Latest Posts

Get more out of mindfulness

Mindfulness “What Skills”: How To Get More Out of Being Mindful

Imagine the following.  You’re sitting at home alone, amid a rare chunk of free time.  You stop scrolling through Netflix aimlessly and decide to do something “productive.” A million ideas come to mind of things you could do.  Run an errand? Pay a bill? Call your mother? Nothing feels like the right thing to do with this precious gift from the gods of modern living.  

Suddenly, it clicks.  Mindfulness! All these monks, therapists, and TED talkers seem to think it’s the cat’s pajamas.  Let’s give it a whirl.

You review a trusted protocol on how to be mindful.  You know, the one that starts with “Find a comfortable position with your back straight…” You focus on your breath.  You watch your thoughts. You notice yourself drifting off.  

*Dinggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg* 

The meditation timer rings and you don’t feel at all transformed.  You want to get it, but you just can’t see what the fuss is about. All those enlightened gurus can’t be wrong though? You think, “What’s wrong with me?”

If this story sounds familiar, then this post is for you.

Cheri Huber’s book above, Nothing Happens Next, is a lovely read and approaches this phenomenon from a deep, spiritual, and profound philosophical perspective.  It’s certainly worth a read. It’s heady, yet has a typeface of like 36, with childlike font, and is presented in a digestible Q&A form.  I love ALL of this author’s books and she is an amazing teacher.

But…

At this moment, I don’t want profound.  I want a return on the time invested. After all, how often do I have a spare 20 minutes to do nothing?  I’m not seeking enlightenment, but I’d like to feel a little less anxious and stressed.  I’d like to feel rejuvenated and a little more spiritually full–perhaps even more rooted in my body.  

Unlike monks, I don’t have the luxury of abandoning all my earthly possessions to sit silently in the Himalayas. So where does this leave me?  What am I to think about this mindfulness mumbo jumbo, and where will it fit in my life?

The Problem with Mindfulness

Search online and you can find thousands of mindfulness exercises.  But what you won’t find is much guidance on which exercise is most likely to make you feel like the 20 minutes you are about to spend is worthwhile.  The last feeling you want to have after committing precious spare moments to self-care is that the time was a waste. Or even worse, you don’t want to be left feeling inadequate, ashamed, and/or envious of those who “get it.” 

Sorting Out Who Gets What

The main point I want to make is that you will get different benefits from different types of mindfulness practices depending on your personality style.  This could get quite complicated given the diversity of distinct personality types. So, for the sake of simplicity, let’s broadly classify people into one of two distinct personality types: externalizers and internalizers.

Externalizers vs. Internalizers

The easiest way to classify yourself into one of these categories is to remember yourself as a child.  Children are much easier to sort into basic temperaments since their emotions tend to be closer to the surface.  What did you do when you were emotionally upset? How about bored?

Externalizers are the kids who couldn’t sit still.  They are impulsive, jittery, and have difficulty tolerating under-stimulation.  The externalizers are the ones who show distress and/or boredom through impulsive, and sometimes, destructive action.  The function of this “acting out” is to prevent too much self-reflection, since doing so hurts. Boys tend to be externalizers more often than girls.

Internalizers are the opposite of this.  Internalizers deal with emotions by turning inwards.  If an internalizing child becomes bored, she is likely to be both quiet and more visibly upset.  A common response for internalizers in the face of boredom is to daydream and imagine herself at some fantasied location engaging in a more stimulating activity.  Rather than taking out distress onto the world, internalizers favor self-reproach and feeling down and discouraged. Girls tend to be internalizers at higher rates than boys.

Aspects of Mindfulness

Now that we’ve differentiated between two basic character styles, let’s look at some different ways we can be mindful.  Marsha Linehan, a major proponent of mindfulness as a source of healing, created Dialectical Behavior Therapy as a way to help patients with fragile egos to develop strong mindfulness skills.  She made mindfulness accessible by breaking it down into three bite-sized components: Observing, Describing, and Participating.

DBT What Skills & How Skills Infographic

Observing means assuming a watchful stance of thoughts, emotions, or sensations.  Mindful describing is translating observed data into neutral, just-the-facts, language.  Participating is reminiscent of “flow,” where mindful attention is consumed completely by experience.  Another synonym could be “play.”  

Using this framework, let’s consider what may be happening when mindfulness is NOT helpful.  

Infographic showing how personality type affects mindfulness practice

Copyright 2019, Michael Kinsey Ph.D.

Internalizing

The ruminative qualities of anxious worry and depression are reasons why some people try mindfulness.  The idea goes something like: well, if you can just notice the thoughts and not take them personally, then mindfulness can improve your mood.”  True enough. However, observing thoughts for internalizers takes attention away from where it’s most needed: emotions and pure experience.  

Anxious and depressive rumination are byproducts of avoiding feeling more basic emotions, like anger and sadness.  Mindfulness can be helpful though in connecting more deeply with feelings. Instead of falling into the trap of starting with following thoughts (this can be a useful practice, but is a more advanced application of mindfulness), start by focusing on a specific body part, physical sensation, or listening to a guided body scan.

Ruminative states are most damaging in the way they remove us from the mindful state of participating.  For my anxious and depressed thoughts, I find most relief in engaging in an activity that consumes all of my attention and brings me into a healthy state of flow.  For example, one of my go-to hobbies is birding. Walking, scanning, listening, and attuning to nature contains multiple organic antidepressants, but mostly it helps me through channeling my attention into an all-consuming state of mental play.  

Writing, crafting, sewing, woodworking, athletics, running, lifting weights, etc. are other examples of activities that extract our attention away from indulgent rumination.  

As for the mindful state of describing, if your goal is to maximize returns on 20 minutes, describing practices are too thought-based to be helpful in most cases.

Externalizing

With externalizers, bad moods tend to be more disconnected from patterns of thinking.  Externalizers regulate moods through action–action that observers would call impulsive.  Action occurs because thought does not dampen the connection between feeling and action. In internalizing states, the tendency is just the opposite; thinking suppresses feelings and blocks action, thus becoming more active (i.e., participating) is the most helpful response. 

If your personality best aligns with the externalizing profile, traditional meditative forms of mindfulness provide the most bang for your buck.  Observing thoughts and describing (or labeling) emotion states helps to build a barrier of healthy thought between feeling and action. While externalizers benefit most from observing thoughts and describing body and affective states, the externalizer will find mindfulness practice most challenging.  He will likely feel overcome by agitation or restlessness.  

Borderline personality disorder, ADHD, and other forms of maladaptive impulsivity disorders (e.g., oppositional defiant disorder in children), have the most to gain from contemplative mindfulness.  The benefits of mindfulness are so well-suited to these types of externalizing characters that mindfulness is the core of Linehan’s Dialectical Behavior Therapy (DBT). But because mindfulness can be so hard to bear for externalizers, Linehan broke down mindfulness into more digestible pieces.  Short, guided mindfulness practices are most helpful for externalizers with no experience with mindfulness. As tolerance builds, the externalizing mindfulness practitioner can increase intervals and remove structure.

Conclusion

All forms of mindfulness can be useful to all people.  The problem is that new practitioners begin mindfulness without consideration for what types of practice will yield the most benefits.  Starting with a more advanced or ill-fitting strategy to start means setting yourself up for frustration. Getting immediate benefits is important to build the motivation, habit, and persistence required to reap rewards from mindfulness over time.  

This article recommends types of practice for certain personality types.  Using Linehan’s categorization of mindfulness “what skills,” Observe, Describe, and Participate, I suggested which among these skills best matches personalities characterized by internalizing and externalizing, respectively.  Internalizers, a broad personality label that is marked by active thinking, inhibition, and attention focused inward, benefit most from directing attention outward into an all-consuming activity. That is, internalizers are best served by participating. 

The second personality type I referenced is externalizers.  Compared to internalizers, externalizers are uninhibited in behavior because they are quick to act when an emotion arises.  Externalizers benefit more from observing and describing thoughts, gradually increasing their tolerance for strong emotions over time.  Observing and describing increases the amount of thought in-between feeling and acting, providing a buffer against impulsive action.

If you found value in this post, I humbly ask you to share this post on social media, sign up for my newsletter, and/or leave a comment below.  I’d love to be able to provide even more value by creating a dialogue around this important topic.

You can also follow me on Twitter: @mindsplain.

7 Sleep Tips for New Moms

Here are 7 sleep tips for new moms and borns.

In this article you’ll learn:

  • How to teach your baby to sleep
  • Start with yourself
  • Make sleep a priority for your baby
  • Falling asleep is a skill
  • Creating a sleep routine
  • Understanding your baby’s need to cry
  • Sleep training

How to Teach Your Baby to Sleep

Nobody functions well on little sleep.  Sleep is a basic need for both physical and mental health, yet new parents are chronically sleep-deprived.

Sleep is a loaded area for most new parents.  Not only is our ability to parent as a calm leader for our child impaired by sleep-deprivation, the territory of “sleep training” is full of judgment and anxiety.  Am I harming my child by letting them cry in their crib?  Is cosleeping safe?  Am a better parent if I never let my baby cry or if I let them learn to handle their feelings?  Can babies actually self-soothe?  Family, friends, and even our partners have different feelings about how babies should sleep and this pressure can create enormous anxiety for a parent.  

The truth is there is no one right way to do sleep for every family, and even for every child in that family.  These tips below can help parents get better sleep for themselves and their babies.  

We have to start with ourselves.  

For parents, especially in the newborn stage, we have to be very creative – and committed – to getting enough sleep.  I recommend my doula clients stay in their pajamas longer so that they are more likely to get back in bed and take a nap when their newborn dozes off in the late morning.  It is normal for newborns to wake up every 2-3 hours during the night to feed, so you will likely have to stay in bed much longer than 8 hours in order to get a full 8 hours of (broken) sleep.  Sleeping when the baby sleeps is our greatest key to catching up on our sleep deficit, even if it is hard to nap during the day as a grown-up.  Practice good sleep hygiene to make the most out of your time in the bed.  Turn off all electronics 1 hour before you plan to sleep, have a sleep routine such as reading with a cup of tea or taking bath, sleep in a dark room, and use the bed for only 2 things: sleeping and sex.  

Recruit help when you need to get more sleep.  Ask a family member, friend, or postpartum doula to help care for the baby so that you can nap.  Nighttime doulas will even stay in your home overnight to handle baby’s nighttime needs while you sleep.  Some new parents hire professional sleep trainers to help them implement and follow a plan for maximum sleep.  

Photo by Daria Shevtsova from Pexels

Make Sleep a Top Priority for Your Child, Too.

Naps are sacred for babies.  Plan your day around naptime.  There is an adage that says “The more a baby sleeps, the more a baby sleeps” and in my experience, I’ve found this to be true.  This will probably mean you have to say no at times to dinner out, or a long shopping trip, or even that mommy & me yoga class that is right at your little one’s nap time.  But by protecting your child’s need for sleep you are creating healthy sleep habits for them as well as letting them practice, again and again, the necessary skill of falling asleep.

Falling Asleep is Skill

That’s right, we have to learn to fall asleep.  Eventually, sleep will overcome any of us, but for healthy sleep to occur we have to teach our children to fall asleep.  The best way to do this is to provide lots of opportunities for them to fall asleep on their own.  If our baby is always falling asleep nursing, feeding, or in our arms then that is the strongest association they will have with sleeping.  This is also true for babies that only want to fall asleep in the car.  

Instead, try to lay your baby down in a safe sleeping space (a crib, pack ‘n play, or cradle) when they are well fed and freshly changed.  Step away and tend to your own self-care.  Give your child the chance to fall asleep on their own without interference.  It is fine to let them fall asleep in a variety of places, like the stroller, swing, or car, but ideally, you want their strongest association for sleep to be in the location that they will be sleeping at nighttime.  The more times your baby sleeps in their crib the more likely they are to fall asleep in their crib.  

If you want your baby to sleep with you in your bed, called co-sleeping, that is fine.  Many attachment parenting theorists claim this is the biologically appropriate way to sleep.  Co-sleeping is the most common way for families to sleep across the world and it is possible to get great sleep this way.  Just know that you will likely have to lay down and nap with your baby or go to bed with them each night, too.

Create a Sleep Routine

A sleep routine is essential to making bedtime smooth for babies.  Focus on the 3-5 things you will do each night before bedtime.  Some ideas include a bath, feed, pajamas, songs, books, and snuggles.  Try to do the same thing in the same order each night so that the association of these activities triggers a sleep response in your child.  Once you have a sleep routine down you can apply an abbreviated version to nap time.  Let your sleep routine be a sweet way to connect with your child at the end of the day!

