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NARCISSISTIC PERSONALITY DISORDER (NPD)

  1. Definition of Narcissistic personality disorder (NPD)

The term narcissism was first used in relation to human psychology by Sigmund Freud in his essay “On Narcissism” after the figure of Narcissus in Greek mythology (Golomb 2003: 18).
The Myth: One day Narcissus was walking in the woods when Echo (mountain nymph) saw him, fell deeply in love, and followed him. Narcissus sensed he was being followed and shouted “Who’s there?”. Echo repeated “Who’s there?” She eventually revealed her identity and attempted to embrace him. He stepped away and told her to leave him alone. She was heartbroken and spent the rest of her life in lonely glens until nothing but an echo sound remained of her. Nemesis, the goddess of revenge, noticed this behavior after learning the story and decided to punish Narcissus. Once, during the summer, getting thirsty after hunting, the goddess lured him to a pool where he leaned upon the water and saw himself in the bloom of youth. Narcissus did not realize it was merely his own reflection and fell deeply in love with it, as if it was somebody else. Unable to leave the allure of his image, he eventually realized that his love could not be reciprocated and he melted away from the fire of passion burning inside him, eventually turning into a gold and white flower (Source: https://en.wikipedia.org/wiki/Narcissus_(mythology))
Narcissism is “a pattern of traits and behaviors which signify infatuation and obsession with one’s self to the exclusion of all others and the egotistic and ruthless pursuit of one’s gratification, dominance and ambition.” (Vaknin 2003:18) The narcissist constantly tries to repair his injured self-esteem by adoring and admiring his gilded self. (Golomb 2003: 18)

  • Diagnostic criteria

There is a whole range of narcissistic reactions, styles, and characteristics – from the mild, reactive and transient to the permanent personality disorder. NPD is commonly diagnosed with other personality disorders, such as Histrionic, Borderline, Paranoid, and Antisocial Personality Disorders (Vaknin 2003).
The ICD-10 (International Classification of Mental and Behavioural Disorders) defines NPD as “a personality disorder that fits none of the specific rubrics”. It relegates to the category “F60.8 Other specific personality disorders”, together with eccentric, “haltlose” type, immature,        narcissistic, passive-aggressive and psychoneurotic (ICD-10).
American DSM-IV-TR defines NPD as “an all-pervasive pattern of grandiosity (in fantasy or behavior), need for admiration or adulation and lack of empathy”.
The DSM specifies nine diagnostic criteria. Five (or more) of these criteria must be met for a diagnosis of NPD.
Proposed Criteria:

  • ‘Feels grandiose and self-important (e.g., exaggerates accomplishments, talents, skills, contacts, and personality traits to the point of lying, demands to be recognized as superior without commensurate achievements);
  • Is obsessed with fantasies of unlimited success, fame, fearsome power or omnipotence, unequalled brilliance (the cerebral narcissist), bodily beauty or sexual performance (the somatic narcissist), or ideal, everlasting, all-conquering love or passion;
  • Firmly convinced that he or she is unique and, being special, can only be understood by, should only be treated by, or associate with, other special or unique, or high-status people (or institutions);
  • Requires excessive admiration, adulation, attention and affirmation – or, failing that, wishes to be feared and to be notorious (Narcissistic Supply);
  • Feels entitled. Demands automatic and full compliance with his or her unreasonable expectations for special and favorable priority treatment;
  • Is “interpersonally exploitative”, i.e., uses others to achieve his or her own goals;
  • Devoid of empathy. Is unable or unwilling to identify with, acknowledge, or accept the feelings, needs, preferences, priorities, and choices of others;
  • Constantly envious of others and seeks to hurt or destroy the objects of his or her frustration. Suffers from persecutory (paranoid) delusions as he or she believes that they feel the same about him or her and are likely to act similarly;
  • Behaves arrogantly and haughtily. Feels superior, omnipotent, omniscient, invincible, immune, being “above the law”, and omnipresent (magical thinking). Rages when frustrated, contradicted, or confronted by people he or she considers inferior to him or her and unworthy.’ (Vaknin 2003: 19)

