Adults who have survived childhood abuse are more likely to experience mental health problems than those who were not abused during their youth. Depression, anxiety, panic, posttraumatic stress, eating and food issues, and substance abuse are just some of the psychological conditions that these survivors face. Another consequence of childhood abuse is diminished physical health. Research has shown that negative psychological well-being decreases physical health and can lead to serious health problems, including hypertension and heart disease. But few studies have examined how specific types of childhood abuse affect physical health directly.

To address this gap in research, Cathy Spatz Widom, Ph.D., of the Psychology Department at John Jay College at the City University of New York recently conducted a study that sought to determine the link between three individual types of abuse and later physical health problems. Widom analyzed data from adults who had been abused prior to their 12th birthday. The average age of the participants was 41. Each participant underwent a complete physical examination and blood test in adulthood. Based on documented reports of the abuse, Widom compared how sexual abuse, neglect/maltreatment, and physical abuse in childhood affected the participants’ health in adulthood.

She found that the adults who had experienced neglect and maltreatment had poorer oral and visual health as well as impaired airflow and increased risk for diabetes. The adult survivors of sexual abuse were more likely than the other participants to develop oral health issues and hepatitis C. They also had higher rates of HIV and malnutrition. Those who had survived physical abuse were also at increased risk for malnutrition and diabetes. Although some of these conditions could be attributed to maladaptive coping techniques, such as smoking, drug or alcohol use, and poor nutrition, the findings clearly show that adults who have survived childhood abuse are still at increased risk for significant physical health problems. Widom believes that these findings have strong clinical implications. She said, “Understanding the mechanisms that place abused and neglected children at higher risk for these adult physical health outcomes will help focus these efforts.”

Reference:
Widom, C. S., Czaja, S. J., Bentley, T., Johnson, M. S. (2012). A prospective investigation of physical health outcomes in abused and neglected children: New findings from a 30-year follow-up. American Journal of Public Health, 102.6, 1135-1144.

The process of trauma recovery includes developing a narrative to one’s history, compartmentalizing who is accountable for what, and integrating old material into a new paradigm. Intrafamilial abuse, particularly child abuse, is often layered and complex. The locus of the early stages of the work tends to be the perpetrator of physical, sexual, or emotional injury. However, throughout the progression those who failed to protect slowly come into focus.

Survivors express uncertainty around the parent who did not harm them but did not protect them either. As therapists, our energy is directed towards ensuring that the burden of abuse lies in the hands of the perpetrator. Clarity and relief are common responses to unraveling culpability.

The circumstances under which there is a nonoffending parent (or community) who also failed to protect a child can complicate recovery. Clients report strong feelings towards those who did not keep them safe and express confusion about who or what this person is. “Are they an abuser? Did they love me? If they did how could they have allowed this to happen? How can you watch your own child being abused and not intervene? Is there something wrong with me?”

Abuse in its various forms can sometimes be less convoluted than the failure to act, respond, or protect. It is a complex endeavor to absorb exactly how one can avoid acting in response to someone harming a child. Professionals such as teachers, therapists, or anyone who has regular contact with children are required to report suspected abuse.

In some states, law enforcement is required to intervene on some level with domestic violence, while child protective services views domestic violence as a threat to the well-being of the children in the home. Implicit in such requirements is that there is some culpability in failing to protect. Yet defining nonoffending parents can be arduous for both clients and therapists.

Perhaps our task as helping professionals is to develop our own understanding of parents who, for whatever reason, do not or cannot protect their own children. I often find myself aligned with my clients’ confusion. While not always completely clear or simple to define, categorizing abusive acts as wrong seems more clear than failure to protect, and even more so if the person who did not intervene was a parent.

There appears to be some collective agreement that those outside of the family have a responsibility in safeguarding those who cannot defend themselves. It feels a bit more muddled in applying these rules to family members. How do we define a parent who is otherwise loving and warm but has knowledge of the abuse and does not intervene? Even if the parent is disengaged or emotionally absent, how do we work with our clients in defining them? Is a failure to act a form of abuse in itself, or is the nonoffending parent a victim as well?

The ethics of community response to failure to protect remains convoluted. In addition, working with our clients in understanding this aspect of their story is a delicate pursuit. The circumstances of the client’s story can occasionally provide the answers to our questions. Most of the time, context fosters few explanations. Perhaps in this case, the conclusion lies within the question — bemusement exists because this is a complex issue.

Normalizing a lack of clarity and difficulty in compartmentalizing the nonoffending parent or family member is difficult for all of us, not only the survivor. Hopefully, acknowledgment of the layers and intricacies of intrafamilial abuse is a starting point for all of us, and at least survivors have a partner in their journey for answers.

The word bridezilla has become an oft-used part of our lexicon, and many people who have never been married are confused by the panic and stress that seems to surround wedding planning. But a newly engaged couple quickly learns that the stress of wedding planning is not the overexaggerated fantasy of people who simply have no stress tolerance. Wedding planning is stressful for almost everyone, and yet people never stop to think about why this is. Here’s what is really going on.

Expectations vs. Reality
A wedding is a major rite of passage, and many people—especially women—have been raised to expect their wedding to be a perfect fairy tale. But nothing can be perfect, even a wedding, and the drive for perfection can be profoundly stressful and emotionally fraught. Many people use their wedding as an opportunity to take stock of their lives so far. If they can’t afford a dream wedding, they may feel like failures. Some people have a specific list of things they intended to do before they got married. No matter how unreasonable this list might have been, unfulfilled dreams can still cause stress when you’re planning a wedding.

