward as if all were fine, the relationship appears to be irretrievably damaged. (We did turn out to need 2D – and I did not reference the disagreement; it seemed inappropriate.)

A few months later, my unassertiveness floundered in the personal realm. Details are not necessary; suffice it to say that one person (call this person ‘Bob’) misrepresented a conversation to another (call this person ‘Sam’). Sam approached me with great distress as if I were somehow behind a plan that would involve many people descending upon Sam’s home (there was no plan and had there been, I would have been against it). Fortunately, there was at least some history here of the same type of thing happening in the past with Bob…Bob known to be of the temperament to leap to unexamined conclusions.

A few weeks later, my reluctance to engage in repeated attempts at being assertive ending up costing me two friendships. Back to word problems we go. Friend A said something interpreted to mean something entirely different than A intended by friends B and C. I was (as is regrettably often the case) lost in thought and didn’t hear precisely how the point was (mis)made, or mistaken. B and C elected not to confront A at the time. I, having heard A make this particular point very clearly many times, knew it was not meant as interpreted. When B and C were angry, I felt blindsided. It smacked of the recent colleague problem and social near miss. It is a poor excuse, but it seemed as if, after one attempt, it was useless to be more “assertive.” I felt, as it was with my colleague, that there was apparently no making things clear. I gave up – I dropped my end of the rope – have lost friends B and C, have a strained relationship with a valued colleague, and must face the fact I am the common denominator.

I don’t believe I am the only one at fault. Dismissing legitimate concerns, running off with rumors, closing off explanations: there are plenty of missteps to go around…but there, in the middle of it, am I, retreating into watchful silence when speech seems futile. Determining what is and is not futile obviously takes wisdom, which I lack.

I will still encourage clients to be assertive when it is the appropriate thing to do…we’ll just have to explore whether, and when, it is the appropriate choice.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

When Media Lies Hurt: The Destructive Impact of Sloppy Journalism on Real People

(Originally published in USA Today Magazine, July 2016. A few updates were made for reposting to this blog)

It’s safe to say that most people have long since given up on the idea of unquestioning trust for the media. Walter Cronkite died in 2009. Despite vague mistrust, people are vulnerable to the effect that repeatedly hearing things has. Hearing something over and over engrains it in our brains, even if it’s not true. The repeated lie tends to rise to the top when a related topic comes up. This is one reason so many people believe that, for example, violent crime is up all over the country (it’s not) or that we know for sure exactly what schizophrenia is, or what it’s caused by (we don’t).

As a psychotherapist, I see the pain that sloppy journalism creates for real people on a regular basis. I don’t mean transient worry; I mean the possibility of a lifetime of unnecessary anguish inflicted upon people who believe that the information hurled at them by media must be based in truth.

Three examples will suffice to illustrate; you can no doubt generate plenty of examples of your own.

Media Misrepresentation: People considering suicide always give clues about their intention, and thus friends and family have an opportunity to see it coming and intervene.

According to A. Dadoly in the Harvard Health Newsletter (2011), professional estimates are that 30-80% of suicides are impulsive acts, with little or no planning beyond the immediacy of the moment. That means family members could usually not have read the signs, and could not possibly have intervened. Yet, most people believe, because they’ve been told repeatedly, that warning signs are just about always there and thus are tormented with guilt and self-reproach for failing to see something that was, tragically, probably not there.

Media Misrepresentation: Depression is a medical illness that is a lifelong condition. You’ll be on medication forever because there is something wrong with your brain.

The truth is, depression, or “major depressive disorder,” as it is currently labeled, is a construct. It is diagnosed off a checklist of symptoms. Meet enough of the symptoms for a two-week period of time and, bingo, you can be diagnosed, whether that sadness, poor sleep, lack of energy, poor concentration, etc., is due to grief because someone you love has died, or to some other life circumstance…or, perhaps, something medical. Some research indicates that most cases of depression will improve within 7 weeks whether you do anything to treat it or not. Plenty of evidence shows that lifestyle changes such as proper sleep, diet and exercise, plus social supports and a bit of emotional support via therapy, will create improvement in less time and leave you more resilient the next time life throws you a challenge (which, of course, it will). You can find a wealth of scientific research as well as specific steps to apply that research to real life in Stephen Ilardi, MD, Ph.D.’s wonderful 2009 book, The Depression Cure. There’s plenty of other research out there, of course, but for busy readers, Dr. Ilardi has done a masterful job of tying together many researchers’ work and working out a useful process.

