Parenting Matters

Anger Outbursts: Common Myths About Anger Management and Thought Based Interventions that Actually Work

Dr. David Perna

If you are a parent who is struggling with your child’s anger outbursts stop blaming yourself. Instead, join the crowd. I work with a multitude of educators and mental health professionals who are equally stymied by kids who display anger outbursts. And they are professionals. They typically use outdated solutions that do not work like, “I just have them hit a pillow,” or “I tell them to count to ten.” These interventions typically don’t work. How do I know that these interventions do not work? I simply ask my patients. They have said, “That is the dumbest thing I ever heard-count to ten.” Or, “I am getting really good at hitting my pillow, and my brother.”

Research shows that if you want kids to punch someone when he/she is angry then simply have him/her practice punching something on a regular basis, such as a pillow. Remember, practice make perfect. I help teach kids that angry oubursts are a choice. These behavioral choices are influenced by the thoughts that precede them. By working to understand their unhealthy thoughts they can avoid poor choices. It might sound complicated but it is pretty simple. Here are three examples.

1. Poor Reality Testing: We commonly think that everyone shares a common sense of reality when an event occurs. However, kids who struggle with their anger have a difficult time with shared reality whether they are participating in a sporting event, a birthday party, or a board game. Younger children are more prone to these kinds of challenges given their age and limited ability to understand many cultural/societal/group rules. Kids with anger challenges commonly maintain a more regressed view of the world. In essence they are not tracking the same information that most kids are paying attention to. In the end they make behavioral decisions that cause tension and then lash-out when other people challenge their perspectives.

Example #1: An example of Poor Reality Testing would include a child who “throws a nutty” while hitting during a baseball game. In this situation he is likely to think that the umpire’s call was wrong, quickly feel embarrassed and humiliated, and then start to throw his bat and helmet to the ground. Reviewing with him over and over again, “Take a deep breath,” will not work. He believes he was wronged. A better foundational intervention would be to talk with him about how people see things differently. How umpires sometimes make mistakes. And how although he has a right to an opinion in the end the umpire has the final say. Reminding him before he steps up to hit that he should try his best, but abide by the umpire’s feedback is most critical. After he bats you can encourage him to tell you his opinion of the umpire’s calls whether or not he gets on base. This will allow him to anticipate a difference of opinion and provide him with an outlet for discussion. Increased language usage leads to increased reality testing.

2. Pseudo-Paranoia: Pseudo-paranoia is evidenced by the extent to which certain kids seem to always start off with a negative view of others. No one is trusted until they “prove” themselves, and the proof required is tremendous. These kids are not fully paranoid in the sense that they do not think that the government is planting transmitters in their teeth, however, they tend to focus on what is wrong with others rather than what is right about them. Pseudo-Paranoid thoughts commonly piggyback on top of poor reality testing and enhance it.

Example #2: Sometimes kids will think that their schoolteacher does not like them. Despite any practical proof they think that other children in their class are favored. Many times they will erupt in class and lash out yelling that the teacher is not fair, cares more about the boys than the girls, or specifically chose a writing activity since the teacher knew that she “hates writing.” In such circumstances it is important for the teacher to articulate to the student why certain activities are important.

I will frequently tell teachers that they need to catch my patients “doing things right.” By balancing out one situation where a limit is set with five situations where they offer praise I have found that my patients will typically settle down and feel at ease. Parents will commonly comment to me, “I don’t want my kid to feel indulged or to become spoiled.” I will typically respond by saying that without such balancing their child will be so overwhelmed each day in school that he/she will not make progress. The first step is always balance and calming. During this phase the emphasis is on providing firm examples that substantiate that the teacher is fair. The second step is to offer better reality testing.

3. Rumination: Cognitive rumination is based upon the rather distasteful notion of actual “rumination” which is exemplified by a cow chewing and re-chewing its cud. Unlike most people who are impacted by an event, digest it, and let it go, kids with anger disorders are marked by an inability to let things go and cognitively move on. These issues keep coming back up again and again in their thoughts. When angry kids recirculate these “stuck thoughts” they display a limited ability to show restraint. Like a snowball that gathers energy and weight as it rolls down hill, ruminating thoughts generally gather steam and lead to an explosive release.

Example #3: Adolescents tend to struggle with ruminating thoughts. It is common for them to arrive home, go to their room and start to brew about an earlier conflict. When an unsuspecting parent knocks on their door to tell them it is time for dinner, he/she is typically bombarded with an emotional barrage that throws them for a whirl. Parents commonly start to scream in response, which in turn provokes a verbal trench war. And let’s be clear, trench warfare never really ends pleasantly. In contrast it would be better for parents to remain calm, note their surprise in not knowing that their child was upset, assume that their child has some legitimate reason to be upset and ask him/her to simply put his/her frustration into words. Be patient. Remember, verbal mediation is the “Holy Grail” of anger management. Good luck! Better yet, Good Skills!

 

Dr. David Perna

Dr. David Perna

Dr. Perna is a licensed psychologist who has an expertise in the treatment of child/adolescent anger management and its relationship to learning challenges. He is the owner of Copernican Clinical Services, a group practice with offices in Lexington and Newton, MA. He works with families, schools, and various professionals in addition to running specialized anger management groups. He maintains an academic appointment at Harvard Medical School and is a Clinical Associate at McLean Hospital, the medical school’s largest psychiatric teaching facility. He is the former Director of the Child/Adolescent Anger Management Program at McLean Hospital. Feel free to follow his newsletter/postings/ramblings about anger management, learning, adolescent psychology, and family therapy on the web: www.copernican.us, or visit his personal website: www.davidperna.com.

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Pop Quiz: Which Mouse has ADHD?

By Henry David Abraham MD

If you harbored any doubt that ADHD is real, take a look at the time-lapsed photo below. It comes from Duke University where they are trying to define ADHD on a molecular level. The mouse in the left test-tube is normal. The one in the middle is missing a certain gene. The one in the right tube is missing a pair of those genes. The blurred image tells the story. Hyperactivity is for real, at least in mice.

But if you or your child has suffered from attention deficit-hyperactivity disorder you don’t need evidence from a lab. The classroom tells the story well enough. The ADHD child is the one who can’t keep his seat, who runs and climbs at the wrong times, who can’t wait his turn or keep from talking. A more subtle form is found in the kid who can’t pay attention, can’t organize, is forgetful, distractible, and forever losing things. This is the inattentive type of ADHD. Kids with poor attention have trouble reading. Kids with hyperactivity have trouble listening. Some kids have both types.

We even know where it comes from, sort of. Genes have been identified. Smoking in pregnancy increases the chances a baby will have ADHD. Even Tylenol in pregnancy increases the odds somewhat. The problem is that there is no simple test that clinches the diagnosis. It’s more a matter of a consensus between parents, teachers and doctors that seals the deal. Knock one of those out of the discussion, and you open the door to years of error.

Consider a short list of some of the other problems that can cause hyperactivity without ever being ADHD: learning disabilities, autism, mood disorders, drug abuse, caffeine, thyroid disease, asthma medication, to say nothing of a new sibling, new school, divorce, or death of a parent or grandparent. If there is one take home lesson, it’s that diagnosis should drive treatment, not the other way around.

When people agree on the diagnosis, treatment should follow two principles. The first is to create a state in the child of what AJ Martin calls “academic buoyancy.” That’s when a student develops the capacity to overcome setbacks that are typical of ordinary life at school. In severe cases medication is nearly always essential, since a strictly behavioral program is not likely to succeed alone. But behavioral steps in class and at home are essential. These children are not simply going to be cured by a pill. Needed as well are getting classroom accommodations, building classroom citizenship, making and keeping friends, and seeking schoolhouse victories in class and after school.

This brings up a second principle. Treatment must protect the children from us- the swarm of well-meaning parents, teachers, counselors and doctors who all want to do something about this whirling dervish of a child. Too often an overly aggressive treatment plan labels the child as trouble, a poor learner, not normal. The result is stigma, social isolation, and the continual drumbeat of inadequacy that the child hears and comes to believe. It’s not that you should do nothing. But whatever is done has to be done carefully. Note that on the average, symptoms diminish by about 50% every 5 years between the ages of 10 and 25. It’s fair to ask if a child’s problems are likely to disappear by adulthood, why treat in the first place? Because they may not, and without treatment she is in for a childhood surrounded by handwringing adults. This is not good for anyone.