A Stressful Engagement
The time before you get married should be one of the happiest, most romantic times in your life. Instead, many people spend this period frantically planning a wedding, stressing about finances, and fretting over guest lists. Wedding planning can cause you to pull away or turn on your future spouse, and constant planning certainly eliminates any opportunities for romantic time together. Thus some people arrive at their wedding day feeling pretty humdrum about their future marriage and pretty frustrated with the process that got them to the altar.

Finances
Disagreements about money are among the most common marital problems. When surveyed, people indicate that financial problems are one of the biggest stressors in their lives. Weddings are expensive, with the average wedding in the United States costing well over $30,000, so it’s no wonder people can be driven to a state of panic by weddings. Couples frequently must make huge sacrifices, compromise with their parents, and work extra hours to get the money to pay for their weddings, and all of this effort can take a toll.

Requests of Others
Many newlyweds report that it wasn’t the wedding planning itself that was stressful. It was the constant pressure, opinions, and criticism from other people, such as the mother who’s enraged that you’re keeping your maiden name or the father who insists on a traditional wedding ceremony. A wedding frequently puts the differences between parents and their children on full display. Many engaged couples worry about their parents making snide remarks just before their wedding, or spend the entire time they’re engaged bending over backward to please their parents, only to find out that nothing they do is enough.

Relying on Others
No matter how much you might want it to be just you and your fiancée, a wedding is a group event. From bridesmaids to florists, officiants to flower girls, you must coordinate with many people, not all of whom will be cooperative. Trying to get everyone to understand your vision for your wedding can be like herding cats. And even simple tasks such as getting your best man to finally get fitted for a tux can be extremely stressful. When people have to rely on others to get tasks done, their stress levels tend to rise. This reliance on others is made even worse by the stress most couples feel to create a perfect wedding.

So, no matter how simple you may try to keep the wedding plans, there will still be stressors that you should anticipate and plan for, just as you plan for your cake and photographer. Start thinking about the people and events that may create stress for you and your fiancé, and take steps to reduce those predictable conflicts. Acceptance of the things you can and cannot change is key, and practicing now can only help once you become a partner in a marriage.

Sources:

1. Miller, R. S. (2011). Intimate relationships. New York, NY: McGraw-Hill.
2. Reis, H. T., Rusbult, C. E. (2004). Close relationships: Key readings. New York, NY: Psychology Press.

Related articles:
The Fear of Hurting the Other and the Inhibition of Self
Embrace Conflict as a Path to Deeper Connection
Decision Making in Relationships: Three Important Values to Help you Know When to Give in or Dig in

Your social life, the quality of it, was wired into your gray matter by the age of 3, according to current thinking on child development. After a minute of contemplating that statement, the immense impact of early childhood caregivers becomes clear. This subject comes to mind after reading a recent news story about Artyom Saleviev.

Artyom was first in the news in 2010. He is the Russian boy who was adopted by a U.S. couple, the Hansens, 3 years ago. After being part of the Hansen family for 5 months, Artyom was put on a plane bound for Russia by his adoptive mother. Artyom carried a letter which stated the Hansen’s no longer wanted him because of his disruptive behavior related to psychological problems. The recent news article states that Artyom is now living in a foster home (in Russia) and his behavior there is not disruptive.

In the United States, the number of children in the foster care system is close to 500,000. One-quarter of them are infants when they enter the system; 15% are age 3 or younger, some only infants. The most common reasons for removing them from a parent or relative’s home are an absence of supervision (36%) and a failure to provide (31%). What affect does this have on a baby or toddler? Are they so young they will not remember neglect or abuse by early caregivers? If only that were true.

Caregiver Influence

To understand the effect early caregivers have on infants and toddlers, we can look at the implications of attachment theory. This theory, which has been substantiated by research, states that interactions with our initial caretakers determine our future capacity to build emotional bonds with others.

By the age of 3 years, children are either secure in their attachments to their caregivers or insecure. Children who are secure have the benefit of responsive caregivers that consistently meet their needs for food, safety, and affection. In adulthood, they can form lasting emotional connections with others.

There are three types of insecure attachment: avoidant, ambivalent, and disorganized.

When caregivers discourage expressions of a child’s distress or affection, an avoidant style of attachment develops. The child learns to discourage his or her own feelings, which damps down the child’s capacity to feel loved by others. Avoidant children typically withdraw from social interaction and grow into adults who are extremely uncomfortable with feelings and intimacy.

Ambivalent attachment occurs when early caregivers give comfort inconsistently. They sometimes respond to the child’s needs and sometimes do not. With this kind of care, children become unsure whether their needs will be met. As adults, they are slow to trust and at risk for mood and eating disorders.

When a child’s needs are not responded to, or the child is abused, a disorganized pattern of attachment can lead to delayed development, social withdrawal, and aggressive or disruptive behavior. Adults with disorganized attachment are susceptible to personality disorders and chronic mental health problems. Their relationships are often chaotic or short-lived.

Our attachment style sticks with us for life, although alternative behaviors and ways of thinking can be learned to improve relationships.