Yet millions of people have been sold the lie that their symptoms are evidence of a brain disorder that requires lifelong medication. The medications change the brain, cause all sorts of unpleasant side effects, such as weight gain, loss of sexual interest and/or function, and general apathy towards others, and often cause terrible withdrawal symptoms. They also carry a risk for impulsive acts of self-harm, including suicide, and violence against others. Almost every adolescent and young adult mass killer in the US in the past couple of decades, with the exception of avowed Islamist terrorists, has been on one or more psychiatric drugs, including many antidepressants.

Do these medications help some people? Apparently so, according to them and their doctors. That does not, however, prove that everyone who is sad for more than two weeks has an incurable but manageable brain disease and is “mentally ill.”

Media Misrepresentation: Your gay son or daughter is going to burn in hell just because he/she is LGBT.

This lie is a criticism of many religions, and recently has been part of the background of a television show called “The Real O’Neals.” One part of the plot involves a gay young man whose supposedly Catholic mother is consumed with despair because “her religion teaches her that her son is going to burn in hell because he is gay.” That’s a paraphrase from interviews I’ve read with a star of the show. I have seen many families suffer under this belief. Parents are alienated from their children; children believe that their parents are condemning them; parents and children alike reject their faith. I will address this from my Catholic perspective; you can do the homework on your faith.

The Catholic Church has an international apostolate (a fancy term for an approved special ministry) called Courage, focused entirely on providing spiritual, emotional and social support for LGBT Catholics. Its intention is not to “make them straight,” but to help them live Catholic lives with the orientation they experience. The official Catechism of the Catholic Church isn’t exactly politically correct: like the psychiatrists of just one generation ago, it considers homosexual behavior disordered – but you could say Catholicism (and all orthodox Christianity) says about the same about any sexual activity outside of marriage.

However, the Catechism of the Catholic Church also says: (paragraph 2358):

The number of men and women who have deep-seated homosexual tendencies is not negligible…They must be accepted with respect, compassion and sensitivity. Every sign of unjust discrimination in their regard should be avoided. These persons are called to fulfill God’s will in their lives and, if they are Christians, to unite to the sacrifice of the Lord’s Cross the difficulties they may encounter… (that “uniting to the sacrifice of the Lord’s Cross, is of course, what all Catholics do when, faced with challenges, we talk about “offering it up” – this is not a unique imposition upon GLBT persons).

Paragraph 2359 ends with, “They can and should gradually and resolutely approach Christian perfection.” Hmmm. No ineluctable path to hell and damnation there.

One can, however, imagine the pain of a parent who imagines their child is immediately rejected by God. One wishes they were bold enough to seek right guidance.

Our Responsibility

It’s easy, of course, to blame the media. Journalists go to college and seem to take pride in getting the “real story,” or whatever they imagine they’re doing. So why don’t they do their homework? Why present the easy, available tale? Psychologically, they appear to indulge in confirmation bias: the tendency to seek out and focus on things that verify what they already “know.” We consumers of media need to check the facts.

Bad information creates pain and suffering. Don’t assume what you read is the whole truth. Do your research, and turn to people who might have access to information you don’t have. Someone’s peace of mind may be at stake.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

Never put off until tomorrow…

The American Association for Marriage & Family Therapy now estimates that the average couple seeking therapy has been having problems for over 5 years when they finally make the call. If you’re a math person, that’s 5.5 x 365 days of practicing being hurt, resentful, bitter, etc. Rehearsing that much will make you pretty good at just about anything…which you might remember a parent telling you, repeatedly, about the music lessons you didn’t want. Your brain is changing, becoming better at remembering the bad times, the hurt feelings, the resentments: you become more efficient at bringing up anger and contempt. Meanwhile, the old, tender pathways are less traveled and harder to find.

Some problems are transient, but others are a pattern. It’s not the details, usually, so much as the pattern. If disagreements always seem to take the same, predictable, awful path from sarcasm to shouting to the silent treatment, something needs fixing.

Would you keep driving your car with the engine light on and smoke rolling out from under the hood for five minutes, much less five years?