What about the child with mild or moderate ADHD? They look OK for the most part, like the mouse in test-tube 2, but they still stand out by being inattentive rather than hyperactive, girls rather than boys. They are also annoying, irritable, friendless, indifferent to school work, anxious, or depressed. They may be helped by classroom accommodations, tutoring in tough subjects, and a little more parental involvement. Medications may be an option if behavioral approaches don’t do the job.

Medication is a big stick, and there are risks as well as benefits. Medications for the most part are stimulants. They are abusable, addictive, and with unpleasant side effects like insomnia, anxiety, and weight loss. In large doses they cause paranoia and psychosis. On tests and papers they can result in blithering. Worse, in a Dutch study of heroin addicts, fully one quarter of them had ADHD. And among ADHD patients, the risk for drug abuse was increased seven times.

So why has the sales of stimulants for ADHD quintupled in the last ten years? The answer is vividly described by Alan Schwarz’s recent piece in the New York Times, “The Selling of Attention Deficit Disorder.” The sale of stimulant drugs is big business. Shire, the world’s biggest producer of ADHD drugs, just recorded some of its highest profits, largely based on sales of its stimulant Vyvanse. Shire even supports an on-line six question self-quiz to tell you if you suffer from their favorite disease. Nearly half the people who took the quiz for the Times were classified as possible ADHD cases. (Trouble wrapping up a project? Sounds serious. Call your doctor!) Stimulants have a ready market among desperate parents, hurried doctors, and students willing to divert their drug supply to friends who want to pull an all-nighter. The medications also have a thriving after-market among addicts. Heroin may have killed Philip Seymour Hoffman, but stimulants helped. A reporter for Al Jazeera asked me recently if normal college kids should use stimulants to enhance their school performance. Brave new world, that has such questions in it.

 

Henry David Abraham, M.D.

Henry David Abraham, M.D.

Dr. Henry David Abraham is a psychiatrist in Lexington, MA. He is the author of several books on drug education, including What’s a Parent to Do: Straight Talk on Drugs and Alcohol, and the e-book for teens, The No Nonsense Book on Drugs and Alcohol, available on Amazon.com and BN.com.

 

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The Lexington Asian Mental Health Initiative Invites You to a Community Forum

Balancing Stress and Success – An Asian American Perspective

By Laurie Atwater

The demographics in Lexington are changing. Our Asian population is increasing and it is especially notable that 30 percent of school aged children are of Asian descent (Chinese, Indian and Korean). The pressures facing all students in affluent communities: pressure to create a “resume” of impressive extracurricular activities, the accumulation of AP credits and test prep craziness, often combine with culturally specific problems to create excessive stress and can lead to depression, anxiety and suicidality among our Asian American students.

SATURDAY, MARCH 29TH 9AM-NOON
MARGE BATTIN AUDITORIUM
AT CARY HALL
MASSACHUSETTS AVENUE, LEXINGTON

YOU WILL LEARN:
What does the data tell us about Lexington’s Asian-American students and parents?
How can you help your child balance stress and success?
How does immigration influence mental health?
How can you communicate better with your child?
What resources are available to help?
PRESENTERS:
Tim Dugan, M.D., Assistant Clinical Professor Psychiatry, Harvard Medical School
Rama Rao Gogineni, M.D., Dir., Div. of Adolescent Psychiatry,
Cooper University Health Care
Josephine Kim, Ph.D., Lecturer, Harvard School of Education
Ed Wang, Psy.D, Director, Multicultural Affairs, Mass. Dept. of Mental Health
The Breaking Silences performance with Christina Chan and Pata Suyemoto
Lexington Asian students

Although financial problems are often the drivers of health disparities among immigrant groups, this is not the case in Lexington. Pressures on Lexington’s Asian American children come from two sources: family and society. Family pressures revolve around performance and achievement and respect for parental sacrifice. Societal pressures include the difficulty of straddling two cultures, dealing with stereotypes, prejudice and bullying. Young Asian American women (15-24) have the highest suicide rates across all racial and ethnic groups according to the National Alliance on Mental Illness (NAMI). Three decades of NAMI research on Asian American mental health shows that Asian Americans exhibit high numbers of depressive symptoms and suicide is the fifth-leading cause of death among Asian Americans, compared to the ninth-leading cause of death for Non-Hispanic white Americans.

Asian American teens experiencing mental health issues do not want to appear problematic or create problems for their families. Success is very important in Asian families so Asian American students who are having a difficult time academically may become depressed and isolated because asking for help can be interpreted as a weakness. Feelings of shame accompany issues of mental health in many Asian families, in fact, Asian attitudes toward mental illness are generally negative. Asian parents may feel that it reflects poorly on their parenting. Asian Americans as a group do not seek mental health help. At Lexington Youth and Family Services (LYFS) the therapists began to notice a pattern: Asian kids would drop by for help, but they wouldn’t come back. That was 2011.

This was concerning to Marsha Lazar who was the director at LYFS at the time. “It really jumped off the page at me when I saw the numbers,” she said in a recent phone conversation. While Asian kids were coming to LYFS at a percentage that reflects the number of Asian students (29%) at the high school, it was difficult to get them into therapy because they wouldn’t involve their parents according to Lazar. As a former community organizer, this struck her initially as a health disparity. “These kids are under as much or more stress than the Caucasian kids, but they don’t have access to the same kind of support because they don’t feel free to tell their parents they are having problems.”

When she began to ask Lexington therapists ‘what’s this all about?’ Lazar encountered lots of acknowledgement and agreement on the subject. For whatever reason, Asian kids were not getting the mental health help they needed. For Lazar who is also a social worker, it was time to jump into action. LYFS needed more information, so they wrote a small grant and submitted it to CHNA 15 (Community Health Network Area). They were approved for $5K and that got them started.

They put together a committee with members from LYFS, the Indian Americans of Lexington (IAL), Sophia Ho and Peter Lee from the Chinese American Association of Lexington (CAAL), Lexington parents Wenjie Cheng, Eileen Jay, Gwen Wong, Lorelle Yee, Fuang Ying Huang and Nirmalla Garimella, students, clinicians and representatives from the Lexington human services department, Officer Hsien Kai Hsu of the Lexington Police Department and Lexington public school Guidance Counselor Cynthia Tang. “The fact that we got buy-in from all of these community partners was so encouraging,” Lazar says. “The police had 2 to 3 people there every meeting,” she says. Emily Lavine, Lexington’s Assistant Director of Youth and Family Services and new youth outreach coordinator Matt Ryan have also been involved.

One of the most exciting initiatives that the committee has been able to complete was spearheaded by “two hotshot kids” (as Lazar calls them) from LHS. Asian American students Sirena Luo and Charlotte Wong Lebow were able to get a special survey incorporated into the junior year health curriculum. Soon they will also have results from a freshman survey and will present their findings at the forum. In addition to the student surveys, Lazar has received 147 parent surveys that were conducted with the help of CAAL. She is very excited to be able to present the findings to a wider audience at the upcoming.

CAAL president Peter Lee is very excited about the program and hopeful that they will get a good turnout from CAAL families. “This is how we as a community, we as parents, can help our kids,” he commented in a recent phone conversation. “I think it’s pretty universal for Asian parents—you want to see your kids succeed.” Peter feels that Asian parents and kids often don’t know how to communicate when it comes to these issues. “The problem is out there,” he says, “and I don’t think people are really aware of how much of a problem it is. I do think communication is critical.” Peter is hopeful that the forum will help both parents and students. “I think there’s a lot that each group can learn from each other,” he states. “How do kids talk with their parents about the challenges they may be having? How do parents listen? That’s a good place to start and a good reason to attend the forum,” he says.

“We really want to invite people to join us for this forum!” Lazar says. Participation among all groups in the Asian community is especially important to the success of this initiative. Tim Dugan, LYFS Chairman of the Board and Clinical Consultant also has high hopes. As a Lexington resident, Tim is vested in the community and its kids. “We’ve been working together to understand what Asian kids need, what parents need and how we can respond as a community,” he says. “We are so proud to have joined together with Lexington’s Asian parents and community organizations to learn how we can better support Asian students.”

The greatest hope is that the Asian families in Lexington really run with this opportunity. “All parents want the best for their kids, but sometimes it’s not clear what the best thing is,” says Tim Dugan. “In the end, we are reminded again, that we were all kids of immigrants at one time or the other and needed help of one kind or the other to develop truly satisfying lives. We hope that all members of the Lexington community can join us in a joint contemplation of strain, challenge and hope.”