Not All Memory Is Conscious

When Artyom Saleviev arrived in the United States, was he secure, avoidant, ambivalent, or disorganized in relation to others? The Hansens painted a picture of a very disorganized child, although his current foster mother in Russia does not. Regardless, his experience with the Hansens, and the ill-conceived way he was sent back to Russia, are not stand-alone events. They rest on the foundation of interactions he had, or did not have, very early in life.

Even if a school-age child like Artyom is adopted or finds his way to a nurturing foster caregiver, a pattern of connection with others is already established. It begins before the child enters foster care, as a result of the child’s experience with his first caregivers, and the pattern continues after he leaves the system.

Around one-third of those 18 to 24 who age out of foster care are homeless within 18 months (in the U.S.). Up to one-half are unemployed within 4 years of leaving, and approximately 30% to 40% have a mental disorder and likely no health insurance. More than three-fourths will become parents.

Perspective

To keep these sobering numbers in perspective, we can consider that people with less than stellar starts in life can, and do, lead productive lives and find a share of happiness. Humans are highly adaptable and resourceful. It is also a fact that people from “good” homes enter adulthood with mild to severe attachment issues, usually the avoidant or ambivalent type.

Difficulty trusting and connecting with others is not just a single family issue. It is part of the human condition and drives the drama we call history.

The foster care system is imperfect, but it is a nested problem. Looked at as a whole, the problem begins with the child’s experience of insufficient early caregiving and is later aggravated by the lack of support for these children during the transition to adulthood. The system is situated in a disorganized world where, unfortunately, such institutions are necessary. The best we can do is to strive to keep making improvements based on what we continue to learn about the special needs of these children.

References:

1. Child Welfare Information Gateway. Available from: http://www.childwelfare.gov
2. U.S. Department of Health and Human Services, Administration for Children and Families. Abuse, Neglect, Adoption & Foster Care Research: National Survey of Child and Adolescent Well-Being (NSCAW), 1997-2010. Available from: https://acf.gov/opre/project/national-survey-child-and-adolescent-well-being-nscaw-1997-2014-and-2015-2024
3. Radia, K. Adopted Russian boy rejected by U.S. mother adjusts in foster care. Available from: http://gma.yahoo.com/blogs/abc-blogs/adopted-russian-boy-rejected-u-mother-adjusts-foster-110037054–abc-news-topstories.html

Related articles:
Patterns of Attachment in Adults
Understanding Difficult Behavior – For Foster and Adoptive Parents

Healthy conflict resolution is essential to maintaining positive and constructive adult relationships. Individuals usually learn how to handle conflict in childhood. Children watch the way adults work through disagreements and model those patterns of behavior as they develop into adults and begin to form relationships with others. The bonds that children have with their caregivers also influence the way in which they address conflicts. People who have secure attachments with their parents and caregivers are often able to work through challenges with other people in respectful, affectionate, and loving ways. They are capable of recognizing when they need to ask for forgiveness and are willing to compromise to achieve a resolution that is mutually satisfying to all involved. Individuals who have insecure attachments, however, are often unable to handle situations as amicably. Insecure attachment can be expressed through avoidant or anxious behaviors. People who are avoidant in nature tend to withdraw and shut down when faced with conflict. Anxious individuals may demand attention, even negative attention, and use aggressive and hostile tactics to engage someone in a conflict dispute.

For children who have grown up witnessing dysfunctional conflict resolution strategies, having a secure attachment with others could help them avoid making the same mistakes of their parents. Rather than continuing the negative behaviors they have seen displayed by their own parents, these secure, self-reliant, and confident people may choose to use healthier mechanisms to maintain harmony in their adult relationships. Joyce A. Baptist of the School of Family Studies and Human Services at Kansas State University wanted to better understand how attachment style affected emotional processing learned in families of origin. She enlisted 203 young adults who had been raised in families with various emotional functioning styles for a study that evaluated how the adult children managed conflict.

Baptist found that the participants who had witnessed extreme disengagement in childhood were more likely to use aggressive and antagonistic disagreement strategies in adulthood. The most anxiously attached individuals in this group were the most apt to engage in hostile behaviors as their anxiety escalated. Those with minimally avoidant styles worked through disagreements in a more civil way. Baptist believes these results suggest that secure attachments can help protect individuals from dysfunctional and destructive conflict resolution patterns. These findings could impact how professionals assist people who have communication and compromise problems in their adult relationships. She added, “Considering the interrelations between emotional processing in families of origin and insecurities in attachment will allow therapists to better identify and treat the root of the destructive conflict behavior.”

Reference:
Baptist, J. A., Thompson, D. E., Norton, A. M., Hardy, N. R., Link, C. D. (2012). The effects of the intergenerational transmission of family emotional processes on conflict styles: The moderating role of attachment. American Journal of Family Therapy 40.1, 56-73.

Psychotherapists and clients who are working with issues of dissociation talk about being grounded a lot. What we usually mean by grounded is the experience of feeling present and aware in our bodies and being able to interact with the world around us with a clarity of our senses. There are even formulas that seem to have developed for how to be present—“feel your feet on the floor, your butt in your chair, and breathe.” Sometimes this is enough, but often it’s not.

Moving your body is a much faster and more reliable method for becoming grounded. Although movement in general is often helpful for restoring awareness to the body and breaking free of dissociation, centered and well-organized movement is even more useful.