Understanding Your babies Need to Cry

Understanding that crying is a normal expression for babies – and all humans – and is not something to be stopped or scared of is helpful in nearly all aspects of parenting.  This is our child’s way of communicating and also their way of letting off steam.  Some babies cry a little bit at bedtime each night no matter how familiar they are with falling asleep.  Think of your baby’s cries as their way of saying “I don’t like this,” “This is hard,” or even, “I’m tired!”.

Sleep Training

Any changes and habits you make with your child around sleep are considered sleep training.  There are many methods you can choose from Cry-it-out to No-Cry, but the important thing is to make the plan that is right for you.  Babies are incredibly sensitive to our moods and anxieties so you must be comfortable with the plan you are implementing.  It doesn’t matter that Richard Ferber says you have to wait 45 minutes to check on your child and your best friend says you can’t go in at all until morning, if you feel you need to check on your child every 15 minutes to let them know you are still there for them, then that is fine.  If you feel you need to stay in the room until they fall asleep, do that.  If you feel the best thing for you and your child is to not check on them at all, trust that feeling.  When you trust yourself you can be a confident, kind leader.  It is confusing for a child if they sense your nervousness.  

You can help without overhelping.  If you choose to stay in the room while your child is falling asleep they know that you are there, even if you cannot hold them or nurse them as they want.  The same is true if you choose to come in and check on your child every so often as they fall asleep.  Setting boundaries around sleep does not have to be done in a mean or negligent way!  It is a part of loving leadership.

Try to implement your own self-care while helping your child learn to sleep.  Use the periods of crying a chance to take a shower, drink a cup of tea, and take some deep breaths.  

Baby Steps

When tackling sleep changes, I find it easiest to take just one step at a time.  You may want to focus only on teaching your baby to fall asleep first, and then tackle staying asleep through the night later.  Or allowing your baby to nap however they need to nap (remember “the more they sleep, the more they sleep”?) and only focus on developing a bedtime routine first.  Pick your starting place and commit to it.  Then once that area of sleep is more manageable, add in another aspect of sleep training.  It doesn’t have to be all or nothing.  What you are looking for is consistent movement in a positive direction.

No matter how you approach sleep, know that you are in the company of thousands of parents out there trying to figure out how to get their child – and themselves – to sleep in the healthiest, happiest way.  While it is often a challenge, it doesn’t have to be filled with dread and anxiety.  You are teaching your child a skill they will use every day of their life, and one that is primary for mental and physical health: how to sleep!

Guest blogger, Elisabeth Mitchell, is a writer, doula, and postpartum mental health advocate living in western North Carolina.  You can find more expert parenting information from Elisabeth at www.heartcenteredmamas.com.

To be notified when the newest posts arrive, subscribe below to keep up to date with all of mindsplain’s newest content.  If you enjoyed this post and want to learn more, leave a comment and engage with the Dr. Kinsey and the mindsplain community.

Dealing with Stubborn and Unmotivated Kids? Read This…

Guest Post by NikWilk

Every parent gets frustrated from time to time. If you can train the dog not to bark so loudly by giving his nose a swat, is that acceptable in child-rearing? Some parents think it should be! But motivating a kid is a lot harder than motivating a pet, and the results far more rewarding.

Homework

One of the many frustrating things parents must deal with is homework. And perhaps your first mistake is taking this burden onto yourself, rather than placing it where it belongs – on your child. To a large extent, a child will be careless about homework simply because he or she knows just how much you feel responsible for them completing it. It can devolve into a matter of control. Children have such little control over their lives, they may choose to exercise what control they have in inappropriate situations, such as homework. The more important it is to you, the more they will sense they have the upper hand. Or control of the situation. You must reinforce the idea that they are responsible, that they have control, of the homework situation. Allow them to make their own choices, but also allow them to suffer the consequences of their decision. Offer them guidance and support, anything that’s necessary, but don’t allow them to believe that you will shelter them from any consequences of their bad decisions. They will likely find motivation if they believe they have autonomy.  The Empowering Parents website offers some excellent advice on the subject. Another important matter to consider is that, although that swat on the nose may work for Rover, praise and rewards may be much more practical, and efficient, when it comes to your kids. Maybe your child is not engaged in a power struggle, or on a quest to gain some mastery of his own life. Maybe he or she is just too lazy to bother. If this is the case, it’s time to offer something in return, a reward or a privilege, in exchange for his/her effort. This should not be a foreign concept. We are all rewarded, in the form of a paycheck, for our efforts. Why should you expect your child to be motivated when they can see no payback. It’s the proverbial carrot and stick approach. And consider that they may believe the homework task simply not worth the effort simply because they find it so difficult. Offer them any assistance that you can provide to help them get through it. And review their work once they have completed it. You can find some excellent advice on how to deal with a child whose slacking off at Wiki How.

Chores

Another area in which your kids may require some motivation is chores. In order to make your child feel that they are truly part of the family and household, it is important that you allow them to contribute. This doesn’t mean that they should chip in on the mortgage payment, but they can certainly perform certain tasks around the house. Kids are naturally “doers”. They want to do something, to stay active. It’s up to you to focus this energy, to motivate them to do something other than run around the yard or play video games. Start when they are young by having them help you with certain simple chores. If you do them together, this will reinforce the feeling of being a member of the team, the family. Try to make the chore fun. Perhaps have a dance party while you mop the floor? Allow them to change their chores as they age. An older child will soon become bored with the simple things he was previously delegated. As the child grows, allow him/her some independence. Make suggestions instead of demands. Parents website offers some excellent advice on chores for children. And then there is the question of paying your children for doing their chores. Motivating them with money. But is this the correct choice? Some parents will argue that this is the only way to train them for the real world of adulthood. Others will tell you that the motivation to do chores should come from a sense of belonging, of contributing to the family unit. You can find the pros and cons spelled out Self Sufficient Kids.

Transitions

Humans are creatures of habit. We all would prefer that things remain constant. An adult may dread the transition from job to job or home to home, but for a child, transitions on a smaller scale are just as daunting. Time to go to bed? Transition! Leave the playground? Transition! Head off to school? Yet another transition! So how can we motivate them to handle these transitions without melting down? First, create a routine leading up to the transition. Bedtime? Brush your teeth, say your prayer, go to bed. Tell the child what is about to happen, and give a countdown until the time when the transition will actually occur. You might sing a song describing the transition. And providing a visual representation of what is to happen, a chart, will provide positive reinforcement about the process. Make sure you have the child’s attention when you request the transition. Maintain eye contact, perhaps touch his arm or shoulder. A shout across a room will not encourage him/her. Reward the child when he transitions without a fuss, but apply appropriate consequences when he/she does not. And praise for a job well done always works well to motivate good behavior in the future.  The Child Mind Institute offers advice on how to motivate a child to transition successfully, as does RaisingChildren.net.

Bedtime

Every parent knows that bedtime can be the most problematic of situations. Young children may not want to go to bed because of fear of being alone, or fear of the dark. Older children may see a forced bedtime as a matter of control, and strive, in inappropriate ways, to assert their independence. Whichever it is, parents must find a way to motivate them to get into bed. It’s best to start at a young age. Make sleep time a family priority. Everybody goes to bed at their own specific time. Make a schedule and stick to it, even on weekends. Be sure to deal with any problems which can affect your child’s rest, such as difficulty falling asleep, breathing problems, and fear of the dark. If your child suffers from a fear of the dark, allow them to have a nightlight or leave the hall light on for them. Work as a team to establish a bedtime routine, such as brushing your teeth, storytime, or reading time. Allow them a bedtime snack such as whole-grain cereal or fruit to sustain them through the night. Be consistent about the temperature at which the bedroom is kept, cool but not cold, and their attire, as well. Your children may be cooperative if you allow them to set their own alarm clock to wake them up in the morning. WebMD offers some great advice on motivating your child at bedtime. If your child is older, you may be dealing with control issues. An older child may be quite capable to make their own decisions about some things, and it’s up to you to decide if bedtime is one of these things. Lack of sleep can make a kid lethargic, nasty, and confrontational. If your child is experiencing none of these things, gets himself up in the morning with a relatively cheerful attitude, and is doing well at school, you usually nothing to worry about. If not, it’s time to take action. The older the child, the abler. They know now the meaning of consequences. These can be consequences due to his lack of sleep, or the consequences you provide due to his lack of adhering to a proper bedtime routine. If your child is not self-motivated, you will have to motivate them. Most teens will not find it a punishment to be sent to their room. Their room is often an electronic wonderland. If you have problems with a child, who will not adhere to a bedtime schedule, remove the electronics from their room. This can mean removing the devices themselves or simply taking the remote control. And don’t forget your cell phone. Keep it with you after you take it from them to make sure that they don’t have access to it at all. Check on them before you retire for the night, but remember to knock before you enter, thus reinforcing their sense of control. Once your older child has proven that they can follow a bedtime routine, and see for themself that they an improved attitude and less trouble at school, they will likely self-correct. EmpoweringParents.com offers good advice on how to deal with older children as well as younger ones.

Morning Routines

Mornings can be very hectic, as anyone with kids knows, and having unmotivated children dragging their feet can only make them more so. Start by giving yourself extra time to have your kids get ready for school. Enough time so that impossible time constraints don’t make the task undoable. Everybody knows that unexpected things happen all the time, so prepare for the..impossible. Or simply nerve-wracking. Have your children complete any tasks they can the night before, rather than at the last minute. Keep younger children close where you can supervise them. If a younger child needs help getting dressed, have them do so in the kitchen with you, rather than leave them to become frustrated in their own room. Consider having a family meeting to discuss the plan for getting ready for school, and make them a part of that plan. And get out the door! Don’t waste time dealing with a minor problem in such a way that will make you, or your child, late. Discuss the concern with them at a less stressful time. Bright Horizons can help with having the kids get ready for school with some helpful advice.  Motivating your kids to do anything can be difficult. Getting ready for school is no different than anything else. It can be especially difficult if it is made more imperative by the necessity to adhere to a tight schedule by the requirements of a parent’s life. It can also be difficult is the child has some problems with the school itself. A child will respond to simple motivations and won’t really care if Mommy will be late for work. Tips on how to motivate your child in any situation, with techniques that are meaningful to them, can be found at Parents.com

Summing Up

Parenting is difficult.  Right answers don’t really exist, only more or less effective strategies.  Above are some tips you may find useful in helping to motivate kids to do homework, chores, transition, get ready for bed, and get moving in the morning.  

If you’ve found any of this useful, please share it with others!  A tweet or share goes a long way, as does subscribing to the blog below.  You can also help by making this article more useful to others by commenting and interacting with the mindsplain community!

Deconstructing Narcissism: A Model of Emotional Dynamics of the Narcissistic Personality

Narcissism | Emotional Dynamics of Narcissism | Mindsplain | Narcissistic Personality DisorderIntroduction:

With the aim of simplifying and clarifying my own understanding of the dynamics of the narcissistic personality, I set out to create a simple, clear flow chart. In particular, I wanted to link the grandiose narcissistic behavior, with narcissistically-injured/deflated narcissism, and other forms egocentrism can take.  What I ended up with was not the neat, simple chart I had in mind. Instead, I got the thing above. Still, it helped me to clarify a bunch of stray thoughts, experiences, and theory associated with narcissism. I’ll do my best to go through the different components and make it more clear.

Inside Out:

The first thing to know while looking at the chart is that the center represents what the narcissist feels, and would express if asked. For the narcissistic organization, it’s important to understand that the area of emotional awareness is very small.  Most of the big and powerful emotions are outside of conscious awareness. However, the narcissist will likely only experience a diffuse sense of anxiety and/or depression.

On the outermost area of the chart, are existential, annihilation anxieties. These are deep-seated, hard-wired, reptilian fears that are not conscious for anyone on a moment to moment basis.  Yet humans share these with the animal kingdom. All creatures are at some level wired to avoid being eaten, drowned, or disfigured. We will see though conceptual links between these primitive fears and more recognizable emotions.

Core emotions:

To use an analogy, have you ever used a bubble level?  The ones you use when hanging frames, or for ensuring straightness when building?

I imagine the 3 core emotions of narcissism to function something like this level. Although narcissists seem impenetrable and cold at times, they simply suffer from an emotion regulation problem. The way narcissistic individuals manage stress is like trying to keep that damn bubble on a level in the center of the guides. What I mean is, it’s difficult to keep there; the bubble shifts with the slightest provocation, and it consumes an immense amount of physical and emotional energy to maintain an equilibrium. This is why, at the center of the diagram, is a pervasive feeling of enervation and deadness (i.e., depression), and/or a pervasive tension that narcissists experience as a diffuse sense of anxiety.  That is, the experience is a vague feeling of distress that is

1. Disconnected from discreet, identifiable emotions; and

2. Not linked to internal thinking or feeling states (it’s explained as either completely perplexing and befuddling, or it is assumed to emanate from the external environment).