One thing is certain—if parents are involved the forum will be more successful. Please plan to attend this very special program.

 

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Energy Drinks

Henry David Abraham, M.D.

Henry David Abraham, M.D.

By Henry David Abraham, M.D. The story goes that coffee was discovered when a shepherd noticed his sheep dancing after they ate beans growing on a hillside. Humans have been using that bean ever since for alertness, inspiration, and energy. Caffeine is the world’s most popular drug. The US is the world’s greatest importer of coffee- nine pounds a year for each one of us. At birth caffeine is present in 75% of infants, and thanks to sodas and cocoa, in preschoolers, too. So when caffeinated “energy” drinks appeared in gas stations and supermarkets, consumers yawned, until now. Today brands like Monster Energy and Red Bull are household names and a $20 billion a year business. One third to one half of teens and young adults will try them. As the use of these drug vehicles has increased, so have reports of problems. Most people are familiar with the common problems of caffeine- jitters, insomnia, and anxiety. Energy drinks kick that list up a notch, to include seizures, strokes, and at least 13 possible deaths. There are now 20,000 emergency department visits a year related to energy drinks. Kids with preexisting medical conditions, especially those of the heart or brain, are particularly vulnerable. Recently, the makers of Monster Energy moved to sidestep the FDA requirement that they report any problems with their products by calling them “beverages.” This moves Monster to a different aisle in the supermarket and lets them sweep bad news under the rug. “But wait a minute, Dr. Abraham. Aren’t you just being a caffeine cop? How much caffeine is in an energy drink in the first place?” Answer: about one to three cups of coffee. How bad can that be? This year 18 experts on child nutrition said how bad in a letter to the FDA. They pointed out that a caffeine drink is different from a cup of tea or coffee in a number of important ways. Caffeine in coffee or tea is in a natural, botanical form, while the caffeine in energy drinks is added by the manufacturer. Another difference is that chemically concocted caffeine drinks contain a wild mix of Frankenchemicals: compounds not often mentioned in polite company that have little or no connection to normal human nutrition. Occasionally these chemicals do things to you. Guarana, one energy additive, for example, has one of the highest concentrations of caffeine in any plant, triple the caffeine in coffee. A third important difference is a matter of the use of energy drinks by children. There is no minimum legal age to buy them. If a child consumes a drug at a dose intended for an adult, this is an invitation to an overdose. The smaller the child, the greater the trouble. This among other thoughts led a committee of the American Academy of Pediatrics to say, “…caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents.” That brings me to the cultural differences between coffee, tea and energy drinks. Hot tea or coffee is sipped slowly. People meet for coffee. They serve coffee and tea at the book club. They drink tea together at the Chinese restaurant. The makers of energy drinks live on another planet. An ad for Monster Energy on Amazon says it all. The 16 oz. can of Monster “packs a vicious punch but has a smooth flavor you can really pound down.” Not exactly “meeting a friend for coffee.” This Brave New World of “beverages” may explain a recent study where Australian teens suffered cardiac and neurological toxicity after drinking three to eight bottles of energy drinks at a clip. From a public health point of view, the greatest harm from an energy drink is when it is mixed with alcohol. Being drunk is bad enough, but being wide-awake drunk is stepping on the accelerator with your eyes closed. Under no circumstance should an energy drink be thought of as a cure for alcohol intoxication. It’s not. Now before the proprietors of Starbucks and Peet’s take out a contract on me, let the record show that I am not a caffeine cop. Coffee is my favorite drug- er, drink. Of all the drugs I worry about, coffee is not even a warning blip on my radar. Its benefits vastly outweigh the risks. Its psychological and health effects are varied and proven. It reduces the risks of Alzheimer’s disease, certain cancers, heart disease, and type II diabetes. Should teens drink coffee? It depends. As kids enter the teen years their clocks for sleeping and waking, like daylight savings time, spring ahead an hour or two. That means when adults are getting sleepy, kids are getting ready to rock. That also means that the next morning, as the world awakens, teenagers are zombies. This also means for many teens early morning classes are cruel but usual punishment. Short of starting the school day later, a cup of tea or coffee may work wonders for the early morning zombie. It does for many of us. But it’s not for everyone. Steven Spielberg never drank a cup of coffee in his life. Voltaire drank 30 cups a day. They both turned out all right.

No-Nonsense-Final-Cover-640x1024Dr. Henry David Abraham is a psychiatrist in Lexington, MA. He is a co-founder of the International Physicians for the Prevention of Nuclear War which was awa rded the Nobel Peace Prize in 1985. Material for this article was adapted from his most recent book, The No Nonsense Guide to Drugs and Alcohol, an e-book for teens and young adults. It is now available online at Amazon.com and BN.com.

Parenting Matters is a collaboration between the Lexington Human Services Department and The Colonial Times Magazine.

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Facilitating Healthy Adaptations to Grief and Loss

Kevin M. Kozin, MTS, LICSW

Kevin M. Kozin, MTS, LICSW

By Kevin M. Kozin, MTS, LICSW

When experiencing a loss, it can seem that everyone has some sage (and often misguided) advice they are ready to give you. For example, you may hear remarkably unhelpful things like: Get over it, Move on already, Time heals all wounds. While possibly well intentioned, these words imply that a loss is something that a person “gets over.” For many losses, we do not “get over” the loss. Instead, we need to find a way adapt to the loss. We cannot “get over” things like the loss of a child or a partner, but we can find new ways of relating to that experience and adapting to the new situation.

Speaking about a loss can be difficult. Sometimes, “I’m sorry for your loss” is the best statement you can provide. When you are asked difficult questions about a serious loss, it’s OK to say, “I don’t know.” You may be joining with them in the “not knowing” of what is going on for them, and it can help to feel connected. It is often more helpful to use words like “died” or “death” instead of “passed on.” Especially with younger people, it helps them to understand what really happened.

Dr. J. William Worden describes four “Tasks of Mourning” that one must go through to facilitate a healthy adaptation, and Elisabeth Kübler-Ross describes the “Five Stages of Grief” which help to conceptualize some of the key emotions that people experience.

Dr. Worden is clear that these are active tasks, not things that happen to us, but things that we must do, to facilitate a healthy adaptation to loss. I’ve adapted Dr. Worden’s tasks to include all losses, by using “lost attachment.”

1. To accept the reality of the loss

2. To process the pain of grief

3. To adjust to a world without the lost attachment

4. To find an enduring connection with the lost attachment while embarking on a new life.

These tasks look nice and tidy with a simple four point plan of action. However, they can be remarkably difficult. Dr. Kübler-Ross describes the “Five Stages of Grief” as:

• Denial

• Anger

• Bargaining

• Depression

• Acceptance

In grieving, it is useful to experience all of these stages of grief as we process a loss. Unlike Dr. Worden’s tasks, you may notice that these aren’t numbered, but in bullet points. Worden’s tasks are more linear. You accomplish one task and then move on to the next. Dr. Kübler-Ross’s stages of grief are more fluid emotional states, and we may experience any one of them, and then move to a different stage at any time. There isn’t any one stage that is most useful or even necessary. A useful guiding principle is that in moving through the stages, the main concern is getting “stuck” anywhere but acceptance (that’s the eventual goal). So, one can experience denial, then depression, then acceptance, and move back to denial. It’s useful to notice when we are in these stages, but not to judge ourselves for being in any one of them.

There isn’t a timeframe for when things should change or healing should occur. In fact, some people never work thorough their losses. That’s why it is important to address the tasks in a deliberate and meaningful way. Healing isn’t about the amount of time that it has been since the loss.

Various age groups tend to process grief and loss differently. Infants and toddlers may sense a change in routine and caregivers, and can experience separation anxiety and regression. Having consistent caregivers is very useful at this age. Children of three to six years often struggle with the concept of the body not-functioning and finality of a death or loss. They can be prone to magical thinking and also regression. Consistent limit setting, patience, and simple (concrete) explanations are most effective. For example, a burial can be frightening if not better understood, since they may not understand the finality of death and become concerned that their loved one can’t breathe underground.