Try the following experiments to see if you can notice the benefits of grounding movement:

1.  Jump up and down and side to side while waving your arms wildly. What was that like for you? What did you notice physically and emotionally, both during and after the exercise? How satisfying was that?
2. Now try standing with your feet shoulder width apart and begin rotating in your hip joints. Twist side to side, letting your arms follow the movement of your torso. (Some people find it helpful to imagine that they are a washing machine). What was this like? What were your physical and emotional sensations? Did you find this movement satisfying?

People typically report that the second exercise helps them bring their surroundings into focus and reduces anxiety and fearfulness. They feel more grounded and less dissociated.

This works because it offers an organized and nonthreatening way to quite literally expand the body and bodily awareness.

Dissociation is a flight response to a perceived threat. Checking out, via either partial or total amnesia, or switching into another part of the self, makes awareness of the threat disappear. This is a very handy skill for small children who are not able to adequately protect themselves. This is less useful for adults who have developed habits of dissociating—whether the threat is present in the moment or remembered.

The problem with dissociation is that adults, who are capable of protecting themselves, lose access to that protective ability when they split. As a colleague of mine likes to say, if there’s a tiger in the room and you pretend it’s not there, that doesn’t actually make the tiger disappear. Dissociation doesn’t make you more safe, and it actually makes you less safe.

But, clients often tell me, if I don’t dissociate and I choose instead to be present, then I’ll be stuck in my fears—how does being petrified make me any safer? Good point, I reply. They’re right, after all. Being frozen with fear is not any more effective than dissociating is for dealing with that oncoming tiger. What is effective for safety is being present and grounded.

Here’s another experiment you can try which demonstrates this point:

1.  Imagine that you’re afraid. It might help to recall a time when something scared you—perhaps a loud noise, a spider, or something else that frightened you a little bit. Notice what happens in your body (pay attention to your breathing, posture, and points of tension).
2. Now imagine that you’re safe and satisfied. Pull up a memory of an experience of being warm and secure and loved. What’s going on in your body this time?

In general, people report that when they’re afraid, their bodies constrict and collapse, their stomachs tighten, breathing becomes shallow, jaws clench, and they notice tension in their arms, chest, legs, and/or back. When doing the second exercise, they typically feel their bodies open up and relax.

The feeling of safety is a lot like the feeling created by the washing machine exercise at the beginning of this article. This suggests that being present in our bodies is the path to safety. Instead of having to only choose between dissociation and petrifaction, people working with dissociation can make use of movement to come into a state of groundedness and safety.

The following is an open letter to my sister Andrea Haber, who died from complications due to alcoholism on 10/31/11.

Dearest Anj:

Just a note to let you know how much I miss you. It’s still so bitterly ironic to me that what killed you is the very disease I’ve devoted my life to battling. But in a way, your alcoholism never gave you a chance.

I’m sorry we never talked about it, although you can’t say I didn’t try. There was a time, a few years back, when you told me you wanted to talk about it, and my heart leapt. But that talk, like so many hoped-for moments, never materialized.

I believe when I first got sober I wrote you a somewhat long-winded, pompous letter about the perils of drinking. I’m sorry again that I preached at you like that. You handled it with grace but I cringe now at the thought of my presumptuous rambling. Newly sober people often think they can save the world with a few well-chosen phrases. I guess I thought there was really something I could do. Naïve, yes, but even at the end, and maybe even now, I often feel the same way.

I miss your letters. They really made me laugh. You were a fabulous writer and I think that you, as with so much else, underestimated yourself. Their absence has created a very loud silence.

I’m sure you’re thinking, “Gee bro, nice cheery letter!” I only wish I could be more cheery. This is an occasion I never wanted— that even with the grim medical news coming from Pittsburgh, I never really saw coming. There’s just no good way to spin the loss of someone so young, so beautiful, so amazing. Part of the tragedy for me is, I don’t think you ever truly understood just how loved you were. Mom told me you were shocked when she said to you, near the end, how much you’d be missed should the worst happen. This too, is another symptom of addiction: the disbelief that we matter to people, the certainty that we’re really “only hurting ourselves.”

Hard to be cheery when feeling so cheated…

Of course, denial is the hallmark of this loathsome affliction. We grew up with rationalizations and minimizations aplenty when it came to Dad’s drinking and the family’s Nixonian “cover up”—i.e., “Don’t talk about it, too embarrassing” (Dad’s favorite) and “It’s not that bad” and “Don’t exaggerate,” all repeated like mantras. Even I, near the end, felt that chances were good you’d come around; see the light, get sober. Your disease made a mockery of my optimism.

So hard to sit on the sidelines and simply try to accept. I’ve struggled lately with, “Did I really do enough?” Should I have gone all out and planned an intervention, John Wayne style? Should I have demanded you listen to me until “the truth” sank in? I already felt like a stick in the mud, the voice of gloom, whenever you called or wrote me and wanted to laugh or kid around; I loved the jokes but was so terribly worried about your well-being. We had a trove of inside jokes, a bulwark against the despair of growing up in that chaos and emotional violence. I cherished the humor but wondered what might be going on underneath. There is a pain we can’t hide from, I have found, no matter how clever or humorous we are. When your doctor handed you that grim prognosis last year, that you either stop drinking or die, I thought “well this is it, she can’t ignore it any longer.” Wrong again, bro!