The brain changes in response to experience. Experience isn’t just what happens to us. It’s also what we’re doing in our own heads (thinking angry vs. kind thoughts, for example). This means that, whether it’s a personal problem like social anxiety, depression or stress, or a relationship problem, we have some control over changing the direction our brain takes, developmentally.

Whatever the problem may be, it’s better to seek effective help early, before it gets out of hand.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

Surprise! Today is mostly the same as yesterday…

Surprise! For most of us, today is mostly the same as yesterday!

Huh?

Well, maybe I am letting a pinch of my grew-up-in-Jersey show, with an unhealthy indulgence in sarcasm…but I have a point.

Why are so many people surprised when every day, so much is the same?

Why do some sources tell us the “average American woman” tries on four or five outfits before leaving for work? Is it really possible this hypothetical average woman is perpetually surprised by the obligation to wear something besides yoga pants and a slept-in t-shirt? Imagine: “D’oh! Get dressed again???? What the…?” It’s much more likely that what-to-wear becomes, under pressure, an emotional decision (what do I feel like wearing) instead of a practical one. The cool, calm decision on Sunday (what makes sense based on the demands of each day of the week) turns into a workday morning emotion-fest for people who get caught up in “I feel fat” or “I look terrible.”

It’s not just about prepping for the non-surprising workday.

Why is anyone over the age of twelve stymied by the multiplication of dishes in the sink, the need to do laundry, or the fact that garbage cans get full? Worse yet, why are so many couples arguing, night after night, about “what to do about dinner,” as if the need to eat sometime between finishing lunch and going to bed caught them unawares?

I try not to be surprised by the every-day. Maybe I am flattering myself by mincing words here: I am dismayed that Darcy the twelve-year-old cat has once again thrown up in the middle of a wood floor. I am, regrettably, not surprised.

The school year is beginning here in West-Central Florida, and so families all over are waking up to unpleasant (non)surprises: pack lunches? Matching socks? Complying with uniform rules? What??? I am right there with you, folks, amazed that it is once again time to get into the autumn routine.

For me, that includes packing a week’s worth of lunches and ironing a week’s worth of clothes on the weekend. Crazy, right? Until you imagine it taking two minutes to get dressed for work and a few seconds to grab a lunch out of the fridge, instead of trying to figure out what to wear, heat up the iron or touch up shoes, wash fruit and veggies, etc., while the work day morning clock’s ticking. I have it figured out: less than 30 minutes total for all clothes- and lunch-prep on Sunday or cope with 15 minutes or more five times a week. I am saving myself, at minimum, 45 minutes

Emotions are what get in the way for families bickering about “what to do about dinner,” or “how are we going to get the laundry/kitchen/pet duties done.” People are tired, they are hungry, they are stressed out from the day. Tired, hungry, stressed people are not as good at negotiating and decision-making, whether at home or work. Instead of wishing you could come home, magically downshift to a Zen-like mindful state and engage in creative cookery and Pinterest-worthy home maintenance, why not just plan to deal with reality?

The reality is, you will be tired, you will be stressed, and you will wish you had something easy, tasty and nutritious. You will not want to spend a half-week’s worth of grocery money on takeout because the dinner hour caught you by surprise.

The 1990s bestsellers by Elaine St. James (Simplify Your Life, Living the Simple Life, etc.) included very down-to-earth, helpful tips: have a weekly menu that rarely varies. It keeps life simple. That doesn’t mean you can’t have wonderful, complicated meals, but it does mean that you can also plan for: Ugh, it’s been a 14-hour day door-to-door and that homemade soup from the freezer/half a lasagna/whatever ready to go and bag of salad are going to taste really, really good…in about five minutes, instead of spending a half-hour bickering, grumbling, and absent-mindedly eating a half-bag of chips while you try to figure out what to do.

Slices of the culture are having a virtual love affair with simplifying, decluttering, etc. How about decluttering and simplifying the routines of life, the predictable little tasks that are the same each day, so you have more time and mental energy for the things you’d rather do?