Someone with a narcissistic personality tend to seek treatment when “anxiety” or “depression” reaches a critical threshold of pain. The idea of a maladaptive personality style is often so far from conscious awareness that it could take months or years of psychotherapy before this fact is even acknowledged, let alone addressed.

Diagram of emotional dynamics of the narcissistic personality

Take a look at the infographic above.  The center of the diagram shows unconscious emotions coexisting in concentric rings; each ring representing a greater distance from the narcissist’s conscious, subjective experience.  Returning to the bubble level analogy, for some narcissists, the center of the bubble level is a grandiose state of disgust. Others default to the reclusive, shameful solipsism of deflated narcissism. Others feel empty and envious and thus try to manage emotions by spoiling others’ feelings of fullness–including the fullness one might get from helping the very same narcissist.

Let’s go through the diagram one level at a time.

Narcissism: Emotional Dynamics

Types of Narcissism:

The Grandiose Narcissist:

This is the prototype of narcissism.  The closest emotion to conscious awareness for the grandiose narcissist is disgust. In evolutionary terms, disgust is an emotion that has the purpose of keeping us uncontaminated.  We recoil at anything outside of us that might be harmful if taken in. It’s no coincidence that pregnant women get morning sickness and young children are the pickiest eaters (in other words, oral fixations). Most vulnerable physical states are being in utero and being a young child; the narcissist is someone who did not advance very far from this period of vulnerability, which, paradoxically, is characterized by “narcissistic omnipotence.”

Narcissism Treatment Center Take A Number

The narcissistic personality displays a powerful, grandiose exterior. Yet, s/he protects the self as if its existence were so precarious that it could not survive the most slight threat to its physical and emotional wellbeing. If you have spent much time around narcissists, you will know that they reject anything that might touch a nerve, and “spit out” any attempt to know them, see their vulnerability, or question their impregnability.

The Narcissistically Injured/Deflated Narcissist:

The narcissistically injured, hereafter referred to as the deflated narcissist, is someone who embraces shame but, this narcissism comes from the rigidity with which the individual tells the story. It’s a “woe is me tale,” and the experience of being with this type of person is that they have a monopoly on the world’s suffering.  No one could experience the type of pain that they feel. And how dare you suggest that they make any kind of effort to improve their situation. Don’t you understand how they have been wronged? If you think they should assume a position of agency and be more proactive in their psychological healing and growth, then you are aligned with the abuser and are blaming the victim.

The ashamed person is a cave dweller–quite cut off from others, but sheltered. The “cave” in this metaphor is a narrative of grievance that grows with every instance with every day its occupant remains there either ignored or improperly helped (“proper” help is often a moving target and a fantasy of perfectly attuned care).

The story behind the shame is impenetrable as the grandiose narcissist’s persona.  The ashamed and isolated loathe themselves for two reasons:

1. To receive care from others without expectations of reciprocation; and

2. To express rage towards the person upon which they depend.

How can shame be an expression of rage, you may ask? Shame is an expression of extreme self-annihilation that presents a system, whether dyadic (i.e., parent-child), family, or societal, with the effects of the other’s cruelty.  Every expression of pain is thus hostile accusation against a wrongdoer.

The Empty or Depleted Narcissist:

The classic manifestation of this type of narcissistic personality is characterized by the emotion of envy and is one that every clinician knows well: the help-rejecting complainer. This type of narcissist will often find him or herself “seeking help” by way of dragging the world down to his/her level. No solution is ever good enough, as no nourishment can fill the bottomless emotional pit inside of this type of individual. In Buddhism, there is a specter of suffering known as the “hungry ghost,” whose attributes capture the state of the empty narcissist’s state of emotional equilibrium. These hungry ghosts are known to have enormous stomachs with an incredibly narrow neck.  In other words, they can never feel full, nourished, or sated.

The state of emptiness is the most emotionally regressed of these three core emotions. It is a replication of the ungratified infant’s experience, of feeling hollow while abundance was felt to be withheld.  This individual does not want help. S/he wants one of two things:

1. An endless stream of support and comfort; and/or

2. To destroy those who have what s/he lacks.

It warrants underscoring that these three core emotional states of narcissism can be experienced by any type of narcissist, or any person at a low point of life, like the bubble in the level can occupy any area within the tube. The point is that experience dictates in which one of these three positions a narcissistically organized person feels most stable.

Defenses:

Having outlined the bubble level metaphor for three types of narcissistic states of being, I’ll define the predominant defenses used by each type of narcissist to remain at a state of equilibrium (that is, at the center of the bubble level). These defenses are used to keep primary affective experiences of disgust, shame, and envy outside of conscious awareness, and can be found on the infographic above, along with the most likely direction in which they are deployed.

Splitting:

A defense where the bad is disconnected from the good. It is a type of defense used by those who struggle to see themselves as combinations of good and bad personality traits.  In short, it means disconnecting from the bad. It’s used pervasively by all forms of narcissism.

Identity Diffusion:

A defense wherein standing alone as a separate person creates too much anxiety to be tolerated.  In short, it means merging with the good instead of risking being bad. It’s used in all iterations of narcissism.

Introjection:

Taking in the bad to protect against abandonment.  It’s used by the deflated narcissism as a self-effacing means of attaching to another. Preferred defense of the deflated narcissist against abandonment.

Projection:

The defensive process of seeing in another what is bad in oneself.  Defending against shame to remain all good. One of the preferred defenses of the grandiose narcissist against shame.

Masochism:

Attacking the introjected object to gain separation and express rage at another who cannot tolerate direct attacks.  Preferred defense of the deflated narcissist against envy.

Regression/Idealization:

Defending against shame by becoming envious and idealizing. Preferred defense of the empty narcissist as a defense against the shame of separateness and to obtain a parasite-like relationship to a compulsive nurturer.

Denial/Disavowal:

Primitive defense against the bad by asserting the bad’s absence. Used as a defense against the emptiness and envy characteristic of being in a state of dependence.

Projective Identification:

Attempting to defile the good in another through projection then attacking it to defend against feelings of envy, powerlessness, and emptiness.

Anger: The Closest Emotion to Conscious Awareness

Narcissism: Anger, Rage | Narcissistic Personality

It will surprise no one who knows or works with narcissistic people that a great deal of anger can be found within a narcissist without too much digging. Interestingly, most narcissists don’t see themselves as angry and thus the anger they express is not considered to be either a feature of their personality or abnormal in any way. Any outbursts of anger will be rationalized as necessary or required by the situation. And no matter whether the narcissistic personality tends more towards grandiosity, injured, or empty, anger is outside the narcissist’s conscious awareness. As stated earlier, narcissists will only feel the reverberations of intense emotions like anxiety or depression.

However, depending on the state of the narcissistic personality, the way anger exists outside of conscious awareness can take different forms. For example, for the grandiose narcissist, irritability, annoyance, or jealousy are common forms that anger takes. Subjectively, the narcissist may feel this anger as the way in which people are trying to knock him/her off his perch or take something away. When the grandiose persona is attacked, the grandiose narcissist’s anger and disgust will assume the form of holding on to a sense of grandiosity (and all the extensions of this grandiosity and will throw out nasty barbs to put others in their place.)

To the narcissistically injured, rage will either be impotent, keeping the bearer stuck in a shameful position. Another possibility is for the rage to be coopted, turned against the self, to ensure others are know how cruel they have been to evoke such a state.

The empty narcissist is filled with primitive oral aggression, the kind displayed by infants who bite the breast that feeds.  Rage gets expressed as “if I can’t have it, no one can!” These people are happy to sacrifice themselves for a more fair distribution of profound suffering. Empty, envious rage can be seen in the disastrous applications of communism throughout the world; civilizations were destroyed out of envy for the rich, while the masses shared in collective starvation (i.e., emptiness).

Just Beyond Anger: Sadness

Narcissism, Sadness

The dynamics of the narcissistic personality are designed first and foremost to make vulnerability as distant from conscious awareness as possible.  Therefore, the narcissist has very little access to genuine emotions of sadness. One point of clarification is that sadness associated with depressive feelings, shame, or emptiness is better conceptualized as covers for anger, as the sadness is more about impacting others than it is about healing and connection.  Yet, beyond anger is a deep and profound sadness that narcissists are quite justifiably afraid to feel.

For the grandiose narcissist, a facade of impenetrable confidence conceals both a history of and a commitment to banish feelings of intense vulnerability. The deflated narcissist isolates in shame to confront an aggressor (very likely to be a grandiose narcissist) with evidence of the other’s cruelty; this maneuver turns “active into passive,” appropriating the act of abandonment to prevent feelings of loneliness and despair. For the empty narcissist, a preoccupation with filling the void of emptiness so that an overwhelming sense of grief over a lost sense of fulness or completeness will not be felt.

Annihilation Anxiety and Existential Fears

Narcissism: Narcissistic Personality | Fears

The most remote level of feeling for both the narcissistic personality and all other personality types are ancient existential annihilation fears that we humans share with creatures in our deep evolutionary past. The grandiose narcissist’s Teflon exterior protects against hardwired existential fears of penetration–whether through rape and violent impaling–inclusive of mutilation/castration. The deflated narcissist’s deepest fear of annihilation is to be abandoned and exiled from the larger group. Thus, the defensive maneuver is to pre-empt rejection and banishment by self-isolating while assuming a stance of accusatory aggression.

The empty narcissist’s annihilation anxiety is not immediately intuitive and requires a theoretical context. The empty-feeling person’s fear ultimately is of being a victim of predation or being devoured/swallowed. The conceptual connection to envy is that feelings of emptiness arise from psychological cannibalism. Theoretically speaking, emptiness and envy come from having one’s needs denied and being used by early caregivers as a source of psychological nourishment. Feeling full or complete is perceived to be a zero-sum game, where only one person in a relationship can feel fulfilled, and that a mutually satisfying arrangement cannot be imagined.

Personality Disorder Diagnostic Criteria

The DSM-5 offers an atheoretical and purely descriptive summary of Personality Disorders and Narcissistic Personality Disorder

Diagnostic Criteria for Narcissistic Personality Disorder

The DSM-5 offers an atheoretical and purely descriptive summary of Personality Disorders and Narcissistic Personality Disorder

Wrapping Up the Narcissistic Personality:

The infographic above is a new model I have developed to better understand the emotional experience of narcissistic individuals, as well as to understand the relationship between well-known types of narcissism (e.g., grandiose, deflated). This graphic is both more complex than I intended, yet still is an oversimplification of the emotional nuances of narcissism. My hope is that this will provide some useful understanding for those whose lives have been affected by narcissism, or see some narcissistic traits in themselves. Although recipients of narcissistic abuse (understandably) feel weary of trying to see things from the narcissist’s perspective, the capacity to put ourselves in the shoes of another can be a powerful source of resilience.

I’d love to get questions and feedback in the comments to help clarify all our understanding of the phenomenon of narcissism.  Please subscribe below and share widely–the more join the discussion, the better!

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Further Reading on Narcissism:

To review what the DSM-5 (Diagnostic & Statistical Manual of Mental Disorders) has to say about personality disorders and/or narcissism, a review copy of the DSM-5 section on Personality Disorders DSM-5 can be found here.

Dear Survivors of Narcissistic Abuse: Own Your Healthy Narcissism!

Bromberg, P. (1983) The Mirror and the Mask—On Narcissism and Psychoanalytic Growth. Contemporary Psychoanalysis, 19:359-387

Bach, S. (1977). On the narcissistic state of consciousness. International Journal of Psycho-Analysis, 58, 209-233.

Freud, S. (1957). On narcissism: An introduction. In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works (pp. 67-102).

Envy & Destroying Others' good fortune

Envy: The Camouflaged Emotion

More and more I encounter an emotion in patients that is quiet, hidden, nagging, and insidious.  Most people seem surprised when it’s named, and the notion of inviting an open exploration of the feeling in their relationships seems quite unthinkable.  To own the emotion feels shameful, and the detection of said emotion elicits guilt in the perceiver. It’s a primitive feeling we can easily recognize, yet conveniently tend not to take notice of.  What is the feeling?  

Envy.

It’s at the heart of relationship problems, in families and between lovers.  Its corrosive properties lurk at the heart of political divides and toxic discourse.  Individuals and groups grow further apart and disparities emerge, more seeds of envy are sewn.

Quote on Envy

What is the Experience of Envy?

One thing I find interesting about envy is that it is much easier to feel than it is to define.  As stated above, it’s primitive and easy to access in our bodies. But what exactly is it?  

Before defining it, I invite you to feel in your body.  Bring to mind someone or a group of people who always seems to get what they want.  Life seems to open up a path to them no matter what challenges others face. They have all the love and money they need without seeming to suffer the hardships of pain or loss.  They are gorgeous and seem to find even more beautiful, doting, and passionate lovers. They have charisma, make others laugh with ease and always seem to be having an amazing time.  They have boundless energy and confidence.