Of course the cliché is that there’s nothing you can do to get a person to stop; no amount of begging or pleading or coercion will ever do the trick. Maybe briefly, superficially, but it’s an “inside job” (as they say) when it comes to lasting change. We can give someone just about anything, except motivation to do the hard but necessary thing. I kept thinking you’d finally “hit bottom” when the doctors told you your liver was shot…until mom told me this wasn’t the case, that she feared nothing was changing. I backed off a bit because I know how she hounded you. Maybe that was a mistake. Maybe hearing it from me would’ve got you moving.

I cringe when I see the pride and ego in that last sentence. Yes, you should have heard it from ME, your big brother, sober white knight on the West Coast, brandishing a master’s degree in psych., saving souls and fighting the good fight. I wonder if you’re chuckling as you read this.

Perhaps it’s pretentious of me to think I had the slightest idea of what might be good for you. I had no idea what was really going on in your life, and I suppose it was none of my business. Maybe the long, hard climb back to sobriety might have been too difficult; perhaps too many skeletons, whatever they were, had accumulated in the closet for any one person to face.

But saying “There’s nothing I could have done” doesn’t seem to help. Maybe that’s why I’m writing you now; perhaps, in my Jewish neurotic guilt, I struggle towards some kind of absolution. Doubt has always dogged me; so hard to not look over my shoulder in almost every instance. This is no exception. Could I have somehow said more, done more, pushed harder to help you “see the light”? (Am I hearing that chuckle again?)

Just this morning I advised the mother of a patient that there was nothing she could do to “get” her daughter to stop using and go to meetings. I thought, “Wow she really thinks there’s something she can do!” So easy to sit in one’s cozy office chair and dispense wisdom to the struggling, misguided souls asking for help…

Here’s the hard part (as if there’s an easy part!): You can detach, stop trying, accept another’s addiction, respect their “life choices” and move on. But how to really “move on” when it’s your own flesh and blood? You can stop obsessing, stop letting the person’s disease hold your serenity hostage, attend Al-Anon meetings, seek counseling…but the kind of Zen-transcendent it’s-all-good acceptance I’ve perhaps subtly advocated to others isn’t possible, at least not for me, at this point in time.

Because I can’t stop loving you. Can’t switch off the caring. How could it be otherwise?

Maybe the idea is to make room for both, the love and the acceptance. It’s not either-or (as I’m fond of telling my patients). You can love the person and hate the disease. It’s just hard to stand by and watch a loved one fall to pieces and to try and pretend it’s not happening. It’s like a fatal car accident happening in slow motion right outside your door. I prayed every night for you to find the desire to stop drinking. I struggle to accept it never happened.

I know you meant no harm, Sis, and I never took it personally. I think if you could have stopped, you would have; as I say, the odds were seriously stacked against us from the get-go. I don’t know why I hit the lucky number; I just know it’s a gift that I protect with my life, and I would have given anything to have shared it with you. I tried.

I hope you know that somehow, wherever you are, I was worried but not condemning you. There is so much shame with this thing but I always longed to say to you, How could you not be an alcoholic, with all the crap we had to deal with? Even so, I underestimated the awesome power of this thing, and can only guess at how you suffered beneath the chuckles, the jokes and that wonderful wit of yours. It’s just hard to accept that, in this case at least, love was not enough…so difficult at those times when I think of our private jokes and laugh and want to email you…hard to really accept that my kid sister—my first friend, my loyal ally—is really, undeniably gone…

 Related articles:
The Pendulum of Grieving
Over-Extended: Thoughts on Boundaries in Addictive Families
In Case of Emergency: Seeking Help When a Loved one Struggles with Addiction

People who have suffered childhood trauma are at increased risk for psychological problems resulting from extreme stress. Borderline personality disorder (BPD) is one such condition that has been linked to severe childhood trauma. When the trauma is inflicted by a caregiver, the child’s ability to cope is significantly impaired. The effects of unhealthy coping, attachment dysfunction, and emotional regulation can affect many areas of the child’s life as they continue into adulthood. Affect dysregulation is the inability to control one’s moods and emotions and has been linked to BPD and other mental illnesses. Underregulation of emotions is expressed by lack of control, extreme emotional overwhelm; while overregulation is the result of numbing and is exhibited by an inability to express emotions. To determine which of these factors is more indicative of BPD in adults who suffered trauma during childhood by their primary caregiver (TPC), Annemiek van Dijke of the Delta Psychiatric Hospital in the Netherlands conducted a study of 472 clients with a diagnosis of BPD.

The participants’ levels of affect regulation were documented and they were evaluated for various forms of TPC, including sexual abuse, physical abuse, and emotional trauma. Van Dijke found that 63% of the participants had experienced some form of TPC and that those with underregulation had more symptoms of BPD than the participants with overregulated affect. Although the study did not consider other factors that could influence BPD, such as family history, other traumas, and the mental health of the caregivers, the results clearly emphasize the importance of examining emotional regulation, and specifically underregulation, in clients with a history of TPC.

The findings also showed that the participants with TPC were at increased risk for posttraumatic stress (PTSD). But Van Dijke noted that no research has been conducted to determine exactly how specific forms of TPC affect the severity of PTSD symptoms or how they are indirectly affected through affect regulation as a result of TPC. In sum, Van Dijke believes that these results can benefit clients who have suffered TPC by educating clinicians on the importance of helping clients build more secure relationships and develop healthier emotional expressions.