Between ages six to nine years, they begin to understand finality of death and may want details as to how someone died. They often have difficulty concentrating and worry about themselves and others, such as a caregiver or parent dying. It would be helpful to provide a space for talking about how the death/loss affects them personally. For ages ten to thirteen years, they may be able to understand that death is inevitable and happens to everyone. At this age, they may identify more with adults of their own gender and experience an array of feelings. They are often thinking about how death/loss affects relationships. For this age, it is helpful to encourage expression of feelings and foster open communication about death/loss.

Teens will often have the ability to confront and prepare for an impending loss. For teens and adults, they may not just be grieving for a current loss, but what might have been. They will often desire time with their peers. Some concerns is that the teen will be “parentified” and attempt to take on the role of the parent a parent during a major loss. Another possibility is that they may turn to risky behaviors. During this time, it is important to have open communication with the teen about their experience and to allow them the space to process their feelings, while offering support for when they are ready.

For all ages, be on the lookout for complicated bereavement, such as a grief response that is extended, amplified, delayed, distorted, absent, conflicted, chronic, or unresolved. This is when the grief response is interfering with psychological functioning, which can co-occur with adjustment disorders, depression, anxiety, substance abuse, PTSD, and suicidality. Some common indicators are sudden loss, conflicted relationships, pre-existing mental health issues, limited successful coping skills, financial or employment distress, or multiple stressors.

Never Worry Alone. In grief, one should not be alone in the process. Connectivity is a healing and protective factor. If you have concerns for another person, family, or yourself, you may benefit from working with a grief counselor. Below is a list of resources that may be useful in getting help or learning more about grief and loss. The way through grief and loss is together, not alone.

RESOURCES

The Children’s Room in Arlington – www.childrensroom.org

Offering a full array of bereavement services for families who have experienced early loss. Their website is full of helpful bereavement information.

Compassionate Friends – www.compassionatefriends.org

A national organization that helps families who experience the death of a child.

NASW Social Work Therapy Referral Service

www.therapymatcher.org or (800) 242-9794.

This is a free and confidential service from the National Association of Social Workers that connects people to psychotherapists on a range of issues – not just grief and loss.

 

Kevin M. Kozin, MTS, LICSW is a local psychotherapist and grief counselor in Lexington, MA and works with adolescents, adult, families, and couples. Mr. Kozin is highly active in the community in his work on the Board and Executive Committee of the National Association of Social Workers, Massachusetts (NASW-MA) and serving as the Co-Chair the Mental Health and Substance Abuse Committee of NASW-MA. He holds master’s degrees in Social Work and Theology from Boston University and completed post-graduate training at the Massachusetts Institute for Psychoanalysis. Information on Mr. Kozin’s practice can be found at www.kozincounseling.com or by contacting him at (781) 325-1858.

 

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Parenting Matters~Sweet Dreams

 

Lisa Foo, PhD

Lisa Foo, PhD

By Lisa Foo, Ph.D

The top of many Mother’s Day wish lists is a good night’s sleep for the whole family. What a challenge with our many responsibilities, endless things to think about, and being kept up by other family members!

The average daily sleep requirement is about 14.5 hours for infants, 13 for toddlers, 12 for preschoolers, 10.5 for school-aged children, 9 for adolescents, and 8 for adults. Many of us need higher amounts to compensate for accumulated “debt.” Research has linked insufficient sleep with not only fatigue, but also weight gain, heart disease, and diabetes. Decreased sleep can cause emotional and behavioral problems, including (ironically) child hyperactivity. Driving while drowsy is a major cause of car accidents and related injuries. Sleep serves an important role in learning, so late night cramming can interfere with remembering the information that was studied.

So what causes difficulties with falling asleep, waking during the night, or getting up too early in the morning? Everyone wakes briefly throughout the night when transitioning between deeper and lighter sleep, but most of us return to sleep easily and don’t even recall having been awake. Sometimes, however, our brains “click on” too much or have a hard time “clicking off” as we process stressful thoughts, making it hard to fall asleep or return to sleep.

Many sleep difficulties improve through developing healthy sleep habits. Staying up late and sleeping in on weekends can cause chronic jet lag in which our bodies can’t tell when to feel sleepy. Maintaining a fairly consistent sleep schedule throughout the week can fix that. Relaxing evening activities and predictable bedtime routines signal the body that it is time to sleep. It’s helpful to turn off electronic screens (TV, computers, cell phones, etc.) 30 to 60 minutes before bedtime, as they may keep our minds active and the lights that they emit signal the brain that it’s still daylight and time to be awake.

Regular exercise (not too close to bedtime) can improve sleep, as well as overall physical and emotional health. Utilizing deep breathing, muscle relaxation, and visual imagery can make it easier to fall asleep at bedtime and return to sleep after waking during the night. Noise, brightness, and temperature levels of the bedroom, as well as the comfort level of the bed and bedding, should be conducive to sleep. It’s helpful to avoid the bedroom during the day so that when you get into bed at night your mind associates that space with sleep and becomes drowsy, just as we often become hungry when entering a kitchen. When having prolonged awakenings during the night, try getting out of bed, going to another room with the lights dimmed, and doing something relaxing until you feel sleepy enough to return to bed.

Caffeine stays in the body for hours before being fully eliminated, so caffeinated coffee, tea, soda, and energy drinks can be eliminated or reduced and consumed only in the morning. “Decaf” coffees usually still contain some caffeine, and if taken in large quantities or throughout the day, can still interfere with sleep. While alcohol can cause sleepiness, it can also disrupt nighttime sleep. Abusing other chemical substances can also cause sleep problems. Regular use of over-the-counter sleep aids is not recommended without consulting with a medical provider, as long term use can cause grogginess or memory problems, and they may also become less effective over time. Sleep medications should NOT be mixed with alcohol, as the result can be fatal.

It sometimes can be tricky to use these recommendations with a child who doesn’t see the importance of sleep. Children may also need parents to ease bedtime fears or set limits regarding bedtime or middle-of-the-night behavior. It may also be necessary to address any larger anxiety or behavior problems. If your teenager is not getting enough rest, you might choose to have electronic devices turned into you before bedtime so as to reduce the temptation to talk or text during the night. Infant and toddler sleep is especially challenging due to the complexities of naps, nighttime nutritional needs, and little ones’ limited comprehension abilities.

Difficulties sleeping or chronic daytime sleepiness can be symptoms of underlying medical conditions. Individuals with sleep apnea have difficulty breathing while sleeping, and so without even knowing it experience frequent brief awakenings to breathe. Being overweight increases the risk of apnea, though individuals at a healthy weight can also have this condition. Discomfort, pain, or heartburn can cause sleep difficulties and may be assisted by strategies such as relaxation, not eating or drinking close to bedtime, avoiding trigger foods, or receiving appropriate medication.

If you or a loved one experiences sleep difficulties that are interfering with emotional or physical functioning, please consider seeking help from a mental health or medical provider. We can help create a plan to make it easier to fall and stay asleep, and also screen for and treat underlying disorders. For example, psychotherapy might be useful to address depression or anxiety, or behavioral therapy could help train a young child to follow bedtime limits. Individuals with sleep apnea can often be helped by a device that helps them breath better at night, or with assistance losing excess weight that is contributing to the problem. Sometimes prescription medications for other conditions can interfere with sleep and so can be switched, reduced, or eliminated in consultation with your provider. If a member of your family experiences other problematic sleep-related behaviors (screaming or walking while still sleeping, bedwetting or frequent urges to toilet during the night, attacks of excessive sleepiness during the day, etc.), please make sure to have them professionally evaluated.

I’ll end with a confession – I have children, and some of this article was written in the late evenings after they went to bed. And my infant sometimes woke me up a few hours later. Life happens. However, instead of just telling myself “I’ll sleep after I finish everything on my list,” I try to prioritize tasks so that I finish the most important ones before stopping for bedtime. Our children follow the examples that we set. Parenting takes a lot of energy and patience, both of which are easier to provide when we are well rested. I wish us all the best on our quest for households full of sweet dreams.

Lisa Foo, PhD, is a psychologist in private practice in Lexington. Dr. Foo is a Harvard graduate and Fulbright scholar who specializes in assisting individuals and families affected by health-related concerns. She previously worked as a senior psychologist and supervisor at a Level 1 trauma center. 33 Bedford Street, Suite 11; 612-237-8471; drlisafoo@gmail.com; www.drlisafoo.com .

 

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Calming the Chaos

 

Drs. Blaise Aguirre and Gillian Galen

Drs. Blaise Aguirre and Gillian Galen. Photo by Jim Shaw.