Feeling it yet? Where? 

I feel my stomach twist and my molars being forced together.  It’s painful, yet also perversely stimulating.  

Melanie Klein, a key pioneer of child psychoanalysis, posited that envy is first experienced feeding at the breast, especially when gratification is either withheld or delayed.  It’s primal and oral, born out of a drive for food and intimacy–and crucially a desperate feeling of want. Envy is lustful and (omn)impotent(?) rage in the face of deprivation coupled with the innocent hope of that comfort, closeness, and oral satiation can be obtained through unrestrained desire.

Klein observed in her own experiences as a mother, and thus her own empathic regression to infancy, that envy is the experiential consequence of parting from the womb.  What once was one is now two, and the divide can never again be bridged. When discomfort comes, intuition screams that goodness has been stolen. When gratified, the infant begins to learn that comfort can be taken away at any moment, and thus self is no longer connected to goodness.  These disparate experiences of goodness and badness, in the mind of a newborn child, seem inherently irreconcilable. In other words, having and not having is a zero-sum-game. If you have it, I don’t. If I have it, you don’t. Coercive action to reclaim goodness is the only solution if self is to have it.

Eventually, humans learn that reality involves getting some of what we want, and some of what we don’t, and that the source of pleasure can also be the source of pain simultaneously.  But in moments of dysregulation, regression, or plain weakness, we all return to the primal state of envy from time to time.    

Envy Defined

Envy_Resenting_Happiness

Envy means resenting and wanting to destroy others’ happiness.

In the Kleinian tradition, the definition of envy is “the expression of destructive impulses,” in the sense of “If you have it, I can’t; therefore I must destroy you and/or it.”  In the same tradition, envy is distinguished from jealousy by the presence of this destructive impulse (For more in-depth psychoanalytic explorations of envy, refer to this document: Psychoanalytic Electronic Publishing Consolidated Psychoanalytic Glossary).

Marsha Linehan, a clinician and researcher in the behavioral tradition and creator of Dialectical Behavior Therapy (DBT), has a slightly different way of defining envy.  Linehan created DBT to treat Borderline Personality Disorder, a personality type characterized by (among other things) insufficient development from the primal emotional “split” reality between envy and gratification.  Defining and working with envy is thus a feature of her therapy. Linehan defines envy as simply the state of desire for something another has, but the self is lacking (that is, it lacks the zero-sum-game quality of Klein’s definition).  She differentiates envy from jealousy in a more simple way: jealousy is a protectiveness of what one has but is afraid of losing, while envy is the wanting of something lacking.

Both Klein and Linehan’s conceptualizations of envy seem to contribute to a complete understanding of this covert emotion. 

What is the Function of Envy? 

In Linehan’s view, all emotions must have functions.  Feelings without reasons to exist would be an inexplicable evolutionary superfluity.  Three of these useful aspects of envy are as follows:

The provision of energy to organize action towards a goal

  • Motivation to fight injustice and inequality
  • The will to fight for resources in the face of scarcity
  • The signal to ask for self-benefitting changes or to assert one’s needs in intimate relationships

Some psychologists have made the distinction between a “benign” and “malicious” envy.  In Linehan’s model, envy only becomes a problem (i.e., malicious) if envy’s demands and desires exceed what an individual can reasonably expect–or perhaps that envy’s influence is undermining rather than strengthening relationships (presumably because expectations are unreasonable). 

Where is Envy Hiding?

Envy, hate, moral indignation and virtue

Envy often disguises itself as virtue.

So I’ve made the claim that envy is everywhere.  What follows is a non-exhaustive list of where we find envy every day.

Social Media:

No matter the platform, underneath every “like” and at the top of every “troll” comment is envy.  Social media is, among other things, a breeding ground for social comparisons, and by extension, envy.  Influencers and content creators constantly get attacked because they do what we everyone wants to do: put themselves out there, connect, and get rewarded for their efforts.  This is difficult to bear, especially when we have stronger tendencies to hide from others, remain isolated, and see few returns on our pain and suffering.

Politics:

It’s difficult to imagine an era where envy was more prominent in political discourse.  Critics of Trump want to destroy him. I abstain from commentary on this, but I’ll paraphrase critics the following way: he is a nasty, privileged, self-serving, entitled, lying manchild who acts selfishly, faces no consequences, and gets rewarded with the most powerful position in the world.  Plenty of similar attacks are leveled from the opposing extreme: “Leftists” are entitled children who can’t accept election results and throw temper tantrums in the streets, discuss how oppressed they are, and try to destroy a legitimate election result by illegitimate means. Whether you are more outraged about the audacity to withhold tax returns or the lack of the elites’ concern over immigration and its impact on employment prospects, your outrage is partially fueled by envy.

Activism: 

Activism is a concern over fairness and justice, and by definition, includes some individuals profit at the expense of others–thus the emergence of envy.  To name a few recent cultural examples, Black Lives Matter, Blue Lives Matter, Social Justice/Intersectional Feminism, Antifa, Free Speech Movement, etc. are all examples of envious energy channeled into activism.  Any accusation of the term “privilege,” carries with it the motive of envy.  The presence of envy does not mean any of these movements or labels are ill-conceived or immoral, but the passion emanating from them does come from envy.

To make one editorial comment: envy can be a force for good when it is sublimated through activism, but the goal of destruction, whether “whiteness,” “fascism,” “socialism” or any other abstract label, toxicity and incivility ALWAYS manage to mar constructive efforts.

Terrorism: 

Terrorism is perhaps the most extreme manifestation of envy.  There can be no more powerful expression of malicious envy than the destruction of another through the destruction of self.  Whether a mass shooter or a suicide bomber, envy lurks underneath every act of melodramatic masochism. Although it is a topic for another post, the film The Joker is an extremely successful depiction of envy, its origins in a prototypically Kleinian enmeshed mother-son relationship, and how destructive envy arises from feelings of emptiness, deprivation, alienation, and failed attempts to obtain what others have.

Friendships: 

Competitiveness in friendships is often a clue that envy is present.  In boys, this might take on a more physical and/or ostentatious form, whereas the feminine version most likely takes more sophisticated, social aggression.  For evidence of the dynamic of envy among friends, the movie Mean Girls stands out as a film about envy and the insidiously destructive forms it can take.  There is also a buddy comedy called (wait for it…) Envy that deals with similar themes.  The point is that friendships inevitably lead to social comparisons, where we are much more likely to observe things we lack than what we have.

Family: 

Envy is certainly a frequent occurrence in sibling relationships.  Fights over fairness and whiny interrogations into “How come she got it and I didn’t?” are an easily recognizable trope.  What’s less discussed is the envy between parents and child. Parents often envy their child for having opportunities of which they were deprived.  In fact, parents often go out of their way to supply precisely this kind of opportunity, only to envy their kids for receiving it. This is why envy is often at the core of enmeshed relationships between mothers and their children; the child understands that independence threatens the parents’ connection to envied love, nurturance, and care.  

Conversely, a core tenet of psychoanalysis is the Oedipus complex, where the father is envied for his access to the mother.  The primal scene is another classic image in psychoanalysis evoking feelings of envy.  The defining element of these two images is that the child, who once was harmoniously connected to mother in utero and in the first few months of life, has lost Mother and must destroy Father to merge again.  In the primal scene, the specter of a sibling is introduced, as the child actively witnesses the possible conception of the next child. The feeling evoked by these symbols is prototypical envy.

Workplace:

Have you ever been passed over for a promotion?  Been outshined at work? Felt you were more deserving of a high position than the one occupying it?  Then you know what envy feels like at work. A sense of unfairness frequently emerges if you stay in a position long enough–perhaps rightfully so.  That feeling, whether adaptive or not, is envy.

Romantic Relationships: 

The theory that “opposites attract” is predicated on the notion that the other has something we do not, and therefore is destined to be envied.  Even similar romantic partners are bound to observe differences in power, wealth, attractiveness, power, family support, etc. of which we can become envious.  Similar dynamics can develop here as in platonic friendships, but with the added intensity of heightened dependency and sexual attraction.

Guilt: The Envy Detector

Suzanne Collins Quote on Envy

While guilt can mean that we have violated an important social contract and need to atone, it simultaneously is a signal that means others are envious.  To violate a social more or rule means putting oneself ahead of others. This expression of audacity conveys to others a sense of entitlement along with the unconscious desire that we too would like to ignore social rules and put ourselves first.  This form of envy is more or less benign unless punishment involves a brutal act of scapegoating.

However, the world is filled with people who feel guilty because of their special talents and/or gifts.  A former teacher of mine, Jerald Grobman, MD, has made a career treating the conflicts experienced by gifted and talented individuals.  Gifted and talented people have many hidden challenges, but guilt in response to being envied stands out as the most insidious.  A person who is attractive, successful, funny, rich, charming, etc. could just as easily feel guilty about their gifts. What can compound this guilt is the fact that naming it can be difficult.  Expressing conflict surrounding admirable traits threatens further alienation by potentially breaking the taboo against boastfulness. After all, complaining you feel guilty because you feel fed up with being envied for your attractiveness is more likely to elicit more envy than empathy.

Why is Envy So Shameful?

In addition to asserting that envy is widespread, I also stated that we are silent about its presence because of its shameful nature.  And yet it’s not at all obvious why would we conceal such a basic and universal feeling? Below is a list of some of the possible reasons.

  • Envy is one of the “seven deadly sins” in The Bible and is thus connected to violating sacred socio-cultural values
  • Envy is a primitive emotion and therefore reminds us of primitive vulnerability
  • Discussing envy means discussing ways in which you think the other person is better than you
  • Discussing envy means discussing ways in which you lack something significant
  • The feeling of envy contains a highly stimulating and erotically charged feeling that evokes taboos around sex
  • Incest taboos are embedded in the Oedipus complex and the primal scene, which theory tells us is closely connected with early experiences with envy
  • Activism the motivation of envy may be viewed by self or other as discrediting to the cause 
  • Envy contains feelings of need and a desire for caretaking; current cultural mores increasingly stigmatize needing things from others

What’s the Antidote to Envy?

The antidote to envy is gratitude, just as the antidote to starvation is feeling nourished and full.  However, lasting gratitude comes from laying a foundation of accumulated emotional maturation and the establishment of a meaningful identity.  Psychotherapy is one way of remediating deficits in structural and developmental emotional deficits.

But urgent and threatening surges of envy can arise, requiring immediate attention.  In crises of envy, where our feelings of emptiness and aggressive impulses coalesce into a (self) destructive force, here are a few things you can do:

  1. Make a list of 5 things for which you are most grateful.  The hack here is that before you arrive at the top 5, you’ll ponder numerous other things for which you are also grateful.  Additionally, a sincere effort here is rewarded with an awareness of aspects of your life that truly have value.
  2. While you are likely to have come across tip 1, the trick I find even more helpful is to really imagine trading places with the object of envy.  Would you really want that? Do you really want to take over someone else’s life? Envision what this would look like. Think of all of someone else’s choices you’d have to live with.  Think of all of the adaptations you’ve developed that would no longer be useful. Think about how confusing it would be to know which aspect of you is really loved and valued. Immersing yourself experientially in this exercise is the key. 
  3. An extension of number 2, focus on playing the hand you have been given.  Games are fun because not everyone gets dealt an equally desirable set of cards.  We play though to test our skills, to immerse ourselves in the problems unique to our hand, and to see how far our minds can take what we did not choose.  Think about the unique challenges you face and how it’s your life’s work to play these cards to the best of your ability. Sometimes working to change the rules is necessary–real and correctible unfairness exists; but be mindful of how you felt playing games with people who wanted to change the rules after the game has already begun.
  4. This is number three slightly restated.  Constraints are the agitators of creativity.  When anything is possible, creative solutions aren’t needed.  To be a creative force in your life, you must have limitations that others don’t.  The more we embrace our deficits, the more creative our solutions, the more meaning we find in life, and the more we inspire others.  You may even be envied.

Call to Action:  

Every week I try to post 2 new articles that offer new perspectives on common problems, increased depth and outside the box approaches to common difficulties, and overall interesting content.  If you like this and other posts, I’d love for you to subscribe, by entering your information below. I’m always on the lookout for new challenges to take on with this blog. Plus, you’ll be among the first to know when something new gets posted.

5 Reasons to Consider Psychiatric Medication

Top 5 Reasons to Consider Psychiatric Medication

Introduction

A surprising dichotomy of viewpoints seems to arise around the topic of psychiatry and management; the first is that psychiatrists are real doctors and psychotherapists are quacks.  The second is that medication is for suckers, weaklings, and the desperate. The polarization I’ve observed about these topics is surprising considering all evidence seems to indicate that both work pretty well together.  While it’s not my place to tell people they must be on medication (As in, legally I’m not allowed to), I can certainly tell you about my experience with medication as a supplement to psychotherapy, and why it may make sense to consult with a psychiatrist about your needs.