Reference:
Van Dijke, A., Ford, J. D., van Son, M., Frank, L., & van der Hart, O. (2012). Association of childhood-trauma-by-primary caregiver and affect dysregulation with borderline personality disorder symptoms in adulthood. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0027256

If you have completed Codependency Workbook Exercise One, congratulations to you. Please take a moment to pat yourself on the back. You deserve it, because it must have taken a great deal of courage to write about your family history. Most people shed some tears in our therapy session when they share it with me. Then they feel very relieved.

Many people are not ready to share the letter with their family of origin right away. If you have a therapist available or a sponsor, discuss it with that person. If not, review it with a supportive, nonjudgmental friend. Before sharing this with your family, it is important that you be ready to deal with their reactions. Unless they are in recovery, most families will not be able to validate your experience. However, it is very therapeutic to put your family history on paper and share it with another person.

[fat_widget_right]

Now we are ready to begin the next workbook exercise, which concerns relationships. Please make a list of the most important people in your life. This may include friends, lovers, a spouse, family members, coworkers, or a boss. Spend a few minutes thinking about each relationship. How many people on your list do you believe are dysfunctional? How many are addicts, have untreated mental illness, refuse to work, even if they are able, or have other major issues? Are you taking care of some of the people on your list? Are some of the relationships lopsided, where you do most of the giving?

You may wonder why some of your relationships are lopsided. Dysfunctional people can sense that you are a caretaker and are drawn to you. It is almost as though they can smell you. You may find yourself drawn to them as well.

Last night, I saw a married couple where the wife was unsuccessfully trying to stop her alcoholic husband from drinking. She was anxious, frustrated, and very angry. Of course she would be frustrated. She was trying to control something that she had no control over. The facts are that we are powerless over other people, places, and things. Realizing this is helpful to codependents because they can learn to let go and relax. Trying to fix others is impossible, and just upsets the fixer. It also is not helpful to the dysfunctional person. Normally addicts only get help because of the consequences of their using. If the caretaker undoes the consequences, they caretaker unknowingly helps enable the dysfunctional person to remain sick.

Since caretaking may make you miserable and help your loved one stay sick, maybe we can work on not doing it. How? You can begin to learn to set boundaries. For example, you might tell the loved one that you will no longer bail him or her out if he is arrested. You may tell him that you will no longer call in sick if he is too hung over to work. You may tell her that you will only talk with her when she is sober.

I suggest that you put your list away for at least 24 hours. Then pick the relationship that causes you the most stress. Think about a boundary that you may set and write it down. Practice telling your loved one about the boundary. He or she will probably not like it, but in the long run it will be good for both of you. Be sure that you are prepared to maintain the boundary before you set it. The first time you do this, you are taking a major step in your recovery. Be sure to spend some time with someone who will support you setting a boundary.

“I’ve been suffering for years,” Marcelle said. “When I tell Andrew that he’s hurt my feelings, he gets angry. Can you imagine that? What kind of human being gets angry when he sees his wife crying?”

This is a good question, and one that I get asked often. The answer is that a person like Andrew, who gets angry at being told that he has—once again—done it wrong, is a human who has never heard a word of praise and experienced more criticism in his life than he knows what to do with.

Such a person—often, but not always, a man—is highly conflicted. In moments when he does not feel put on the defensive, he cares deeply for his wife, loves her, and doesn’t want her to hurt. On the other hand, when he thinks he’s being attacked, he reflexively circles the wagons to protect himself.

[fat_widget_relationships_right]

“So finally, I got good and angry myself,” Marcelle went on. “How much of this can I take? I get mistreated and I can’t even express myself. That’s not right! That’s not fair! I deserve better, so I told him a thing or two. I let him have it. And, frankly, I felt much better after that.”

That’s a typical pattern—and highly destructive.

The Elusive Satisfaction of Retaliation
Marcelle has every justification in the world to feel hurt. It is also human for her to be angry at the cause of that hurt when he is so unsympathetic. But her reaction in this scenario is wrong. For one thing, she’s hurting herself more by lowering herself to his level. If she acknowledges that his anger is hurtful, then her anger is hurtful too. If she acknowledges that anger displays a lack of humanity on his part, then it displays a lack of humanity on hers as well.

Later, alone with her feelings, Marcelle will confide that the good feeling of “giving it back” was short lived. Over time, the idea that she had betrayed herself by stooping to his level gnawed at her innermost being. She had always liked herself for her own kindness and goodness. “Now who am I?” she wondered. Not only did she reduce herself to a level that she did not respect, but in doing so, she also became alienated from herself.

Many victims of mistreatment feel this way. They feel estranged from the person they thought they were, they don’t like the person they’ve become, and they’re still depressed over the way they were treated. They add depression to depression. Being mean and striking back is completely self-defeating.

How Retaliation Makes Bad Behavior Worse
There’s another, even worse problem with Marcelle’s reaction: it ensures that Andrew’s behavior will also get worse. Now that’s bad.

Andrew doesn’t want to be the bad guy that he is, but he has no clue how to make the awful feelings go away when he is repeatedly reminded of his failings. When he hears what comes across to him as a criticism, he is thrown into a pit of despair. After all, if he knew how to handle the problem in the first place, he would not have created it. Growing up in a home in which such things as compassion, sharing, consideration, and respect were not taught or modeled, he is unaware of how to deal with situations which call for these traits. How can he fix a problem he’s clueless about?