New Book by Lexington Authors Applies Mindfulness Practices to Living with Borderline Personality Disorder

| By Laurie Atwater

 

Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy Blaise Aguirre MD (Author), Gillian Galen PsyD (Author) Available at Amazon.com, barnesandnoble.com and newharbinger.com.

Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy.
The new book by Aguirre and Galen is available at Amazon.com, Barnesandnoble.com and newharbinger.com.

 

 

 

“I need to want to die less.”

This line appears in the introductory chapter of Lexington resident Dr. Blaise Aguirre’s new book Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy (New Harbinger Press) coauthored with his colleague and fellow Lexington resident Dr. Gillian Galen. Both Aguirre and Galen have spent their careers working with BPD patients at 3East, unit at McLean Hospital in Belmont devoted entirely to the treatment of females with borderline personality disorder (BPD).  Dr. Aguirre is the Medical Director at 3East and Galen is the Director of Training.

Sylvia, the woman quoted above is reaching out for help.

Working with patients in this kind of mental pain is the challenge at 3East. Currently women are more frequently diagnosed with BPD (75-90% of those diagnosed with BPD are women according to the Borderline Personality Research Center at New York Presbyterian Hospital). Research is being done to validate this working assumption and the situation may change in years to come, but for now, female teens are the faces of BPD.

Because many of the symptoms of borderline personality disorder can closely resemble what we perceive as ordinary adolescent behavior, BPD often goes undiagnosed until a traumatic event occurs. According to the Borderline Personality Research Center, “10%, or one in ten, people with BPD commit suicide. Thirty-three percent of youth who commit suicide have features, or traits, of BPD. This number is 400 times higher than the general population, and young women with BPD have a suicide rate of 800 times higher than the general population.”

Parents faced with moody, withdrawn, sad or angry adolescents often assume that their child is just suffering the normal ravages of teen years—and most are. However, individuals with BPD are so emotionally charged that their feelings erupt quickly and more intensely than an average teen and they take much longer to calm down. This emotional instability is the calling card of the disorder.

They also experience self-loathing, feelings of worthlessness and hopelessness about the future combined with an intense fear of abandonment. They are very often suicidal and many BPD sufferers make several suicide attempts. About one in ten are successful, and this is why it is critical to identify this disorder early and get effective treatment.

Many teens are great at disguising their suffering and looking quite “normal” on the surface for long periods of time. In fact BPD patients can be very high functioning, but they almost inevitably erupt in episodes that are so out of control they are really scary—especially to parents. BPD kids’ lives are in a perpetual state of drama and chaos.

Galen says that patients come to McLean when they are in a pretty fragile state. “They are sick a lot, chronically tired, sleeping is poor and they are often overmedicated. These kids are living on a constant roller coaster of emotions. A typical adolescent might come home from school angry and frustrated and there could be door slamming and screaming, but they will go to their room and regulate themselves and come down to dinner. They can have momentary mood dysregulation but still have a normal life—go to school, do their homework.”

“But BPD kids are so mood dependent that they can’t finish things. They drop out of activities. They don’t make it through sports season. They can’t ever find something that they like.”

BPD is obviously very disruptive to the family unit. “People start walking on eggshells around these kids because they are so unpredictable,” Galen says. “What happens is the child threatens an extreme act like suicide as a way of getting what she wants and if the child has that history (of attempting suicide), the parents become frightened and refuse to set limits. Out of fear for their child they end up reinforcing the bad behavior.” This dangerous dance can have dire consequences.

Behaviors like cutting (self-injury that involves puncturing or cutting the skin to release tension) burning, excessive drinking, irresponsible sex and reckless driving may provide behavioral clues for concerned parents who are ill equipped to handle these kids who have huge emotional swings and can be chronically acting-out.

 According to DSM-IV criteria (DSM-IV is considered the diagnostic “bible” for psychiatric disorders), signs and symptoms include:

  • Make frantic efforts to avoid real or imagined abandonment.
  • Have a pattern of difficult relationships caused by alternating between extremes of intense admiration and hatred of others.
  • Have an unstable self-image or be unsure of his or her own identity.
  • Act impulsively in ways that are self-damaging, such as extravagant spending, frequent and unprotected sex with many partners, substance abuse, binge eating, or reckless driving.
  • Have recurring suicidal thoughts, make repeated suicide attempts, or cause self-injury through mutilation, such as cutting or burning himself or herself.
  • Have frequent emotional overreactions or intense mood swings, including feeling depressed, irritable, or anxious. These mood swings usually only last a few hours at a time. In rare cases, they may last a day or two.
  • Have long-term feelings of emptiness.
  • Have inappropriate, fierce anger or problems controlling anger. The person may often display temper tantrums or get into physical fights.
  • Have temporary episodes of feeling suspicious of others without reason (paranoia) or losing a sense of reality.

 

A great YouTube video about BPD , Back From the Edge offers guidance on treating Borderline Personality Disorder. The video was created by the Borderline Personality Disorder Resource Center at New York-Presbyterian.

http://www.youtube.com/watch?v=967Ckat7f98&feature=youtube

 EARLY INTERVENTION IS KEY

In his 13 years as the Medical Director at 3East, Aguirre has remained passionately hopeful about the prognosis for those diagnosed with BPD, though he admits they can be frustrating to diagnose and treat. Patients often have symptoms that overlap with other illnesses and many teens may have received several different diagnoses that never quite fit before making it to 3East. Dr. Aguirre stresses that it is extremely important to get the right diagnosis because BPD sufferers do not respond to the same drugs or treatment modalities as more commonly diagnosed conditions like conduct disorders, depression or bi-polar disorder. It’s also important to catch this disorder early. Although there is some controversy about the diagnosis of BPD before age 18, temperamental tendencies can be identified early, and Dr. Aguirre feels that early intervention is critical. Research shows that dialectical behavior therapy (DBT) reduces the incidence of suicide attempts and keeps teens in therapy for longer periods of time. Untreated, BPD symptoms can persist into adulthood, but with treatment the outlook for a successful life is greatly improved. “Kids stick with it,” Aguirre says, “because they want out of their misery—they are in so much pain.”

THE BRAIN AND THE ENVIRONMENT

Marsha Linehan of the University of Washington is one of the leading experts in BPD. Dr. Linehan has developed a biosocial theory of  BPD  over many years of dealing with highly suicidal, treatment-resistant patients. On the biological side of the equation she theorizes that BPD patients have a lower neurological threshold for emotional stimulation.

New research published in the journal Biological Psychiatry in this past January shows that the emotional priming for BPD may well be biological as Linehan theorizes. A recent review of imaging studies by neuropsychologist Dr. Anthony Ruocco at the University of Toronto (Ruocco is a clinical neuropsychologist who specializes in the use of neuropsychological and brain imaging techniques to understand the brain. His primary area of interest is in identifying biological liability markers of borderline personality disorder) recently observed heightened activity in brain circuits involved in the experience of negative emotions, and reduced activity of brain circuits that are normally recruited to regulate emotion.

Aguirre and Galen have an entire section of their book devoted to brain imaging, genetics and brain chemicals. They present the science showing that BPD sufferers have an overactive amygdala (fight or flight central) and an underactive prefrontal cortex (the seat of reason and control). The interaction between the two regions of the brain is out of balance in BPD sufferers as brain scan studies like the one cited above have shown.

On the social side of BPD, Dr. Linehan has identified that BPD patients suffer the effects of an invalidating environment. This is an environment that is experienced as hostile by and to the BPD patient—where their emotions are seen as unacceptable and are often dismissed or punished. This can be very difficult for loved ones to comprehend. Dr. Aguirre explains that many “invalidating” remarks and behaviors are often used  innocently by loved ones to “console” or to “help” someone who is in psychological distress. Things as common as telling someone ‘cheer up, it’s not that bad’,  ‘you’ll be fine’ or  ‘just get over it,’ can invalidate a BPD sufferer’s feelings. When the BPD sufferer experiences a negative and stressful situation like a breakup with a boyfriend or a fight with a friend and is met by invalidating comments, a cycle of self loathing, anger and acting-out may begin. These episodes often end in self-harming behaviors that are, to the BPD sufferer, a form of self-calming.

Based on her clinical experience, Dr. Linehan pioneered a practice known as DBT (dialectical behavior therapy), the therapy that is now considered the gold standard treatment for BPD. This  program used with great success with teens at McLean.