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

Cut Them Some Slack

Doing unto others as we would have done for ourselves…well, there is one thing that most people tend to do for themselves that they are often slow, reluctant and resistant to do for others: cut them some slack. Consider the historical narrative on this:

Jesus of Nazareth: “Why do you notice the splinter in your brother’s eye but not perceive the wooden beam in your own?” (Luke, 6:41, NAB)

Soren Kierkegaard: “Most people are subjective towards themselves and objective towards others, frightfully objective sometimes – but the task is precisely to be objective towards oneself and subjective towards all others.” (Works of Love)

CS Lewis: “…It is no good passing this over with some vague, general admission such as, ‘of course, I know I have my faults.’ It is important to realize that there is some really fatal flaw in you: something which gives the others just that same feeling of despair which their flaws give you. And it is almost certainly something you don’t know about…” (Essay: The Trouble with “X”, from God in the Dock)

Psychologically, of course, it makes sense: we, after all, know what we intend to do/say; we have deep awareness of all the people and events that obstruct our good intentions. Meanwhile, we have no clue – or concertedly avoid taking notice of clues we trip over – about whatever obstacles and heartaches might underlie others’ disappointing and often frustrating behaviors. We cannot know what it is like to have the particular limitations that someone else has –anymore than they can understand the particular limitations we tote around with us.

Sometimes someone will say to me in the context of therapy how badly they feel that they are struggling with some particular issue – anxiety, or depression, for example – when (from their perspective) other people all seem to be going around, carefree and without this sort of anguish. In a country in which 20% of women and 10% of men are prescribed antidepressant medications each year, and who knows how many various prescriptions for anxiety, it hardly seems fair, to oneself or others, to assume that everyone is skipping along as carefree as they often very deliberately attempt to appear. Then there are physical pains and illnesses; the sufferings of loved ones; the anxiety for a loved one in a danger zone; grief; loneliness. These are so often invisible except for the side effects of passing crankiness or thoughtlessness or scatterbrained-ness that annoy other people who are, to quote Kierkegaard, being “objective” about others.

For the person who is suffering and, unable to see evidence of suffering in others, believes s/he is alone, it is disheartening. To be so alone in suffering…! But no one is alone in their suffering.

Not all the objective/subjective dichotomy concerns suffering. Sometimes it is about unseen limitations or differences. No doubt you have something you are not naturally good at doing. Perhaps it’s spelling, or “being handy,” or math. If you are a grownup who is doing well in life, you may have turned this into a kind of joke, or perhaps you use this as exhibit A, the evidence that you know you’re not perfect: “Oh, I know I’m far from perfect…you should see the disaster my checkbook is,” but in fact you have a certain secret pride that you do not have to bother with this, or that your flaw is so small and even borders on not being a real defect at all…and, after all, at least you are not “stupid/lazy/arrogant/whatever you perceive in someone else.” Yet unless you are in that experience, you cannot understand the frustration of someone with a brain injury who on the one hand knows that a certain skill set used to come naturally but is now a fuzzy memory and source of perpetual struggle. You cannot know what it is really like for someone with an IQ thirty points below yours to struggle through a complex and fast-paced world, when their processing speeds are so much slower, and you likewise cannot know what it might be like for someone with an IQ thirty points higher than yours to bear patiently with you.

Part of good psychotherapy, like good spiritual growth, is becoming aware of one’s flaws – not for the purpose of self-recrimination and useless shame, but as opportunities for growth of oneself as well as a growth in compassion for other people. The process, once begun, is the work of a lifetime.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

If you won the lottery…!

We all know the stats: that six months after a major windfall, such as the lottery jackpot, people are no happier than they were before they won. Most of us assure ourselves, WE would do better. WE would know how to manage that blessing in such a way as to increase the happiness of many people – including ourselves – on an ongoing basis. WE would be happier, not succumb to dopey decisions and would never blow up our lives with self-destructive, self-indulgent bad behavior.
Here’s a question: what would you do if you won the lottery, and why aren’t you doing some version of that already?
If you imagine you’d travel, see new places and try new cuisines, are you saving money for a trip and seeking free/cheap adventures in your own area, experimenting in the kitchen and otherwise exploring here at home?
If your job is a poor fit, are you meeting your intellectual and creative needs via outside pursuits, or investigating how to transition to something that’s a better fit, or are you just feeling “stuck”?
Most changes people imagine making after winning a lottery are really superficial and thus, much to their surprise, they show up in that new, changed life with the same “them,” with all their flaws, quirks, and preferences. That means that we all would tend to level out at whatever our prior level of contentment was, pre-jackpot. If you’re a happy person, you’ll keep on being happy…and if you’re cranky, well, you’ll just be a rich, miserable person to be around instead of a not-rich miserable person. Worried people will keep on worrying until they decide to learn how to change that – which doesn’t require a lottery jackpot.
You can be happier today. You can find a new adventure in your town this weekend. You can learn something exciting and be on the way to mastering a new skill this week. Alternately, you could sit around and wait to win the lottery. You get to pick.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC
© 2016
Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Too busy!