But Andrew does know the one thing he learned very well growing up: how to defend himself, strike back, or tune out. It’s only natural that when he feels attacked, he’s going to do what it takes to prevent those old feelings from rushing in. What better smokescreen than for him to attack back?

Will he feel better? No, just as Marcelle didn’t feel better when she retaliated. Will the marriage improve this way? Obviously not. What should be done?

Alternatives to Retaliation
Marcelle has to switch her approach from telling Andrew what he did wrong to what she wants him to do. It means changing a negative sentence to a positive one. This might not seem hard to do, but listen to what Marcelle has to say about it: “What about my feelings? Are you telling me to stifle my feelings? He’s my husband; shouldn’t I be able to tell my own husband that he hurt my feelings?”

Marcelle has a point. She should not have to stifle her feelings; she should be able to express them to her own husband. But we are not operating in a fair and just world. Her husband simply cannot hear this until he has healed from his past pain.

So Marcelle’s real job is to deal with her “shoulds.” Theoretically, she should be free to express herself, and in reality, she shoots herself in the foot when she does. What are Marcelle’s options?

• Marcelle has to make a list for herself of healthy ways to self-soothe such as doing affirmations, practicing relaxation and deep breathing, getting sufficient sleep and exercise, and deriving pleasure from her work and daily tasks. She can also journal or talk to a marriage counselor who is pro-marriage. All of these serve both as channels for her bad feelings and as ways to empower herself to feel good, despite the tough hand that she was dealt.

• Marcelle should learn to assertively ask for what she wants in very specific terms, such as, “When I come home with groceries, please help me with them, and please smile at me when you do.” She herself should be pleasant and smiling when making these requests. Andrew did not have the benefit of learning how to handle interpersonal relationships growing up, so part of his attraction to Marcelle was that she was so skilled at them. He is actually looking to her for a way out of the labyrinth. Furthermore, by being pleasant in her request, she is also modeling the very behavior she wants—and putting in a teaspoon of sugar to make the medicine go down.

Retaliation is not one of Marcelle’s options, but she will find that if she follows the options above, she will be empowered and happier, even before Andrew has started to “get it.” Eventually, he will “get it” and then they will both be happier.

Bad person feelings typically develop early in life. Although it may not be intended, children can get the message that it isn’t simply what they do or think or feel that is bad, but that they themselves are bad.  When these feelings are communicated, verbally or nonverbally, children soon learn to avoid them by working very hard to please and not disappoint parents. They may try so hard to be good (i.e., to be the child the parent expects), that they have little room to develop their own unique selves.

The Experience of “I Am a Bad Person”
When parents yell at their children or verbally or physically abuse them, we can imagine that this might frighten, shame, humiliate, or terrify a child.  But parents can also respond in more subtle ways that can damage a child. When a parent expresses hurt or disappointment by a sigh, a look, crying, head shaking, or leaving the room, the impact can be devastating: “How can I have done this to my parent? I must be a terrible person.” When the parent’s displeasure is expressed as hurt, it is especially difficult for the child to mobilize a strong sense of self and fight back.  The parent’s hurt is evidence that the child is a bad person. It then feels necessary to always please others and behave in ways to avoid the “I am a bad person” feeling.

People Pleasing
In my practice of psychotherapy, I frequently work with patients who have a strong desire to please. They often come to therapy when they find that their anxiety about pleasing others is having a serious impact on their lives.  Worry and rumination about whether or not someone “likes me” characterize most relationships.  Their concern is not only about the feelings of significant others; coworkers and casual acquaintances can create as much worry about being liked as a parent, spouse, or boss.
The focus on pleasing others interferes with developing the ability to consider what would be pleasing to oneself.  Alan came to therapy struggling with what to do with his life. At the age of 29 he wasn’t sure how much he really liked the woman he was dating. He felt he couldn’t trust his feelings. He also had doubts about his job and couldn’t figure out if he was being realistic in what he wanted. He reported that he was tired of trying to keep his girlfriend and his boss happy.  He wasn’t comfortable telling them what wasn’t working for him and he worried that he was too demanding. As is typical with people pleasers, he frequently second guessed himself and questioned what his true feelings were.  Alan spent so much time avoiding displeasing others that he hadn’t developed a sense of who he was, what he wanted, and how to get it.

Disappointment
When struggling with bad person feelings, experiences of disappointing and being a disappointment are prominent. My patient Diane often described how she felt a pit in her stomach or on the verge of tears when she thought she disappointed someone. But what was totally intolerable was when she felt she was a disappointment. She recalled that her mom would look sad and hurt and shake her head when Diane refused to wear what mom had chosen for her. She told me that it wasn’t simply that she felt that her behavior had hurt and disappointed her mother. Tearing up, she said “I felt that I am a disappointment and it felt like that defined my very essence.”
Diane also would become very anxious when she felt that someone disappointed her. She felt she had no right to such feelings and believed she was wrong or exaggerating if she allowed herself to feel that way. She told me “If I let my husband know some of the things that trouble and disappoint me in our relationship, I will hurt his feelings. Then I will feel terrible, that I am a bad person.”  What Diane described is her fear of asserting herself:  someone could get hurt and this will be proof of her badness.