DIALECTICAL BEHAVIOR THERAPY

DBT balances empathy and acceptance with an unwavering focus on changing problem behavior. Through this balance, DBT aims to help change the behavioral, emotional, and thinking patterns associated with problems in their lives, while promoting the development of, and reliance on, an inner wisdom—something Linehan calls the “wise mind.”

“What makes DBT so successful,” Aguirre explains, “is that it is extremely accepting that a person has the limitations that they have. It accepts them at face value without making any interpretations or judgments.” This accepting and validating  therapeutic relationship nourishes the patient’s ability to see that change is necessary to end their pain and suffering.

But it is not only the therapist that must practice non-judgmental acceptance. The patient must also be able to accept themselves and their situation. Linehan calls it Radical Acceptance which means being nonjudgmental of the self and accepting life as it is. Dr. Linehan found that without this fundamental acceptance it is almost impossible for patients to progress in therapy.  And many drop out because of this.

“This is a process that you have to accept over and over again,” Gillian Galen says. “But,” she adds, “pain plus non-acceptance equals more suffering. We have skills for dealing with difficult feelings, none for non-acceptance.”

The “dialectic” in DBT is this notion of holding the opposing ideas of acceptance and change in balance. This dialectical approach acknowledges the yin and yang of feelings, situations and relationships and get away from black and white thinking (good/bad, right/wrong). Through practice it helps patients synthesize opposing thoughts and feelings into their “wise mind”—a balanced place between acceptance and change.

When patients come to treatment, they often have a hard time with the concept of acceptance. They can’t accept themselves, the diagnosis, the love and caring of their friends and family or the reality of circumstances that they find difficult. They will argue their position and feel extremely misunderstood when others don’t agree with them.  But once the threshold has been crossed the change can begin, and it is typically very effective.

The formal aspects of DBT training involve individual meetings with therapists, classroom style training in the fundamental skills of DBT–mindfulness, interpersonal effectiveness, distress tolerance and emotional regulation—and group training sessions in which patients learn to incorporate the skills into life situations. In DBT therapy sessions life-threatening behaviors are always addressed first and then work continues on specific situations and feelings that have caused pain. It is typically a one year process with follow-up.

“The theory that we hold is that BPD is, in part, a skills deficit,” Galen explains. “These are people, who along the way in their development, didn’t learn these skills so we teach them the skills, how to use them, when to use them and then we give them coaching in the moment.” DBT takes time and dedication to unwind these individual and family patterns.

“The brain does not distinguish in any way, shape or form between adaptive or maladaptive behaviors—good, bad or indifferent,” says Aguirre. “What we know is reinforcement behavior—the more you repeat something the better you get at it. So, if you keep repeating the same maladaptive behaviors you get really good at it.”  The same holds for adaptive behaviors. DBT is a process of identifying problematic thinking and behavior and swapping it out for the newly acquired adaptive behaviors and then reinforcing and repeating the process through role play and therapy until it forms new muscle memory for the patient—a DBT toolkit at the ready when needed. “In large part we are teaching patients to pay attention to those things that just aren’t working for them,” Aguirre says, “As therapists we’re the sympathizers, the tool-givers and the cheerleaders.”

DBT also requires the commitment of the parents. “We ask the parents to participate in a skills group because we have to change these transactional patterns that have developed over time,” Galen says. Aguirre says, “In my psychiatric career, the vast majority of parents who have these kids are the kindest, most well-meaning parents who just don’t understand how difficult their kid’s struggle is, and they don’t always have any experience with these types of feelings.” DBT can work wonders in interrupting this painful cycle and creating new habits for both parents and their suffering children.

Learning to identify the physiology, thoughts and situations that trigger emotional reactivity is the biggest challenge for patients. They have the tools, but when to use them? This is where mindfulness comes in. Mindfulness is the core skill of DBT.

SARAH’S STORY

Sarah was a patient at the 3East Residential Program at McLean. She generously shared her story with us by phone from college where she is continuing her education. Sarah uses the skills of mindfulness and DBT every day. 

“I started getting depressed around my junior year in high school. I’ve always been a perfectionist and a really hard worker in school. I started feeling really overwhelmed with my work. I wasn’t sleeping enough and all I cared about was school. I just felt out of control in life and I didn’t know what was going to happen the next day. That continued into my senior year when I had my first suicide attempt and my first inpatient hospitalization.

During my junior year I started cutting but I never really did it for very long. I went to public schools my whole life, but in an area where everything is so competitive. Everyone was so smart and so good at sports and I just felt—even when I was getting good grades—someone else was better than me. That made it a lot worse. You just lose sight of reality. Everyone in my area is this certain way and it’s expected that you go to college and maybe even get a graduate degree.

After high school I realized that there’s a whole lot more to this world.
In the fall of 2009 I went off to Emory University and I lasted about six weeks there before I had a major breakdown. Before my first exam I had a panic attack. The school sent me home and said I wasn’t taking care of my health. I was really devastated when they told me I had to leave school—I thought it was ridiculous, but when I got home I realized it was definitely the right decision because I needed more help so I went into the day program at McLean.

After my next suicide attempt I went to 3East—the residential unit at McLean. I absolutely loved the program and I would definitely say that it saved my life. Living on the unit with everyone about my age going through the same things—it was like a family.Eighty-five percent of the time I am perfectly fine and then I have a huge breakdown and I get suicidal.

But it was hard at first to go to treatment. My whole life growing up, I never thought it was okay to ask for help. That was the first hurdle. Once you’re able to accept it it’s a lot easier to make progress.

My parents never dealt with anything like this before. I’m the only one in u family to have mental illness and my parents had no idea. They just thought I was being an angst-y teen. I refused to talk with them. They would ask me how school was and I would snap at them. I tried to distance myself from them. That’s when they knew something was up. My friends weren’t really coming around and I was spending all my time in my room. I know they definitely had to read into the signs—it wasn’t obvious to them. Now I realize that my parents have always been pretty worried about me.

I struggle with anxiety. Most of the time I don’t even know what I’m anxious about. But since I’ve learned DBT I’ve started to pay attention to it. I’ve learned to pay attention to all of the feelings and sensations and then I think, ‘is there a cause for this? Is there really anything to worry about? It’s been really helpful. There are four modules in DBT and I’ve probably been through them all many times. In those moments when I’m really distressed, using a skill can really help, but it’s hard. I have to find the skills that really work for me.
I really loved doing the yoga.

I’ve started going to yoga classes on my own and it’s amazing how it can calm you down and put you in a different mindset. It stops you from thinking about the future.”

 

MINDFULNESS

Mindfulness practice has been shown to mitigate the underlying problem of BPD by activating and strengthening the prefrontal cortex and reducing the body’s stress mechanisms.

The concept of mindfulness has exploded throughout American culture.  A mainstay of Eastern religions, this practice has been inching its way into the Western mainstream for some time. In Lexington, our own Jon Kabat-Zinn has been on the forefront of exploring Mindfulness-Based Stress Reduction (MBSR) which he launched at the University of Massachusetts Medical School in 1979. Since that time, thousands of studies by Zinn and others have documented the physical and mental health benefits of mindfulness.  Mindfulness is being used to combat stress in the classroom, in business and in just about any setting where attention is being hijacked by modern life. With roots in the Buddhist tradition, mindfulness meditation involves paying attention to thoughts and feelings in the present moment and accepting and letting go of those feelings and emotions non-judgmentally. A mindfulness practice can give the participant more control over their thoughts and feelings and has been proven empirically to result in more activation in the pre-frontal cortex.

“If you look at mindfulness-based stress reduction it has shown lots and lots of efficacy in many medical conditions,” Aguirre says.  “Though the research on mindfulness specifically for BPD is scant, through clinical observation, we see the kids who use mindfulness recover much more quickly. It is imperative that we as clinicians pay attention to things that work.” Teaching patients to slow down their breathing and check in with their bodies can help them identify the biological stress signals that the body sends before they react emotionally. Once they realize that their pulse is racing, their palms are sweating, their breathing is shallow or any of the myriad physical symptoms they may suffer, they can reach for a DBT skill that might help them to cope.

PRACTICE WHAT YOU TEACH

About 7 years ago Dr. Aguirre was attending a conference in Washington D.C. and happened to be seated next to BPD expert Dr. Marsha Linehan.  Aguirre had been at McLean practicing using the DBT program for several years with adolescents and he was becoming more and more interested in the mindfulness component of the program.