1. Step Outside the System

Our personalities and individual psychologies are complex dynamic systems.  Our character structures consist of many forces, mounting pressures, levers, sources of friction, algorithms, contingencies, etc. that come together to create an overall feeling of goodness or badness of some kind.  The important point about our personalities being systems is that they seem to favor repeated, stable, and predictable outcomes, regardless of how good these outcomes feel.

When these systems create toxic emissions, uncomfortable temperatures, aversive noises, and require a lot of reactive interventions, it can be confusing as to whether or not the system is broken, or that’s simply just how systems are!  In other words, the pain and suffering created by our personalities can often be hidden in plain sight, like water to a fish. Why is this hidden? Well, because our brains are too powerful.  We learn to adapt and habituate.  We get to work on adjusting to the system rather than questioning if it’s broken or not.

No matter how many times it’s explained or otherwise conveyed to us that something is not working, the difference between addressing the issue and continuing the exhausting work of adjusting our behavior and/or expectations often comes down to experience.  Humans quite frequently need to feel differently in the world before they can actually see that the whole damn system is broken.  This is exactly why:

a. Substance abuse is both so rampant at the same time it causes so much suffering; and

b. Psychiatric medication can be such a powerful tool in psychotherapy*–not only as a temporary relief but as a lasting force for good.

Let me say it more succinctly.  Once we know and can accept the scope and scale of a problem, we are much better positioned to fix said problem.  In the world of film, two well-known depictions of being stuck in a system are The Matrix and The Truman Show.  The popularity and the acclaim received by these films may be partially attributable to the way in which the blind spots they depict are a core feature of human experience.

2. Get More Out of Psychotherapy

Psychotherapy is difficult.  I often see the look in clients’ eyes that they would rather be almost anywhere else.  Some even say so. Depressed people, almost by nature of the condition, feel it’s hopeless to be in therapy, and sometimes give the impression that working on ending the depression is getting in the way of the client being left alone to sit in his/her depression.

“And I don’t understand why sleep all day

And I start to complain that there’s no rain”

-Blind Melon “No Rain”

Anxious people often worry the treatment won’t help while simultaneously worrying what the therapist will think or say if s/he voiced these worries.  Paranoid people fear the therapist is trying to do harm, possibly by humiliating the patient after s/he discloses all of his/her darkest secrets. Traumatized people similarly feel that they will be retraumatized.  Etc., etc.

You see, the very nature of mental illness is such that collaborating with a therapist puts us face to face with the worst of our symptoms.  Medication provides a tool to make thoughts, feelings, anxieties, disorganized thinking less threatening to the work of really looking at what hurts with a relative stranger.

Medication is not a “cure,” nor is it the longterm solution to lifelong problems.  But, medication can be a great tool. As one of my mentors once said: “I’ve never seen an antidepressant relieve a conflict.”  That is, medication won’t fix the engine, but it could get you to the repair shop.

A two-pronged approach is especially important since psychiatry requires much patience, collaboration, as well as many adjustments to get the right concoction. Psychotherapy and medication management often need to work hand in hand just to get a patient into a position to begin meaningful work on him or herself.  With both psychology and psychiatry, each component should contribute to the efficacy of the other. When mood improves, anxiety goes down, or mental clarity goes up as a result of a psychopharmacological intervention, the therapy benefits. Conversely, therapists can be extremely helpful in counseling patients through the waiting and trial-and-error approach that medication management often requires.

As a therapist, my bias is that the long term solutions to depression, anxiety, personality disorders, trauma, and other mental health problems, is to work with a psychotherapist.  Medication has the potential to create the conditions necessary to fully engage with a therapist. With observable changes from medication, the patient begins to realize that a different experience is possible.  Once someone believes they can be happy (again), s/he will bear almost any pain to make sure they get all the way (back) there.

A lot of patients object to psychiatric referrals, often rationalizing that they “don’t take pills.”

Underneath this explanation I believe is a feeling that pills are “cheating.”

Medication is not a fix, but it can be an amazing tool. Therapy is the work, but meds can help. pic.twitter.com/sgIvG9Un8i

— Michael Kinsey, Ph.D. (@mindsplain) May 19, 2020

3. Stop Unnecessary Suffering

Suffering can almost take on a moral aspect to it if endured long enough.  A strange logic takes hold that because suffering has descended upon us alone, that we alone must either bear or overcome it.  Of course, this is absurd if we take a moment to identify, observe, and challenge such an assumption. Our suffering serves no one.

A quick proof: Perhaps someone somewhere would like to see you punished.  Your suffering will do nothing for this person, since it’s unlikely that s/he will even know that you are suffering.  This punitive individual may conclude that you have not suffered enough, based purely on an inability to:

a. know that you suffer; and

b. Be sated by the suffering you do endure.

 And so even in this case, your suffering is useless.

However, if you believe that redemption, moral or otherwise, follows dragging yourself out of an emotional funk by finding your own solutions, then medication (and possibly not even therapy) is not likely to appeal to you.  As someone who is inspired by the idea of slaying psychic dragons, I also believe that there is no easy solution, and freedom only follows blood, sweat, and tears. However, I also believe that we do not need to go slaying dragons with our bare hands.  Think of psychiatric meds as a sword. And once you’ve picked up that sword, you can then talk to your therapist about why the hell you tried to fight a dragon with nothing but your bare hands.

4. Instill Hope

A well-known finding in the mental health field is that some of the most dramatic improvements in mood come between booking a therapy appointment and attending said appointment.  Why do these benefits occur? The most plausible interpretation is that taking action instills hope in the actor.

Skeptics and material reductionists interpret this and other common factors in psychotherapy, like the therapeutic relationship, to mean that effects of psychotherapy are little more than placebo effects.  But I think the importance of hope contributes to psychotherapy the way the mantra “I think I can” helped The Little Engine Who Could.  Hope, whether it stems from taking action, seeing an impact from psychiatric medication, or the confidence of an effective therapist, is necessary to accomplish any great feat.  With mental illness, where an absence of hope can be so central to the experience, the more vehicles that exist to help patients viscerally experience that desirable future can be had, the better.

Antidepressants and other psychiatric medications, because they have the potential to work after a few days, weeks or months, can provide an invaluable morale boost to someone who has long suffered with psychiatric symptoms.  To sum up the importance of hope in psychotherapy, the following proverb comes to mind: “whether you believe you can or you can’t, you’re right.”

5. Lift the Fog

We have discussed the fog of negative mood, but there is another kind of fog that can interfere with treatment.  That is, the fog of impaired cognition. When we are anxious, depressed, traumatized, obsessed, or embroiled in unstable views of ourselves and others, we can’t think clearly.  Our attention span shortens. We take the path of least resistance. We’re distracted. We can’t hold multiple things in mind. We make more mistakes and the downward spiral continues.  In the same way that boosting your mood might give you the hope to finally address your mental health, so too can thinking more clearly help to inspire corrective action towards mental health problems, and make better use of your time with a therapist.  Psychiatric medications have the potential to make thinking more lucid and give us more access to mental resources. Over time, good psychotherapy will expand these benefits as well as protect against these mental capacities from becoming depleted once more.

Conclusion

When it comes to psychiatric medications, no shortage of negative opinions exist.  However, most of these opinions are inherently linked to the bad attitudes of a select few bad psychiatrists (just as though there is a distribution of bad, average, and great cashiers, cobblers, lawyers, mailmen, etc.).  Many find the approach of prescribing a pill for existential problems to be dismissive. Others balk at the idea that it will alter some essence of their character, or make them lose control, or worse still, become dependent on something.

I think these objections are unfounded, and that most of these critiques can be addressed by underscoring that psychiatric meds are an imperfect, but useful tool to help people solve real problems of living through some other means–most likely in psychotherapy.  Psychiatric meds are extremely useful in helping people step outside of their mental illness, get more out of psychotherapy, stop unnecessary suffering, lift the fog of clouded thinking, and instill hope.

How to pay for psychotherapy

Affordable Therapy: 11 Ways to Pay for Therapy When You’re Broke

Introduction

Seeking out psychotherapy to address persisting emotional difficulties, especially when you have never had personal experience with it, is almost always a last resort.  Leaving aside unconscious factors captured by the term “resistance,” the cost of competent treatment remains one of the easiest excuses to cite when avoiding needed care.  While this list won’t help you address any negative feelings you have about therapy and/or what it costs, my hope is that it will:

  1. Help people who are ready for treatment and struggling with how they can afford it; and
  2. Gently take away poor excuses for avoiding something that is needed.

Remember that therapists like to help. That’s how we got into this profession.

Don’t let the cost get in the way of the help you need. If you’re willing to do some legwork, there’s a therapist out there for you.#mentalhealth#therapy pic.twitter.com/xTGVlbxrYX

— Michael Kinsey, Ph.D. (@mindsplain) May 17, 2020

1. Ask for a Lower Fee and Present a Budget

Many therapists will consult at no cost with prospective patients to determine whether the fit is right and decide if both parties can agree that the work has the potential to be fruitful.  Fee is one key elements to be established in this session. Ask your therapist if they ever work on a sliding scale, and what the lowest hourly rate they would accept is.

It’s not always easy for therapists to answer what the lowest fee they would take is, since a lot depends on what each patient can afford.  Fee is not only compensation to the therapist, but leverage for change. Money gives patients a stake in progress. If you ask for a below-market rate, then as your therapist, I would want assurance that you are paying what is uncomfortable, but doable.  Bringing a budget to the consultation accomplishes several important tasks when discussing fee:

  1. It shows you are motivated and committed;
  2. It is evidence of your ability to plan, conscientiousness, and sense of responsibility (i.e., will you come regularly? Pay on time? Cancel with plenty of notice?); and
  3. It assures the therapist that your desire to pay less does mean that you are prioritizing therapy less than you prioritize happy hours, frequent and exotic travel, and/or other indulgent non-necessities.  As one of my therapists put it, the fee should “pinch” and come with a reasonable set of sacrifices if you are not paying full price. It is not meant to thwart any and all travel, leisure, or indulgences.

By being transparent, therapists will also recognize your willingness to open-up and share something personal and often shameful.  Many (if anything, too many) therapists are agreeable and help compulsively; if the consulting therapist does not agree to what you can afford, then they may very well help connect you to someone who would agree to your terms.

2. Community Clinics

If you live in or near a major urban area, you are almost certain to have a low-fee clinic clinic whose mission is to serve the community with psychotherapy and/or psychiatric services.  In New York City, there are too many of these clinics to list. Not all of these are of equivalent quality, but a small amount of research and/or travel could be the difference between finding an outstanding therapist vs. a resource-strapped mess.  Don’t assume that because something is low-cost or even free that you will not be able to get the help you need.

In my experience, the downside of these clinics are that there are often waiting lists, and you may be assigned to a trainee.  The problem with the latter is not necessarily quality of work, but rather that trainees rotate through clinics on a yearly schedule, which means you may have frequent changes in therapists.  Not ideal, but not the end of the world if you don’t have the resources for a private-pay option. As a former trainee, I can attest that I (along with many of my peers) put my heart and soul into those treatments and stand by the work I was able to do on a time-limited basis.

As for the waiting list, all I can say is better late than never.  If you are really in dire need of treatment, I know that many community clinics often have the capacity to expedite the intake process when risk is high.  If your need is not urgent and you persist in looking for other options, there is nothing lost putting your name on a waitlist in the meantime.

3. Psychoanalytic Training Institutes

The first treatment I found when I moved to New York was through the New York Psychoanalytic Society and Institute.  This is an institute that trains professionals in psychoanalysis. I ended up meeting with my analyst 4 times a week.  I was a student and worked out a sliding scale fee of $10 per session (with what I know now about how difficult great and affordable therapy is, I’m embarrassed that I was able to get such an amazing treatment for so little).

My analyst was a young psychiatrist who was fully licensed and brilliant.  It was a steal. I’m forever grateful for having this experience and I can’t recommend psychoanalysis highly enough.  In New York City there is a treasure trove of these institutes where fully qualified professionals, who have already completed close to a decade of formal training and commit to spend another 4 years and countless hours further enriching their minds and lives.  Everyone admitted to these institutes, in order to become a fully-fledged analyst, is required to complete several “control cases.” These are usually done on sliding scales and are taken very seriously by the provider. To see if any such opportunity exists to be a beneficiary of this training process, click on the link to the American Psychoanalytic Association low-fee clinic page here.