The Tenacity of the Bad Person Feeling
Both Alan and Diane were overly attentive to pleasing others, not disappointing, and protecting themselves from bad person feelings. Both found it difficult and dangerous to please themselves, believing that if they focused on their own needs, they would create hurt and disappointment in others. Both worked to maintain a positive self-image by vigilantly trying to be sure that they never were experienced as having negative impact.
For people who struggle with bad person feelings, the most important goal in relationships is not so much to be related to with positive regard as to avoid negative regard. As a result, whatever positive regard is directed toward people pleasers tends not to be taken seriously.  Alan explained: “I know I bend over backwards to make sure no one is upset or angry or displeased with me. So when people like me, deep down I don’t give it much credence. Sometimes I think I am always acting.”  The point here is that the bad person feelings continue to define the person and are not easily changed by experiences of positive regard from others.

Changing the Bad Person Feeling
The bad person feeling typically digs its claws into the internal life of those who suffer with it.  It feels real, inevitable, and a fundamental part of “who I am.” The feeling defines how one thinks about the self and typically was developed through early relationships with significant others.  As one develops, many relationships mirror the dynamics of the parent-child relationship where the aim is to avoid hurting the other and to not feel like the bad person. Reflecting on these feelings, it is not so easy to consider that a parent, even without intention, was involved in the development of these terrible feelings. If that were to be accepted, it would mean accepting that I am the hurt one. This perspective turns the way the world has been understood upside down. With such a radical shift in thinking needed, how can these feelings be diminished?
You have to be willing to consider alternative ways of thinking about your early experience. Thoughts that once made sense have to be reflected on and reconsidered.  Even if at first, you can’t emotionally accept a new way of thinking, it is important to start by logically considering what you believe about your experiences, perceptions, and feelings. It will be important to become aware of how many of your relationships mirror the anxieties you felt (and feel) with your parents.
Objectively, you may be able to consider that children do no wrong even if a parent feels hurt when they have independent thoughts or don’t do as the parent asks. Can you apply this thought to yourself?  Can you become aware and intellectually accept that as humans in relationships, we all hurt those we love in unintended ways and that this does not make us bad people? Coming up with new ways of thinking about old assumptions is an important beginning in changing bad person feelings. However, it is not enough. To accomplish a change in your definition of self, from the bad person who is a disappointment to a good enough person who doesn’t always please and can disappoint from time to time, requires an emotional shift internally. Therapy is one means of facilitating this shift. Another means is to gradually use your rational thoughts to urge yourself to risk responding honestly.  By this I mean, it becomes necessary to first remind yourself “Yes, I am human and it is okay to express my own unique thoughts even if they are different. I know someone could respond negatively but this doesn’t mean I have done something wrong.”
This takes time. As you repeatedly risk the possibility of making a negative impact by asserting your separate thoughts and feelings, your tolerance for anxiety, risk taking, and bad person feelings will increase. You need to be able to gradually tolerate situations where you do hurt someone. The goal is to increase the experience of being yourself in relationships and learn that typically, you will not hurt the other by being a separate, individuated self. This lesson is crucial.  Most important is the emotional registering of the other person maintaining their acceptance, love, and admiration for you, even when they feel you have hurt, disappointed, or made them angry. This is the emotional experience that will finally lead to change. The end result is that your tolerance for the other’s feelings of anger, hurt, or disappointment are increased and the bad person feelings are diminished.

Related articles:
The Fear of Hurting the Other and the Inhibition of Self
The Price Paid for Being the Perfect Child
Getting to Know (and Esteem) Yourself

Research has shown that there is a genetic risk factor for suicide. However, until now, very few studies have looked at family history of suicide to determine how it affects second- and third-degree relatives and the maternal, paternal, or spousal influences. Because suicide is predicted to take nearly 1.5 million lives by the year 2020, according to the World Health Organization, being able to identify and treat those most vulnerable for suicidal ideations is vitally important. Current research has suggested the family risk factor for suicide to be anywhere between 17% and 55%. To get a more defined estimate of how suicide runs in families and how environmental factors impact the risk for suicide, D. Tidamalm of the Department of Clinical Neuroscience at Karolinska Institutet in Stockholm analyzed more than 50 years of data from the entire Swedish population. Tidamalm and colleagues assessed how many of the Swedes who had committed suicide during those years, a total of 83,951, had a relative who had also died from suicide, and they compared those rates to a control group.

The research revealed that full siblings had a higher risk for suicide than maternal half-siblings. However, maternal half-siblings were more likely to die by suicide than paternal half-siblings, perhaps because of shared environments. The study showed that identical twins were more vulnerable than fraternal twins, and even cousins were 50% more likely to commit suicide than the control group. Environment influenced the risk for suicide significantly as well. Full siblings were three times more likely to die by suicide than the children of suicide victims, whose risk was twice as high as the controls. Even spouses were more likely to commit suicide than the control groups. Tidamalm believes that degree of relation, combined with environment, is an important element for exploration in treatment. Tidamalm added, “The results confirm the importance of considering the family history of suicide when assessing suicide risk in clinical practice or when designing and administering preventive interventions.”

Reference:
Tidamalm, D., Runeson, B., Waern, M., Frisell, T., Carlstrom, E., Lichtenstein, P., Langstrom, N. Familial Clustering of Suicide Risk: A Total Population Study of 11.4 Million Individuals. Psychological Medicine 41.12 (2011): 22527-534. Print.