“I heard that Dr.Linehan was doing training in Tucson and I asked her to get me in,” he says with a short laugh. What Aguirre learned upon arriving in Arizona was that the “training” had nothing to do with DBT. “It was a Catholic monastery and I had to be sitting there staring at a wall in silent mindfulness for sixteen hours a day,” he laughs.

Admittedly he panicked, called his wife and begged for her to make up an excuse to get him out of there. “She hung up on me,” he says ruefully.

“So there I was stuck in the monastery with Marsha Linehan and it changed my life,” Aguirre says. “I finally woke up to the way my mind works.”

Aguirre’s co-author Gillian Galen came to mindfulness through yoga. A dancer and an athlete, Galen relocated to West Hartford, Connecticut for her graduate work and found herself looking for some dance or sport that she could fit in with her studies. She ended up in a yoga studio and fell in love with the practice. “I got really hooked on yoga,” she explains “and I started to notice myself changing off the mat and I was fascinated by it.”  Galen noticed that she could come to yoga after hours of studying and clinical work and within fifteen minutes my mind would go from spinning to a sense of quiet and soon I became interested in the science behind it.”

Galen ended up writing her doctoral dissertation on the effects of yoga on mental health. “People began noticing how level I was. I was much less judgmental. I was paying attention and I was essentially ahead of my experience and all of this was happening as I was developing as a psychologist.”  Galen had worked for a time at McLean before doing her graduate work so she had some exposure to DBT. “Once I added yoga it all came together.”

The last time I saw Aguirre and Galen they had just returned from a mindfulness retreat. So they are both “all in” on mindfulness and what it can do to enhance anyone’s life.  But its application to DBT is essential for success.

MINDFULNESS FOR BPD: THE BOOK

Skill-building is the backbone of the DBT program or as Aguirre says: “Skills not pills.”

Being mindful, learning to sit with difficult emotions without resorting to old behaviors, learning to reframe internal thoughts and calm overactive emotions—this is DBT and the work that goes on at 3East.  The program has shown so much success that Aguirre and Galen wanted to share it with those who are unable to participate in a hospital-based program. Their new book lays out a path to end the suffering of BPD through DBT focused mindfulness training.

“We had a great time writing the book because we love mindfulness and we love thinking about it,” Galen says. “It’s changed both of our lives completely and we loved trying to figure out how to bring it to people in a very easy, non new-age-y, non-judgmental way.”

Writing this book was a labor of love, but it required lots of hard work. Galen and Aguirre staged marathon writing days on the weekends, joining up with their respective spouses for dinner and then starting it over again the next day. “We have crazy work schedules so we just had the weekends, and we did this for multiple weekends a month,” Galen explains. “Our families were very understanding!”

What they have produced is a highly readable book that incorporates case studies, accessible explanations of the science and symptoms of BPD, and a plethora of mindfulness exercises. The book immediately engages by speaking directly to the reader in a down-to-earth and compassionate voice.

The authors very clearly discuss BPD in all of its dimensions, the concept of mindfulness and its application to BPD, and the neuroscience underpinning both. The balance of the book is devoted to explaining a series of known BPD behaviors like emotional instability and anger, unstable relationships, fear of abandonment, impulsivity, self-injury (and many others), and teaching mindfulness exercises that can be helpful in interrupting old patterns.

“Whether you have borderline personality disorder or not, these skills help anyone,” Galen says. “We’ve had parents tell us that they use these skills at work now.”

Learning to calm a frenzied mind and quiet the emotions through mindfulness helps patients to do the necessary work of building their DBT toolbox and to ultimately learn to see themselves, and the world, in a way that’s less judgmental, gentler and more hopeful.

 

McLean’s DBT Programs

The program specializes in intensive dialectical behavior therapy (DBT). 3East now offers four levels of individualized care; enabling teenagers and young adults to fully benefit from ongoing, consistent treatment and support at varying levels of care:
-3East Residential Intensive. A program for teens and young women, ages 13 through 20.
-3East Residential Step-down. A program for “graduates” of the “3East Residential Intensive” treatment, ages 13 through 20.
-3East Day Program. A mixed-gender, non-residential day program, for individuals, ages 13 through 20, who live in the surrounding area or have completed the 3East Residential Intensive program and reside on the 3East Step-down unit.
3East Transitional Care. A program for women 18 through 25 who have already received intensive dialectical behavior therapy (DBT) treatment and would benefit from extended care before returning to live independently in the community.

CT_Story_End

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Getting Your Partner to (Really) Listen

 

Robyn Vogel, MA, LMHC

Robyn Vogel, MA, LMHC

Do you wish you could tell your partner what you are feeling more easily? Are you looking for a way to have a productive conversation without playing the blame and shame game? Do your “discussions” sometimes last into the wee hours of the night leaving you exhausted the next day?

When you have something important to share with your sweetie, you will need these 4 simple steps:

1. Choose the right time for ‘you’ to have the conversation (consider your time & your energy level)

2. Ask your partner if s/he is willing to talk at that time

3. Be willing to hear ‘no’ and ask for a better time

4. Schedule the conversation and agree to an ending time

Getting your partner to listen when s/he is not truly available can feel very frustrating — which only adds to an already charged situation.

If your experience is anything like mine used to be, your life is busy and it’s hard to fit time in for anything extra! It’s “easier” to avoid difficult conversations than approach them. You are frustrated because you often have to sift your way through the fog of blame and shame to get to clarity. You don’t feel deeply heard.

Several years ago, I learned there was a different way. Thank goodness! And I teach it to all of my clients!

You and your partner are going to love how easy this is for you both.

PRACTICE TIP: Sit together facing each other. Close your eyes and take some deep breaths together. Synchronize your breath for a few minutes (feel silly? keep going…trust the process, it works!) When you feel connected via your breath, open your eyes and look deeply at each other.

Make an agreement: one person will share at a time and the listener will reflect back what s/he heard…bit by bi

Slowly….switching speakers as needed. Use “I” statements. If you find yourself saying “YOU”, take a breath and start over! A do-over is a powerful tool to use! I recommend you limit your conversation to 1 hour max.

Now, what if you have something important to share with your partner, but feel like all you want to do is blame him (or her)? Here is exactly what you need to move forward and avoid a screaming match.

Take 5-10 minutes to journal what you are upset about (don’t skip this very important step!)

Re-read what you wrote and highlight every “you” or “s/he” and change them to “I” (this is called “the turn-a-round” according to Byron Katie’s The Work)

Look over the “I” statements and find nuggets of truth (leave the rest)

Now choose the right time for ‘you’ to have a conversation. Ask your partner if s/he is willing to talk at that time. Be willing to hear ‘no’ and ask for a better time. Schedule the conversation and agree to an ending time no more than 1 hour later.

You’ll want to take the steps above to heart and please share them with your partner. The idea here is that you don’t blame or shame your partner and s/he doesn’t do that to you!

It feels terrible to be on the receiving end of someone else’s blaming! “Well everything’s ruined and I’m upset because of YOU!” “I’m disappointed because you did this and you did that…and you made me feel this way or that way…and on and on and on.” We’ve all heard those words before. Sadly. And have those conversations been productive? Are they loving?

There’s more but I don’t want to give you too much at once. So begin with the invitation above (the steps) – and practice as often as you can.

You and your partner are on your way to deeper love already! Congratulations!

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Child Centered Divorce – A Model for Cooperative Co-Parents

Shawn McGivern

Shawn McGivern

By Shawn McGivern

In September 2000, TIME Magazine invited renowned sociologists and mental health professions to weigh in on What Divorce Does to Kids.

While the issue presented a balance of perspectives, what took front and center stage for readers and experts alike were the late psychologist Judith Wallerstein’s doom and gloom predictions for adult children of divorce. Based on her 25- year study of 131 subjects, Wallerstein concluded that children of divorce “look for love in strange places” and “make terrible life partner choices.”

“Expecting disaster, they will create it,” she writes. “They will delay career choices, delay marriages and likely get divorced themselves.”

 

Both her book and the TIME exposé drew harsh criticism. Christy Buchanan, author of Adolescents After Divorce undercut Wallerstein’s findings stating that, “There’s some good research suggesting that many of the problems attributed to divorce are actually present prior to the divorce.” Penn State Sociology professor, Paul Amato effectively dismissed Wallerstein’s predictions, saying in Time, “What most of the large-scale scientific research shows is that although growing up in a divorced family elevates the risk for certain kinds of problems, it by no means dooms children to having a terrible life.”