People brag about the strangest things.

Not getting enough sleep is one; are Americans in some sort of dysfunctional competition to see who can get by on the least possible sleep – regardless of the effect on their mental and physical health?

Another is being busy – so very, very busy – that one could not possibly do anything healthy, or creative, or refreshing in any way.

Is it real busy-ness? It’s hard to say, but I have my suspicions that it often comprises some combination of underestimating how much time is frittered away on time-wasters, taking on a lot of extra and unnecessary tasks, and, sometimes, more than a hint of pride. You know, the people who find out you actually read books in the evening or squeeze in a date night with your spouse and give that little smile and a hint of a sniff when they say, “Well, it must be nice…” Well, yes, actually, it is. Very nice.

Pride, or arrogance, aren’t necessarily obvious. Healthy humans have a normal, natural need to feel needed and wanted. This is a good, but the fear that somehow your absence will cause all of creation – or at least your workplace or the kitchen at home – to immediately crumble into dust is not good. Even Jesus and Moses sometimes sneaked off for some very necessary R&R, either to be alone with God or also with some of their most loved, trusted friends.

Some people are going through a stage of life that is very busy. People with school-aged kids who each participate in one extra activity will indeed be temporarily overly busy, driving to practice or lessons. They check homework, look under the sofa for shin guards, and use their vacation time for pediatric appointments for yet another ear infection. This stage is transient. Even too-busy parents, though, often hide time-wasters into their day.

When someone asserts always being “too busy” to do things they claim they really want to do, then I suspect that perhaps they don’t actually want to do those things. It would be better to say, “Oh, no – last thing I want to do is be stuck in a gym five mornings a week,” then to dodge exercise by pretending they are just too, too busy. Once they are honest about the issue (apparently they would rather do something else than spend hours on the human version of a hamster wheel) they are free to figure out how to meet the essential need (enough exercise to stay healthy) and stop dodging reality with brag-worthy busy-ness.

It’s hard to give up the busy excuse to oneself. It might be a polite dodge to other people (but remember that “let your yes mean yes and your no mean no” admonition?) but it’s just pointless to lie to oneself.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

The Cancellation

Another day, another call or email: a couple whose first appointment was scheduled for later this week has cancelled. They have “found a doctor who takes our insurance.” That would be fine but for one detail: the appointment was for marriage counseling.

This could create a dilemma for the doctor who “takes our insurance,” if the clients turn out to be shopping for marriage/relationship counseling. This is because unless one member of the couple is diagnosed with a mental disorder, and the treatment rendered in those conjoint appointments comprise empirically supported treatments for that disorder, it is probably not covered by their insurance, whether the doctor “takes it” or not. No doubt this will be part of the discussion during their first appointment, when they inform the doctor that the problem is not helping Partner A cope with depression or anxiety (or some other mental disorder diagnosis), but rather some sort of relationship problem. Now, if Partner A is depressed, and the treatment involves communication skills combined with cognitive-behavioral therapy, or another empirically supported form of therapy that can involve the spouse as a coach/partner in healing, that’s excellent and ethical practice; not so for relationship problems.

At least I found out in advance, sparing the mutual aggravation of patients who imagined somehow that their marriage counseling needs are someone else’s financial responsibility and of a psychotherapist who expects to be paid for services.

This sort of retraction prior to a first appointment happens sometimes in my practice. “I found someone who takes my insurance.” This, despite my spending 10-15 minutes on the phone before setting that appointment and providing this information about my practice. I don’t contract with health insurance companies: it’s clearly stated on my website, and I tell people during that first, free, fifteen-minute consult.

Why bother mentioning it? There are ethical issues at hand.

To be perfectly frank: health insurance is for health problems.