4. Clinical Trials

Just like pharmaceutical companies do experimental trials of their medications, so do psychotherapy researchers.  If you believe that you have a specific set of symptoms and/or diagnoses, you may search for clinical trials in your area for that particular disorder.  This type of research often means committing to being “randomized” such that you don’t know if you will receive the experimental treatment or the “treatment as usual.”  By participating in these, you relinquish some agency over the course of your treatment, but with the benefit of obtaining low-cost, free, or even paid psychotherapy. If you are located by either major universities and/or large teaching hospitals with departments of psychiatry, chances are that opportunities to receive low-cost treatment are available.

One resource for locating clinical trials for anxiety and depression can be found here.

5. Participate in Research

Going the route of obtaining treatment through a clinical trial is a direct way to get free or inexpensive treatment while helping advance psychotherapy research at the same time.  One downside to this option is that you will inevitably have less control over who you work with and what type of therapy you receive. In many cases, researchers may not even be able to tell you much about the type of treatment you will be receiving in order to keep the study “double blind.”

A more indirect way to obtain therapy through research participation while maintaining more control over the type of therapy you receive is to use the money you make through research participation to pay for the therapy you want.  Paid research can be found by going to psychology departments at major universities, searching online (e.g., craigslist), looking for flyers in teaching hospitals, etc.  Some of this research pays quite well and can help cover costs of psychotherapy–especially if you have the time to participate in multiple studies.  Focus groups are another type of research that pay quite well and can expand the amount you can pay for treatment.

6. Barter (being mindful of boundaries)

For many psychotherapists, a barter arrangement for services would be unimaginable, even though psychology ethics codes do not forbid it.  The reason many therapists might balk is because boundaries around barter have the potential to introduce complex dynamics into the consulting room.

However, many psychologists have psychology-related projects outside their practice that could benefit from patient contributions.  As a content creator, blogs, articles, testimonials, etc. can be extremely valuable to me, both in terms of money and in terms of saving time.  I could easily imagine striking a deal with a patient who writes well but does not have the means to support an ongoing treatment where I accepted an article from the patient instead of a check.  Famously, the author/psychotherapist Irvin Yalom co-wrote a book with a patient called Every Day Gets a Little Bit Closer: A Twice-Told Therapy.

I cannot recall if Yalom reduced or waived the fee in order to complete this project, but I like the fact that the barter arrangement of co-writing a book has the added benefit of promoting emotional growth.

If your psychologist is not a content creator, perhaps you have a different skill, such as online marketing, document creation/design, web design, social media management/consulting, etc.  that could be adapted to take the place of a fee. Many types of service/goods exchanges are not appropriate for a therapeutic relationship. But just because many are off-limits does not mean that a fair and appropriately-boundaried exchange cannot be agreed upon.

7. Take Classes & Make Use of Counseling Services

Attending a college or university is huge expense in its own right.  But what about if attending college and mental health problems stand between you and a more prosperous life?  Why not have the cost of one offset the other?

Having completed my training in New York, I had the privilege of working in the Baruch College Counseling Center as one of my practicum placements.  I loved working with the students there. I found most to be mature, smart, and highly resourceful. In my biased opinion, the therapy these students received was also top-notch.

At Baruch, not only was the school a part of the CUNY system, where costs were much lower than other schools, but the counseling center permitted therapists to work with students for the full academic year (some counseling centers place limits on the number of sessions).  Even if the school you might attend places limits on session numbers, the counseling center will then offer practical referrals to ensure continuity of treatment. Health insurance is also obtainable at a reduced cost through universities, and therefore in-network providers off-campus are always feasible.  What’s more, the CUNY and SUNY tuition can be free for New York residents who fall below certain income thresholds.  In short, if you meet the criteria for a tuition-free place at Baruch College, you could get both free classes and free therapy.

Of course, I highlight Baruch because it is exceptional in this regard.  However, the basic principle still applies: If education and mental health stand in your way, both can be obtained with the mindset to find schools, scholarships, and programs that can alleviate the cost of both while obtaining two invaluable experiences.

8. Use a Consulting Clinician’s Network

Therapists know a lot of therapists.  Knowing this, and the fact that many therapists offer free consultations, and you have just instantly improved your chances of finding affordable therapy.  As a member and participant in multiple psychological organizations, I receive emails daily from other providers looking for the right therapist for a patient with whom the sender has just consulted.  It’s extremely common for patients with very particular budgets and specific needs to get connected with a therapist who meets those exact needs; all that needs to happen is for you to tell a mental health provider exactly what your needs are, then ask said provider to disseminate a de-identified email to all his or her colleagues.

Yes, sometimes it is really this easy.

9. Philanthropy

Therapists can be generous in the fee they offer because they want to help.  You know who else can be generous to those in need? Everybody else. Gofundme is a great resource if you are truly in need.  Understandably, you may not want to broadcast your depression or anxiety disorder, but you may get the help you need if you do.  A great use of this resource is in response to a significant, public trauma. Perhaps friends and family learn that you have been assaulted, your wife or husband left you, your child is sick, or you’ve witnessed a tragedy.  If people already know you must be struggling, then why not ask for help?

Receiving help is extremely difficult for many, I’m well aware.  If you are one such person, consider being on the other side of things.  Have you ever not known what to say or do when someone about whom you care deeply experiences a terrible loss?  Wouldn’t it have been much easier to be around this person if this person had communicated exactly what s/he needed?  Asking for help feels good for both parties. What’s more, it’s healthy for both people.

While Gofundme is a very public way of asking for help, I’m sure other options exist for seeking help without the fanfare.  If discretion is paramount due to stigma or simply being a private person, ask people who are as trustworthy with secrets as they are generous.  Nowadays we are all under so much pressure to not need other people. The problem is that we do need other people. Acknowledging this truth is a major strength and could just be the thing that gets you through a tough time.

10. Ask for a Discount in Exchange for a Different Form of Payment

Although I’m mildly embarrassed to share it, I’m a bitcoin afficionado and a goldbug.  I value these stores of value over our national currency. I am happy to accept 50% of my standard (in dollars) if a patient is willing to pay in bitcoin or bullion.  Does this happen often? No, but I hope it does. The therapist you want to see may harbor the same wish. That still might be a significant fee, but 50% off is a pretty generous discount if you ask me.

More commonly, patients ask if there is a discount for cash.  Very often there is. Bitcoin, gold, and cash are all tools to get a therapist to lower his or her fee AND feel good about it.  With this and other options on this list, you have the option of using several of these strategies until you reach an arrangement that works for both you and your therapist.

11. Explore Insurance Options

Nothing allows for affordable psychotherapy better than an excellent insurance plan.  But even if an insurance option is the answer, you still have to have the plan, find the plan, know your benefits, and/or strategize to get the most out of your insurance coverage.  If you’re like me, reading fine print and calling 800 numbers to figure out all of your options evokes feelings of dread and torpor. Luckily, others can help us with this task for a low cost.  For example, the website Fiverr allow us to outsource tedious tasks like this for a low cost, and more importantly, the potential for a high reward.  For example, a quick search of Fiverr yielded this result.

My own aversion to completing these tasks has a great deal to do with my sense of how competent I am at completing them.  If you have more confidence to work the angles and research your way to having the most options, then you may even enjoy taking on this task.

Although much more could be written on this topic, essential questions to ask yourself are:

  • What type of coverage is available to you through your employer, the public exchange, a parent, spouse or domestic partner?
  • Is there a plan that fits within your budget as an expense–especially when considering other medical needs you may have?
  • Who are the therapists that accept insurance in your area and which of these come highly recommended?
  • If in-network providers are not an option, which plans/carriers offer the best out-of-network benefits?

Conclusion

The affordability (that is, the lack thereof) of top-notch psychotherapy is definitely a problem.  Financial difficulties and stresses are often one of a confluence of factors drawing people into treatment.  Conversely, the costs of training on top of ongoing expenses often prohibit clinicians from charging less than they do.

But I don’t believe that this stalemate between the sticker price of therapy and the resistance of the patient is one that can’t be broken by some creative thinking.  Most therapists struggle to charge what they are worth because they tend to prioritize the needs of others over their own. If you are sufficiently motivated for treatment and are willing to create a plan for how to help a therapist say “yes” to an affordable rate, I have no doubt that you can strike a deal with an outstanding provider.

Common Parenting Mistakes

6 Well-Intentioned Parenting Mistakes to Avoid

Introduction

Every parent makes mistakes with their kids.  Kids are resilient and in many ways built to survive parental error.  Almost all mistakes are forgivable–especially if they are recognized as mistakes.  As a psychotherapist, I have observed a strange paradox time and time again: some of the most pernicious parenting mistakes are the ones about which parents are certain are not mistakes.  That is to say, that these particular foibles contain three destructive elements: 1) The mistake is well intentioned and therefore is not recognized as harmful (and therefore may recur with high frequencies without the insensitivity being acknowledged); 2)The parent through superior power and intellect forces his/her conviction that the mistake is in fact beneficial to the child; and 3)The child believes that any negative feelings, misgivings, or correct intuitions he/she has about the behavior/attitude in questions are in fact proof of the child’s defectivity.  

“some day, maybe, there will exist a well-informed, well-considered, and yet fervent public conviction that the most deadly of all possible sins is the mutilation of child’s spirit; for such mutilation undercuts the life principle of trust, without which every human act, may it feel ever so good and seem ever so right, is prone to perversion by destructive forms of conscientiousness.” – Erikson, 1958, p. 70

Below, you will find a list of the most common parenting strategies to which, in my experience, profound suffering and struggling can be traced back.

1. Helicopter Parenting

I use this term to refer to over-involved parents who micromanage their children’s lives, especially in educational contexts.  Taking an interest in your child’s life is undoubtedly an aspect of parenting that fuels healthy development. We want children to feel that what they do matters, that they are worthy of attention and being known, and that we take their safety seriously.  The problem is that we cannot help our children develop self-esteem if they have not had sufficient freedom to develop a self. While parental preoccupation with learning, achievement, and safety certainly show concern, concern about what is the relevant question? Often, the answer has more to do with a caregiver’s need to think of herself as a good parent, live vicariously, avoid negative judgment from the community, etc.  In essence, with helicopter parents, the attention and concern the child receives has nothing to do with the child himself. What’s more, on some visceral level, your child knows this.

In response to a stifling, hovering environment, children learn several harmful things: 1. I must prioritize my parents’ needs; 2. I can’t trust myself; 3. Learning is not supposed to be fun; and 4. As long as I please Mom and Dad, I don’t need to create my own set of interests, likes, dislikes, and skills.  Under these conditions, children learn to become quiet, introverted, tentative, shy. In later years they will be more prone to mental illness–especially anxiety and depression. They will be less resilient and less motivated.  

In short, children need attention and concern, but here’s the kicker: the attention and concern has to be about unique aspects of the child’s growth, independence, interests, and relationships.  It must be about them.  Helicopters are for rescuing, otherwise they are obstacles on our children’s inborn drive to learning and development.  

2. Providing Support Your Kid Doesn’t Need

If there are two things that kids are great at, one would be zealous pursuit of curiosity and learning, and another would be asking for help when they need it.  So why then do grown ups feel the need to intervene when their help has not been requested? Well for one, it feels good to be needed. Second, watching kids learn also brings back anxious memories of our own struggles and frustrations to learn new things.  But here’s the thing: playing, learning, exploring, completing tasks, etc. have very little value to kids if the process is interrupted in order to bring about a quick resolution.  Kids are not nearly as bothered by the frustrations of learning as adults.  Why not? Because learning and socialization are literally their only responsibilities!  

What’s even crazier about this fact, is that when kids get frustrated and need help, they will ask for it! Well, they will ask for it if they have not had negative experiences of adults watching anxiously, intrusively intervening when tasks are not performed with perfect efficiency and fluidity.  What is critical in helping children is not only waiting until you are asked to help, but also how much help you offer.  Take a second to assess what your kid needs.  How do you do this? You ask of course. Here is the tricky part: provide only the minimum amount of help your child needs to complete a task.  Vygotsky, a renowned Russion developmental psychologist, refers to this learning space as the “zone of proximal development.” The hypothesis is that maximum learning occurs when the child receives only the minimum help necessary to reach their goal.  

Not only does restraint help children learn, but it also develops key aspects of emotional intelligence.  They learn to tolerate the frustration associated with struggle. They learn self-efficacy and develop self-confidence.  They learn to be unconflicted about asking for help. They grow bolder in the kinds of challenges they want to undertake.   One other underappreciated fact about learning and play is that not only is it fun for children, but it can also be an important mode of emotional regulation.  It’s difficult to imagine more important lessons to learn.

Self-determined learning is essential for healthy development.  Although you may think you are helping by guiding the round peg into the round hole, you are actually stealing from your child to reduce your own anxiety.