Twelve years later, what seems logical is that the subjects whom Wallerstein began tracking in 1971 reflected the loss that can stem from children being raised in an unhappy intact home and then being subjected to “adversarial ” divorce.

The fact is, divorce, like death, is a profound loss of possibility for the child. To him or her, it is as if a once-whole beautiful egg has been shattered into two jagged pieces.

Divorce will likely interrupt the child’s social, emotional and cognitive development. Studies show, however, that children can adjust and do better in the long-run when parents put their differences aside, work as a team, and model for the child the respect and collaborative spirit that informs a successful business partnership.

With 40-50% of marriages ending in divorce, it’s no surprise to find a plethora of literature on the how-to of divorce. For parents whose chief concern is their child’s well-being, however, some of the best thinking from judges, divorce mediators, attorneys and mental health professionals comes from The American Bar Association publications. My Parent are Getting Divorced: A Handbook for Kids and Co-Parenting During and After DIvorce: A Handbook for Parents offers concepts and codes of conduct between co-parents that aim to minimize conflict while optimizing the trust, autonomy, initiative, social interest, cognitive development, and capacity for friendship and intimacy needed in adulthood.

Tips for Cooperative Co-Parents

Kids’ fears and questions run rampant when parents separate. They may not have the language to voice their fears, but a typical interior diaglogue includes: What is divorce? Will I still see both of you? Where will I live? Will we still have enough money to do fun things? ? Am I going to have to leave my school, my teachers, my friends? This is embarrasing; what will other kids think? How will I buy Mom/Dad gifts for holidays or birthdays? If I’m with Dad on weekends, when can I see my friends?

Kids need assurance that it’s okay to be loyal to both parents. They hear criticism of Mom/Dad as descriptive of themselves. Often, when kids are exposed to parents fighting or negative comments about the other, they feel forced into the role of referree or caretaker. For this reasons, competent co-parents have disagreements in private. They discuss adult matters behind closed doors or with other adults. If and when they introduce a significant other to the kids, it’s understood that the child has input on where and when. Resilient kids are most often the product of two homes where warmth, acceptance, and open communications abide.

Language creates experience. Kids know “friends” are people who get together to have fun, enjoy the same things, laugh, and in times of difficulty turn to each other for emotional support. If you are true friends, kids already feel it . If what you mean by we’re friends is closer to “we’re not enemies,” however, try: “Divorce means that we will be living in separate houses. When it comes to major holidays, your birthday, things at school and other important events, though, we’ll get together as a family. There are going to be some changes for all of us, but one thing will stay the same forever:, your dad and I will always share our joy in watching you grown into the terrific person we knew you were the day we brought you home from the hospital.”

Family Advocate and many other child-centered divorce materials emphasize kids’ need for structure. Cooperative co-parents will ideally offer consistency in both homes with respect to times for dinner, homework, TV, internet,and bedtime.

In its Handbook for Clients, Family Advocate encourages single parents to exercise self care. When the kids are gone, make plans with friends. Join a support group. Let the housework go. Go to the gym. Take a class. Pamper Yourself . Relax.

Divorce marks the end of marriage. As Scott Peck wrote in The Road Less Travelled, however, “where there is love, there is healing.” And, with child-centered divorce, the healing can begin.

 

 Shawn M. McGivern LMHC

 Conflict resolution/divorce mediation

shawnmcgivern@yahoo.com.

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Parenting Matters: Complex Sibling Relationships

PM1111

Patti Grant, LICSW

If sibling rivalry is an issue that affects your household, you may understand how stressful it can be for everyone in the house to bear. You may be at a loss to know how to stop the fighting, or question whether they shouldn’t just, “work things out.” Let’s first take a look at the basis for sibling rivalry.

Tension between siblings can run in a few different forms. One form that is most common is that siblings tend to look at each other as equal even if their age is not. This may come out as, “Why does she get to have a phone?” or, “Why can’t I stay out that late?” School-age kids especially may be very black and white in their thinking about fairness, such as when they see parents giving preferential treatment to a younger sibling (such as greater physical affection).

A second form of tension stems from individual temperaments. These temperaments, including mood, disposition and flexibility, as well as their unique personalities play a large role in how well siblings get along. For example, if one child’s disposition is to be okay with close proximity, but another child delineates their personal space, it can lead to conflict. “But that’s my side of the couch!” Does this sound familiar?

Another form of tension can stem from kids that have special needs, either emotionally or medically. The child who isn’t sick may resent the amount of the parent’s attention that this sibling needs. This child may also not be able to verbalize this feeling well, and it may come out in a way that makes it hard to address, such as, “Why does he always get everything he wants?” Maybe this is a phrase you tend to hear that leads to tension for everyone.

The final form of tension that can impact siblings is their role models. The way that parents-and other close family members-resolve problems and conflict sets a strong example for their kids. If family members tend to yell, call names and isolate themselves, siblings are likely to do the same. However, if family members can work through conflict in a way that’s healthy and respectful, it increases the chance that the children will adopt the same tactics.

So what do you do when the fighting starts? Whenever possible, don’t get involved. If the siblings can work things through in a productive way without your help, that will be the best for their self-esteem and problem solving development. You also risk been seen as taking sides whenever you step in, based on past experiences of the children or simply even the timing of when you step in. However, always intervene in a situation where you feel they might become violent with each other.

If and when you do decide to step in, try to resolve problems with your kids, not for them. Following are some suggestions to follow when stepping in.

Separate kids until they’re calm (as well as yourself). Unless everyone is calm, fighting can resume and the problem solving cannot.

Take the focus off blame, as focusing on who’s to blame only exacerbates fighting. This can be done by encouraging each child verbalize their concerns, one at a time.

Voice your own concerns for their fighting, such as how you feel like family life could improve, or how you’re concerned they’re going to hurt each other.

Ask them to come up with a mutually agreeable and feasible solution that addresses all the concerns. Be careful to throw out solutions that won’t be likely to have follow through, or ones that don’t consider all of the concerns.

Support solutions that children come up with, check their follow through and come back to the table to talk if the solution is attempted and it doesn’t help resolve the original concerns.

There are also some simple techniques that can be used every day to help kids get along. An important one to use is to explain to the child that, “equal is not always fair, and fair does not always mean equal,” in that each child gets what he or she needs, and sometimes one child may need more than another. Another important technique is to set ground rules for behavior. Tell the kids that if an argument starts, they must keep their hands to themselves, and yelling, cursing or name-calling, as well as abuse to objects (slamming doors or throwing things) are not allowed. Explain to kids that they are not responsible for getting angry, but they are responsible for their behavior.

You can also be proactive in getting involved in each of your children’s interests, and make sure you give each child some one-to-one time on a consistent basis. Make sure each child has their own space to do their own thing, either to take space quietly, go outside, or enjoy activities with peers without their sibling tagging along. Tell your kids that you love them both, without limits.

It’s also important to have fun as a family as well. It can be as simple as throwing a ball together or playing a board game, something that establishes a peaceful time that you can all relate as a time that everyone got along well. Also keep in mind that the fighting may be for attention, and if you leave the situation, it may remove the incentive for fighting.

If fighting is occurring daily, you can hold family meetings weekly or daily to review the ground rules and work on solutions to resolve conflicts, as outlined in the bullets above. If children frequently fight about the same issue, it’s a sign that a collaborative approach is needed, with parents modeling problem-solving behavior.

In a small percentage of families, the conflict between siblings is so severe that it disrupts daily functioning, such as the children’s ability to go to school on time or attend extra-curricular activities. Fighting can be so severe that it can affect kids emotionally or psychologically. In these cases, please do seek help from a mental health professional. If you have any questions about your children, you can also speak to their pediatrician, who can help you assess whether you and your family might benefit from seeking out professional help or refer you to local behavioral health specialists.

 

Patti Grant, LICSW

(617) 606-7450

grant@copernican.us

Private Practice:

Newton: 44 Thornton Street, Newton,

Lexington: The Liberties, Suite #11, 33 Bedford Street, Lexington, MA 02420

Copernican Clinical Services: www.Copernican.us  “We Help People Change”

Phone: (617) 606-7450

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