It ought not to be used to get a discounted rate, subsidized by every other person paying premiums to that health insurance company, for marriage counseling, or premarital counseling, or vocational counseling, or any other normal, problem-of-living, life phase process.

My website clearly states my position on health insurance: I don’t contract with insurers because the bulk of what I do is not billable. I do not want my work with couples to be tainted by ethically questionable gymnastics in which we justify treating the relationship because it will indirectly help with a mental disorder. I will not label children with a brain disease because their grownups are getting divorced and upsetting the children, resulting in a custody evaluator referring the children to me. I will not participate in diagnosing people when I am concerned it is not in their best interest – a position supported, as it happens, by the American Counseling Association.

So, no, I don’t “take” insurance. Insurance cards are not debit or credit cards, anyhow: there’s no “taking.” There’s submitting paperwork and hoping one is eventually paid, or being denied payment and then having to bill the client, who may have been discharged months ago.

I don’t diagnose people for the sake of billing. If a client meets criteria for a diagnosis, what we’re doing is aimed at treating the symptoms of that diagnosis and, after being provided information about the process, the client chooses to submit the information to his/her insurance company, I will provide the appropriate form for the client to try to be reimbursed.

I work with human beings who are having problems in their lives (provided they are in Florida, where I am dually licensed for mental health counseling, and marriage and family therapy), and who want life to be better. They want better relationships and a hopeful outlook; they wish to live with purpose and meaning.

Those are not mental disorders. They are signs of health and hope.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

Avoidant Personality Disorder, Social Anxiety, or Just Shy?

Simple shyness? Social Anxiety Disorder? Avoidant Personality Disorder? What’s the difference? Are we just pathologizing normal behavior? Why so many labels?

Well, the labels exist to help professionals differentiate between constructs. That’s what most diagnoses are: categories put together by committee, identifying particular experiences or patterns of behavior, thinking and/or feeling that tend to co-occur. That’s an extreme simplification, but it’s a good jumping-off point for us.

Shyness is normal-people-speak. It’s the way we describe someone, or ourselves, when we are a little reluctant to “blow our own horn” or “put ourselves out there” (whatever THAT means). A little shyness means some mild worry about doing the right thing, not embarrassing ourselves, and wanting to avoid being a nuisance.

Social Anxiety Disorder (SAD) is a psychiatric label that covers a level of shyness that interferes with someone’s daily life. That’s the test: whether the person’s regular life is constricted by worry about saying/doing the wrong thing in social settings and a tendency to avoid social gatherings or work or school related activities. It’s anxiety: there are both physical symptoms of fight-or-flight (elevated heart rate, for example, or more perspiration) and psychological symptoms (worrisome ideas about being in the spotlight and doing something “stupid,” for example). People with SAD usually have close relationships and get through daily life pretty well, with bumps along the way when big events or unusual circumstances – public speaking at a work meeting, for example, or large gathering – looms.

Avoidant Personality Disorder (APD) is sometimes confused with SAD. ADP is markedly different, though, because it encompasses a global low self-esteem and fear of being judged and found wanting in just about every way. So, for example, the person with some social anxiety has close friendships but might feel a bit anxious about going to a wedding reception with a lot of people s/he doesn’t know. The avoidant person has few close relationships out of fear of people finding them just not good enough to be friends. The APD person suffers anguish before annual performance reviews, and even gentle constructive criticism is received as devastating evidence of how deficient they are.

The fear is not “just in their head.” Fear is always a full-body experience. When a situation seems to be a threat (for the person who suffers with APD) to be judged and found wanting, the body responds before the logical, higher brain has even identified what is happening. So the amygdala has sounded the general alarm – the endocrine system flies into action, and as a result logical assessment is curtailed. Telling someone whose heart is pounding, whose blood is full of adrenaline and a massive dose of glycogen and is primed to run away that they are just overreacting is not helpful. Learning how to manage this, how to recover from the old messages of being “less than” and “not good enough,” is a process, not an instant fix. It can be healed.