3. Using Punishment as a Motivator

One of the biggest sources of parenting misguidance is using punishment to address the absence of adaptive behavior. Take for example, not submitting a homework assignment.  Vigilant parents track their child’s performance in school and intervene when kids slack off. Punishing instances of omitted action is less likely to be effective than working with your child to build up feelings of confidence, efficacy, and motivation.  As a therapist, I see people struggle with doing things they don’t want to do everyday. Most people carry with them a self-punitive attitude about their lack of motivation, which in turn motivates them even less. My main role when intervening is to help people connect more to their desire for the outcome they seek than the “good boy” “good girl”  mindset with which uninspired parenting has left them.  

Addressing this type of inaction effectively is certainly much more work than doling out punishment.  It requires attention, engagement and monitoring. Behavior plans, where kids/students earn points/rewards for every day they complete a desired task is one of the most common.  Behavior plans reframe behavior as a means to achieving a desired end rather than as a vehicle through which you escape punishment. Non-judgmental problem solving can be productive as well.  Help your child to make the desired behavior personally meaningful to them. If studying math is the issue, help your child to see what developing math skills can allow a grown-up to do. Help your child to realize that avoiding math leads to mistaken beliefs that “I am not good at math” that can interfere with all kinds of goals your child may create later in life.  Focus on helping your child understand concepts and applications, rather than getting bogged down in the assignments themselves. Being good at something is motivating. A bad grad will not demoralize a student the way a ill-gotten belief that “math sucks” or “I’m too dumb to get math.” Punishing someone for avoiding a behavior that makes them feel bad does not address the underlying issue, and in fact, could make lacking motivation worse. 

4. Overusing Praise

Kids want to be seen, and of course they want to please you.  But compliments are too easily given. I can’t stand hearing exaggerated utterances of fawning over stick-figure drawings.  “Oh my god that is BEAUTIFUL!” No, it’s not. What is it then? It’s an attempt to symbolize and communicate. Look at the features and identify the aspects of the drawing you recognize.  “Oh look you put a bird over here. And over here I see some clouds.” The most nourishing form of flattery you can provide your child is the satisfaction of capturing your attention, getting you to engage with their creation, and observing you recognize what they created.

5. Focusing Too Much on Giving Your Kid What You Didn’t Have

Another phenomenon I have observed time and time again in clinical practice, is the perpetuation of negative behaviors and attitudes across generations despite conscious, preoccupied efforts to stop them.  Allow me to give an example.

A new mother is aware of how many problems her own mother’s indifferent, neglectful parenting caused her.  She will never let her child feel neglected or uncared for. Her new child will be the most loved and nurtured child so he never feels what the new mom felt in her childhood.

How can such a determined attitude go awry?  

Well, this attitude though obviously well-intentioned, is inherently non-responsive.  What about when times when the child needs space? To be left alone? How will this new mother feel when her child does not appreciate how hard she works to provide the love and care that was absent in her past?  

In a way, this mother is not really taking care of her child as much as she is taking care of herself as a distressed child.  Her child may fight for distance, recoil at from affection, and vow never to be such a smothering parent.  Can you see now how the cycle perpetuates? Pushing against a problem is not getting rid of the problem. You are still very much governed by the old issues and retaining an intimate connection to the problem.

The good news is that these cycles are amenable to change and can be greatly reduced by helping parents find other ways of taking care of their own needs, and making them more sensitive and flexible in their responses to the her own children.

6. Frantic Negotiating With Temper Tantrums

It’s difficult to imagine a parent who does not know on some level that he/she is not supposed to reward a child’s tantrum by meeting all or some the child’s demands.  Yet because we all can remember what it feels like to be powerless in the face of a powerful other’s “no,” many parents will simply rationalize why this time is the exception to standing firm.  The implicit charge in your child’s tantrum that you are being cruel is the leverage that the child has by throwing a tantrum.  I have addressed this issue in more depth here, but if I were to summarize the message of that post in one line, I would say:

If we wish to teach our children how to manage strong feelings with equanimity, we must demonstrate that we can respond calmly and confidently when our children cannot regulate their emotions.

I have outlined above 6 of the most pernicious, well-intentioned parenting mistakes I encounter in my clinical practice.  Sadly, even though these mistakes are motivated by positive goals, the negative consequences of these mistakes are no less toxic than “mean-spirited” parenting errors.  The six benevolent mistakes I highlighted are as follows: helicopter parenting, giving unnecessary support, using punishment as a motivator, overusing praise, overly focusing in giving your child what you didn’t,  and caving to temper tantrums.  Of course, avoiding such errors is easier said than done. 

Feel free to contact, comment, and/or subscribe to ask questions and engage further with this or any other topic.  Sharing this article also goes a long way to supporting the site and hopefully contributes to the larger community who struggles with some of these parenting challenges (i.e., all parents).  As the cliche goes, it takes a village to raise a child.

Getting reimbursed for therapy

Out-of-Network Insurance Benefits: A Guide to Getting Reimbursed for Psychotherapy

Introduction:

I hear a lot of people (legitimately) complain about the cost of psychotherapy.  However, there is a subset of these folks that have great insurance that allows them to be either partially or fully reimbursed for sessions outside their network.  Because the paperwork can be a deterrent to seeking therapy, and because it can simply be confusing, I decided to create an informational post about how to submit paperwork for out-of-network claims with a focus on psychotherapy.  By the end of this post, you should have the information you need to bill your insurance company for your psychotherapy.  Any feedback or questions would be of great help to make this the most user-friendly and informative content on the topic out there. Be sure to read or skim all the way to the end for the additional resources.

Getting Started:

As a first step, the name and address of your insurance’s claims department must be printed or typed into the upper right hand corner of the CMS-1500.  The example below is the address for medicare/medicaid claims. Links to forms with major insurance companies’ addresses pre-printed on the form can be found at the bottom of the Links & Resources page.

Field 1: 

Though not technically mandatory, checking the box of the relevant public/private insurance types is helpful in getting a claim processed quickly.  If you are unsure which box to tick, leave this field blank. However, in most cases “Group Health Plan” is the relevant category.

Field 1a:

This is a required field. Patient’s ID number (in case of a child, child’s unique ID number is entered here); the patient’s name also goes in field 4.  Guardian/Guarantor’s name is no longer used. In the case of children, the child’s information/ID number should be entered.

Shown below, your Policy ID number can be found on your insurance card.

Fields 2-5: 

These fields must be completed for the claim to be processed.  Simply enter your name and address in the relevant fields. Phone number is the only field in this cluster that may be left blank.

Field 6 (seen above)

Check “Self;” every individual covered by the insurance plan should have his/her own unique ID number–even if the patient is a spouse or child of the primary policy holder.

Field 10: 

This field is required and simply requires responses to three “yes” or “no” questions.  No is usually the answer to all three, especially when it comes to psychotherapy. In some cases, such as an adjustment disorder diagnosis as well as PTSD and other acute stress disorders, it may be relevant to answer “yes” on one or more of these.  However, unless there is a special need to indicate that a diagnosis is related to employment, a car accident, or other life stressor, answering “No” to all three questions will typically suffice.   

Field 11: 

In this set of fields, only 11d requires an answer.  You will answer “No” unless you are covered by multiple insurance plans.

Field 12 (HIPPA release) & 13 (Authorization to pay provider):

The typical scenario in psychotherapy when Out-of-Network Benefits are involved is that the patient pays up front and submits a claim for (partial) reimbursement.  If this description fits your arrangement with your therapist, then you need not sign either line 12 or 13. If signed, the check and explanation of benefits goes to your therapist.  When it is not signed, those items will be sent to you.

N.B.:

  •  For providers submitting claims on behalf of their patients, you may have patients sign an authorization form at the beginning of treatment and write “signature on file” in both fields.
  •  Date of signature must be within one calendar year of the date(s) of service for which you seek reimbursement.

Field 19: 

Not mandatory.  This field is used when re-submitting a rejected claim.  Use this line to indicate what was corrected for resubmission.  You may write something like: “Correcting lack of provider NPI number” to alert the reviewer of the changes you made.

Field 20: 

This is a required field that is almost always simple to deal with.  For psychotherapy, this will always be “No”. In rare cases, psychiatrists may bill for outside labs for the purpose of monitoring medications.  Otherwise, just check “No”.

Field 21: 

All claims for services rendered should include a formal diagnostic code which should appear on an invoice provided by your therapist.  There may be several diagnoses listed, but most therapists are conservative with diagnoses and will likely only bill for one. The format of the diagnostic code follows the ICD-10 (An international book containing medical diagnoses and their billing codes) format which takes the following form: F##.# or F##.##.  For example, Major Depressive Disorder, Recurring, Moderate = “F33.1”

N.B.:

  • The primary diagnosis goes in field A
  • Only diagnoses overseen by the provider should be included (in most cases the primary diagnosis is sufficient).  That is, a psychotherapist would not include medical diagnoses that have nothing to do with mental health and for which the services are not relevant.

Field 24:

This field contains 6 Rows and 11 columns; all but three columns must be completed for the claim to be processed.

Each row represents a billable encounter.  For weekly psychotherapy, one form is sufficient for monthly reimbursement.  For more frequent sessions (e.g., 2 times per week) you must complete multiple forms per month.

A. For date of service, from and to dates will be the same for individual psychotherapy (dates are different only for inpatient hospitalizations)

B. Place of service is a numeric code arbitrarily assigned to a type of setting.  Office/Clinic is nearly always the setting of psychotherapy. “11” is the code to use in the case of seeing a psychotherapist in private practice or in an outpatient clinic setting.  Exceptions could include “03” for school or “12” for home-based psychotherapy.   Other setting codes are listed below:

C. Not Mandatory

D. CPT/HCPCS.  The standard form for submitting claims (i.e., the form I am currently explaining) is sometimes referred to by insurance folks as a “hicpic” form (i.e. HCPCS form).  HCPCS stands for “Healthcare Common Procedure Coding System”, while CPT stands for “Current Procedural Terminology.”  Put simply, every visit with a healthcare provider is assigned a numeric label according to what the provider does with/for you.  For psychotherapy, you are most likely to see the code “90834” for individual psychotherapy, 45-minutes in duration.  When meeting with a psychologist, other possible codes are:

90791 – Diagnostic Interview (no medical services)

90792 – Diagnostic Interview (prescribers/with medical services)

90832 – Individual Psychotherapy (30 minutes)

90837 – Individual Psychotherapy (60 minutes)

90847 – Family Psychotherapy (Patient Present)

90853 – Group Psychotherapy

96101 – Psychological Testing (hourly)

96118 – Neuropsychological Testing (hourly)

The appropriate service code(s) should be included and appropriately itemized on any invoice you receive from your therapist.  Modifiers are sometimes relevant, but will be provided to you when necessary.  In most cases, the modifier portion of column D should be left blank.

E. Diagnosis pointer refers back to field 21.  When there is only a primary diagnosis in Field 21, “1” will be entered into column E.  In short, you will enter either 1,2,3, or 4 (or some combination of these numbers) to indicate which diagnosis/diagnoses is the one your therapist is treating.  Using a number saves the trouble of squeezing long diagnostic codes into small boxes.

F. Charges – Enter the total cost for a particular encounter or set of encounters listed on your statement.  If you are being billed for one session of individual psychotherapy (45 minutes), or “90834”, then this charge would be the provider’s hourly rate (45 minutes is typically considered to be an hour to psychotherapists).  If it contains three sessions of the same service, simply sum the three rows of charges to get a total.

G. Days/Units – For most psychotherapy encounters, this will simply be “1”.  The exception here would be psychological/neuropsychologcial testing, where multiple hourly units may be billed for one encounter.  For example, “96101” is the CPT code for 1 hour of psychological testing.

 Psychologists will often devote between 2-4 hours per session of testing.  If you spent 4 hours with a psychologist for testing, and the provider’s fee is $100 per hour, then Charges (column F) would be $400 and Days/Units (Column G) would be “4”.  

N.B.

In reality, testing consists of more units/charges than what you spend face to face with the provider.  Testing requires a great deal of labor outside of face-to-face encounters. So don’t be alarmed if your invoice contains more “units” of 1 hour increments than the face-to-face time.  Of course, you should ask for an explanation if the number seems curiously high.

H. Not Mandatory

I. Not Mandatory

J. NPI number: The provider of the services for which you seek reimbursement will have a distinct number that should be included in this column.  For more information about NPI’s and the function they serve, click here.  This number should be provided on any invoice and can be obtained directly from your provider when absent on an invoice.  When not included on an invoice, NPI’s are public information and can thus be found by searching online here.

N.B.:

In rare cases where multiple NPI’s are linked to the same row in field 24, separate forms need to be filled out for each NPI number.  If you received services from one provider, you can ignore this and need not confuse yourself unnecessarily.

Field 25: 

This is a required field where you must enter either the Tax ID/Employer Identification Number (EIN) or Social Security Number (SSN) of your provider.  While your provider, if in private practice and operating as a sole proprietor, can use their SSN here, they are unlikely to do so. Most providers/organizations have an EIN that should be included on the invoice you receive.  