There’s much more to these labels and to the details of treatment, of course, but perhaps the useful take-away today is: help is available. A lot of people will find that solid self-help approaches based in cognitive-behavioral therapy research (David Burns, MD’s books are excellent examples of these) quite sufficient for mild to moderate social anxiety. When that anxiety is all-pervasive, and there are few relationships out of fear of being found wanting, and loneliness and fear of being judged rule one’s life, the additional support of a counselor might be more helpful than trying to struggle through alone. Ironically, group psychotherapy can be quite effective for these difficulties – but it’s hard to find them.

If you know someone who is struggling, try to help them get help.

Dr. Lori Puterbaugh

Why are personality disorders so difficult to treat?

Well, there’s a complicated question! This post attempts to present an overview response.

A personality disorder, like just about all mental disorder diagnoses, is made based on a checklist of complaints, symptoms, and observations. However, personality disorders are very different from what we normally think of as emotional problems.

Consider, for example, depression. “Depression” is diagnosed when 2 weeks have passed and certain criteria have been met (and there’s no “pass” given for grief or other traumatic events in the new diagnostic manual, although we’re supposed to note it in the records). Most people know when they’re sad, irritable, unhappy, and hopeless. It feels awful and they want to get that bad feeling off of them. Some people might not think of it as “depression.” They might identify it as a “low time,” or it might be grief, or a normal adjustment to a new phase of life such as marriage, an empty nest, or graduating from college. It might be a normal but very painful response to some new curveball life has thrown at them: an illness, a layoff, retirement, etc.

A personality disorder is different because it is pervasive; like the personality of any person, it is part of everything. Your personality impacts how you interpret everything that happens, the way you react to people and events, the emotions you experience. This goes for healthy people as well as those whose patterns are far enough from the big, wide range of normal to merit a “disorder” status. So, when someone seems to have a personality disorder (say, narcissism), they are not experiencing their diagnosis as a messy, icky experience to be stopped. They are rolling along (over other people) and having their life. Everything comes through a lens that assures them that they are special, entitled to preferential treatment and to have their way, and, well, let’s face it, just better than us. Problems are experienced as due to the outside world and their own role in those problems is not apparent.

From a therapist’s perspective, when someone comes in with depression, even if that’s not what they, or we, might call it, they know they are unhappy and they want very much to feel like themselves again. They are hopeful that a counselor can help them push through this difficult time.

When someone who meets criteria for a personality disorder comes to treatment, it’s usually because of some other issue, such as work or relationship problems. Remember that each of us is walking around, seeing the world through our own eyes and interpreting everything we experience, including our own thoughts and feelings, through our unique mental structure. You build that mental structure from the earliest moments of life. Is the world safe? Are my needs met? Are the grownups who tend to me patient, gentle and kind? Babies are already sorting out information and creating a set of basic assumptions about the world that will become essential aspects of their personality. It’s so deep, it’s hard to not take for granted that our way of making sense of things isn’t necessarily the only, or best, way. So when patterns of problems arise with colleagues, bosses or family, it’s hard to believe that the problem is fundamental to our mental structure; it defies logic and could be very insulting. The person may be suffering terribly, every day. This is definitely the case with some of the personality disorders, such as Borderline Personality Disorder, Avoidant Personality Disorder and Dependent Personality Disorder. Whether these or any of the personality disorder diagnoses, the person did not choose this burden and it isn’t their fault. However, presenting it as an internal problem – to them – can feel like blaming and attacking – which is definitely not the therapist’s intention.

Imagine if something terrible happened to you: a tsunami. Your workplace is destroyed. You lose your house. You lose your stuff. You catch a mosquito-borne illness and suffer long-term ramifications. It’s a series of terrible events and you find yourself traumatized and perpetually anxious. Is that anxiety your fault? Certainly not. Just so, the early life experiences that set people up for the challenges we call personality disorders are not their fault. However, it’s a problem that they can learn to heal, but that can sound like blaming the victim. Thus, if someone meets criteria for a personality disorder, trying to sell them on dealing with the personality disorder is pretty much like saying, “Look, an awful lot about the way you think and respond to things is kind of messed up. But, never fear! Together we can bulldoze your personality and how you think, feel and behave, pour a new slab, and then we’ll rebuilding you from the ground up. You’ll learn new ways of thinking, feeling and behaving.”

Even when it’s dressed up in tactful, compassionate psychological language, that, my friend, is a very hard sell indeed.

Dr. Lori Puterbaugh

drloriputerbaugh

Psychotherapist, Author, Teacher

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