N.B.:

In most cases, Tax I.D. numbers are privately held and are not available to the public.  This means your doctor/therapist needs to give it to you–typically written on the invoice.  The exception is if the therapist is providing the service as a representative of a publically-traded company, in which case you can also find the EIN by searching here.

Field 26: 

This is a code–letters, numbers, or some combination of the two–that is assigned by your provider.  While I have had claims processed without this information, strictly speaking, this field should be populated.  You may ask your provider for this, check your invoice for a relevant value. Hospitals will assign medical record numbers, which may be entered here.  For private practitioners, Date of Birth (D.O.B.) is a value used to match records with the patient. If you cannot find a relevant value when completing a claim for services from a private practitioner, I suggest simply entering an 8-digit date of birth “code” (e.g., if you were born on October 7th, 1970, you could write “10071970” or “19701007.”  You could also make something else up. The point is, fill this in, but don’t stress about it.

Field 27: 

Not Mandatory

Field 28: 

This is a mandatory field.  Simply sum all of the charges in Field 24, column F, from rows 1-6.  

N.B.

This is also a good place to reiterate that for twice-weekly, thrice-weekly, etc.  psychotherapy and more frequent encounters, one form is not sufficient for a one-month billing cycle.  A second or third form may be needed, each one treated as its own entity when summing charges. I like to keep a template on file with basic information already entered (e.g., fields 1-5) to make completing multiple forms more efficient.  

Field 29: 

You are required here to enter the amount paid.  So as not to fuss over this I recommend the following basic system:

  •  If your provider is an in-network provider and collects a co-pay from you, enter the sum of co-pays that you have given to your therapist.  
  • If your provider is receiving Out-of-Network Benefit checks (i.e., you are signing lines 12 & 13), I suggest simply entering “$0.00” here.  
  • In the most common scenario, where you are paying your therapist’s full fee out of pocket, of course you will sum the charges from each encounter for which you have paid.

Field 30: 

For “Balance Due,” you are required to subtract the number entered in Field 29 from the number entered in Field 28 (i.e., Total Charges – Amount Paid = Field 30).

Field 31: 

Enter name and credentials of the provider, as well as the date of completing claim.  A signature from the provider is not necessary.

Field 32: 

Not Mandatory

Field 33: 

In this field, you are required to enter your therapist’s name, address, phone number, and NPI number (Field 33a).  For private practitioner providers, this will be your psychotherapist’s info. For clinics and/or group practices/mental health collectives, the organization may have its own distinct information, NPI number.  This is the field that tells the insurance companies where the reimbursement and explanation of benefits will be sent. Determine whether this will go to a private practice office, to a clinic administrator, or some other location.

Conclusion: 

The CMS-1500 looks daunting in the beginning, but can be straightforward to complete with a little guidance.  What’s great is that once you’ve successfully done it once, you can repeat as many times as needed.  Be sure to check out the additional links and resources at the end of this post.

If you would like clarification on any of the above explanations, or have other questions/comments about submitting out-of-network claims, reach out to me here.  I will either reply with further clarification or answer your question in a new post.  If you found this article helpful, subscribe below and you will never miss a new post or resource published here.  Cheers!

Resources:

Fillable, Blank CMS 1500 Form (can be used to submit claims for nearly all insurance companies).

Required Fields Checklist to help track whether you have neglected any mandatory fields

Sample Completed Claim Form that (mostly) coincides with the information presented here

Video providing similar information on how to complete the CMS 1500 can be found here.

Other Insurance-Related Links:

NAMI: Understanding Health Insurance

Blank Fillable Claim Form

AETNA Insurance Claim Form

Cigna Insurance Claim Form

Empire/Anthem/BCBS Insurance Claim Form

GHI/Emblem Insurance Claim Form

Humana Insurance Claim Form

Medicare & Medicaid Medical Reimbursement Form

Oxford Insurance Claim Form

UnitedHealthcare Insurance Claim Form

Adolf The Cat | Trauma | PTSD

Adolf the Cat: A Story About Trauma

Below is an excerpt from the article entitled: “Something Wicked This Way Comes: Trauma, Dissociation, and Conflict: The Space Where Psychoanalysis, Cognitive Science, and Neuroscience Overlap” by Philip Bromberg, a leading figure in the world of trauma and psychoanalysis.  I share it to add texture and depth to the term trauma–a term often tossed around without precision or a shared understanding.  I’ll present some takeaways at the end of the post.  However, the story stands alone as a parable about trauma.

Famed trauma expert and psychoanalyst, Philip Bromberg

When I was a kid, an endless source of fascination was looking out of my bedroom window at our backyard garden to silently observe the mysterious interactions between the animals, birds, trees, bushes and flowers.  But like the Garden of Eden, it received periodic visits from an infamous inhabitant of our neighborhood: A cat who was referred to by everyone in the vicinity as Adolf (I was a World War II kid). Adolf was an aggressive, predatory, seemingly fearless animal, whose viciousness and mean-temperedness terrorized the other neighborhood cats as well as most of the dogs.  I hated this animal totally and, I think, somewhat afraid of him myself. Adolf would suddenly appear in our garden as if by magic–by magic because it was a very well fenced-in area, and we were never able to discover how he entered. What he seemed to enjoy most was climbing our fruit trees to see whether he could find a nest containing a baby bird or two to feast on.  He seemed totally indifferent to the parent birds wildly flapping their wings and shrieking hysterically overhead (way overhead, I might add).  In the animal world he was sort of like the neighborhood bully.  

Trauma, dissociation as a defense

Present experience & future expectations are shaped by past trauma

One morning I was watching the action in the garden, I spotted Adolf.  He was climbing stealthily up the trunk of an apple tree, clearly on his way to a nest.  As he neared the top branches, two adult birds materialized, seemingly out of nowhere, and began to put on a performance that was nothing short of awesome.  They were blue jays, and those birds gave new meaning to the word tough.  Screaming, they swooped down on Adolf, reversing course inches from his head, precisely at the point beyond which Adolf’s claws could not reach.  I had never seen Blue Jays in our garden beyond this moment, nor had I seen them in action anywhere else, and, I suspect neither had Adolf. Adolf and I were both in a state of shock, but for Adolf the shock was horrifyingly personal.  Over and over the two jays repeated their dive-bombing until Adolf did what I had never-before seen him do or believed he ever could do. He shinnied backward down the tree trunk, falling the final 8-10 feet, and began to run. But there was no escape.  The two birds pursued him wherever he went, though he was now far from their nest. Neither the ferocity nor the precision of their aerial attacks showed any sign of diminishing, and their abrasive bird-curses became, if anything, even louder. To this day I can recognize a Blue Jay’s call the instant I hear it, and I still love it.  The sound has always reminded me of the strangely comforting rasp of a rusty clothesline pulley as the line was being yanked on by my mother. These guys were literally driving Adolf crazy, and I was cheering them on. He could not fight (because they were not reachable); he could not flee (because it was a fenced-in garden and Adolf apparently had forgotten where his secret passageway was).  It was then that I observed (though I didn’t know it then) what I now realize was a remarkable example of dissociation as a defense against trauma–what Putnam (1992) has called “the escape when there is no escape (p. 104). Adolf suddenly lay down right where he was and remained motionless. His body took on a strange, almost flaccid shape, and I began to wonder if he had died of fright. The blue jays kept up their counterattack for a short while longer and then flew off.  As I said, I hated the animal, and I was in no rush to help him if he was still alive. But I stayed at the window, probably somewhat numbed myself at seeing this feline terrorist reduced to mush. Was he dead?

Trauma and the self

Preservation of the self takes precedence over life in response to trauma

No!  Adolf, as if hit by an electric charge, suddenly sprang upright, fur standing on end, and took off to a far corner of the garden where he lay shaking behind a bush.  As I look back on this now, I wonder what he was like after that incident. I have no recollection of him in the garden after that time, but I don’t really know if that is more of a wish than reality.  Did he develop a cat version of post-traumatic stress disorder? Maybe his memory loss for the location of his hidden tunnel was the first sign. I was probably too young to hope that he was plagued by flashbacks of blue jays, but that is neither here nor there.  The point of this vignette is to make as vivid as I can the power of dissociation when used as a defense. It is a defense unlike any other defense. In human beings, it bypasses cognitive modulating systems and, as LeDoux’s (1989, 1994, 1996) research powerfully demonstrates, is clearly anchored in an evolutionary response that is equivalent in survival priority to certain genetically coded response patterns of lower animals to a life-threatening attack of a predator.

The difference between dissociative experience in human beings and dissociative responses in non-human animals (including Adolf) is that humans are blessed (sometimes it feels more like cursed) with a self and with self-awareness.  The similarity is of course in the Darwinian survival need, but for humans the highest survival priority is the survival of a self. For lower animals it means primarily survival in the face of a potential threat to biological life.  I think this accounts in large part for the fact that the emotion of fear is usually what is observed in traumatized animals and what is studied when observing them as subjects.  But for humans, selfhood (its cohesiveness, coherence, and continuity) is life, and the need to sustain it when it is in jeopardy obliterates all else.  The emotions we find when we look at human trauma certainly include fear, but they are far more complex because they are products not simply of biology but of self-awareness.

The courageous blue jay–the same bird that haunted Adolf

Click here to read the full article

5 Key Takeaways On Trauma from Bromberg:

  1. Trauma divides: A key characteristic of trauma is its dissociative effects.  It splits our subjective experience from what is happening to us.  This splitting effect happens at the time of the original trauma, and again whenever that same individual encounters reminiscences of the original experience
  2. Trauma comes with shame: Shame is an experience we feel whenever an experience of “self” cannot be tolerated.  Most commonly a person feels shame when her core thoughts are feelings meet disgust or condemnation from her tribe.  But shame is also a product of inability to tolerate a subjective experience; that is, when “I” mercilessly reject “myself.”
  3. Trauma gets acted out instead of symbolized: This is to say that the effects of trauma get expressed whether we like it or not.  Since we mostly don’t like expressing feelings of trauma, shame, fear, rage, sadness, etc. get “acted out” or  come out “sideways,” as Marsha Linehan is fond of saying.  An example of this would be to disown shame by banishing it from subjective experience and actively shaming the mistakes of others.
  4. Trauma becomes a script that gets repeated with others: A natural consequence of trauma dividing and getting acted out is that it expresses itself through conflict with others.  It’s easer to fight with you than to fight with me.  Therapists use fancy terms like “projection”, “projective identification”, “enactment”, etc. to label the human capacity to recreate internal drama with people who appear in our lives.  Therapists know the feeling well, but many others well recognize that around certain people they consistently experience intense, alien feelings that overwhelm the usual defenses and coping strategies.  This is a reliable sign that trauma is being revisited.
  5. Trauma gets “healed” by assuming its place within an organized story of self: People are storytellers.  Our sense of ourselves is one in which we are the protagonists acting in a constructed model of the world.  When the story gets overwhelming, we tune out or close the book.  This is trauma.  To heal, we need to stay with our avatar of self, share in the pain, and come through the experience with a favorable–or at least tolerable–feeling about that character.

Conclusion:

Understanding trauma means grappling with abstract and disorienting concepts and psychological laws.  The advantage of learning about this confusing terrain is that it becomes easier to navigate and tolerate the challenges when you have a model for what you are experiencing.  Signing up for my newsletter, commenting, or engaging me on Twitter (@mindsplain) are all ways I’m here for you to help clarify some of the more complex and misunderstood aspects of trauma.

*I’m saddened to have learned that Dr. Philip Bromberg passed away on May 20, 2020.  His obituary can be found here.  Although I never had the opportunity to meet or work with Dr. Bromberg, his ideas and legacy have deeply touched and impacted me.  It pains me to know that such a bright and benevolent presence is no longer with us to help us navigate the challenging times in which we live.

Bromberg, P. (2003). Something wicked this way comes: Trauma, dissociation, and conflict: The space where psychoanalysis, cognitive science, and neuroscience overlap. Psychoanalytic psychology, 20(3), 558.

Bromberg, P. (1983) The Mirror and the Mask—On Narcissism and Psychoanalytic Growth. Contemporary Psychoanalysis, 19:359-387.

Ledoux, J. (1989). Cognitive-Emotional Interactions in the Brain, Cognition and Emotion, 3:4, 267-289,DOI: 10.1080/02699938908412709

LeDoux, J. (1994). Emotion, Memory and the Brain. Scientific American, 270(6), 50-57. Retrieved from http://www.jstor.org/stable/24942732

LeDoux, J. (1998). The emotional brain: The mysterious underpinnings of emotional life. Simon and Schuster.

Putnam, F. (1992). Discussion: Are alter personalities fragments or figments?, Psychoanalytic Inquiry, 12:1, 95-111, DOI: 10.1080/07351699209533884