1.1.2. Short comparison with other personal disorders
As mentioned earlier NPD is commonly diagnosed with other personality disorders. In this chapter I will introduced short comparison with four other personality disorder.
Opposite from patients with the Borderline Personality Disorder (BPD), the self-image of the narcissist is stable, he or she is less impulsive, self-destructive and concerned with abandonment issues. Also they are not as clinging as BPD patients (Vaknin 2003). Borderline and narcissistic patients both idealize and devalue others. But there is a different between them. BPD patient alternates between idealization and devaluation. For example, first they will idealize you, you will be the best therapist they ever had, and in the next session they will devaluated you, you will be the worst person they had ever know.  Nevertheless, the borderline patient cares about others. The narcissistic patient is more exploitative. Idealization is connected with expectation to satisfied patient’s grandiose fantasy. The minute expectations are not met, narcissist abandons you and looks for another one who will meet his grandiose fantasies (MacKinnon and others).
In short, on surface functioning of the narcissistic personality is much better than that of the average borderline patient. In general, NPD individuals are more capable of high, sustained achievement and will have more successful work history than the person with Borderline Personality Disorder. Both kinds seek attention, but unlike borderline, who seek nurturing attention, narcissist feel they deserve admiring attention because of their superiority (http://www1.appstate.edu/~hillrw/Narcissism/differentialdiagnosis.html).
Histrionic Personality Disorder (HPD) and NPD: Both personality types tend towards the demonstrative, exhibitionistic, dramatic and seductive in their behavior. Contrary to the histrionic patient, the narcissist is achievements-orientated and proud of his or her possessions and accomplishments. Narcissists also rarely display their emotions as histrionics do and they hold the sensitivities and needs of others in contempt. While the characteristic distinguishing feature of Histrionic Personality Disorder is coquettishness, the feature of NPD is grandiosity. Person with HPD is warm, playful, and spontaneous and can be dependent on others. These individuals are capable of love, empathy whereas those with NPD are not (Vaknin 2003; look at http://www1.appstate.edu/~hillrw/Narcissism/differentialdiagnosis.html).
While persons with NPD and Antisocial Personality Disorder (ASPD) share tendencies to be tough-minded, glib, superficial, exploitative, and unempathetic, NPD are less impulsive, less aggressive, and less deceitful. All ASPD are assumed to have a narcissistic personality structure, but not all narcissists are ASPD. Unlike a person with ASPD, the person with NPD has not learned to be ruthless or competitively assertive and aggressive when frustrated. A critical distinguishing feature is that in ASPD, there are no feelings of guilt or remorse and as opposed to ASPD, few narcissists are criminals (Vaknin 2003; see http://www1.appstate.edu/~hillrw/Narcissism/differentialdiagnosis.html).
Patients suffering from the range of obsessive-compulsive disorders (OCD) are committed to perfection and believe that only they are capable of attaining it. But, as opposed to narcissists, they are self-critical. However, someone with NPD is more likely to believe that he has actually achieved perfection. Shortly, the OCD seeks perfection, the narcissist claims it. The value systems of these two personality types differ as well: person with OCD has deeply held, rigid but genuine moral and socio-political beliefs. In contrast, the person with NPD might exposed such deeply held values but actually lacks any true commitment to them (Vaknin 2003; see http://www1.appstate.edu/~hillrw/Narcissism/differentialdiagnosis.html).

1.1.3. Defense mechanism
Over all narcissists intended to protect true self from hurt and trauma. He creates False Self which is omnipotent, invulnerable, and omniscient, through which he regulates his self (Vaknin 2003). To maintain that state, narcissists develop different defense mechanisms. There are three defense mechanisms that are the most common for narcissists: splitting, graciosity and isolation/distance.
Graciosity: narcissist creates relationships only with people who admire them or who he admires. Consequently he is afraid that others will disappoint him or demand attention for themselves. When attention is turned away from them, they distance themselves and leaves the relationship (Praper 1996: 180).
Distance and isolation: narcissist doesn’t realize that he is hurt and wounded. When they got the feeling that others don’t see them as perfect, feeling of inferiority is awaken in them. They are unable to take criticism and take a distance when this happens (Praper 1996: 180).
Splitting or black and white thinking can be seen as a developmental stage as well as a defense mechanism, which is also common in NPD. Narcissist believe that they need to be admired by others. The ones who don’t admire them are categorized as bad. Their ego is not capable of accepting good and bad objects in one person (Praper 1996, see http://en.wikipedia.org/wiki/Splitting_%28psychology%29#Narcissistic_personality_disorder).

1.1.4. Types of narcissism
We all go through narcissistic developmental stage in our lives. As infants and toddlers we all feel that we are the center of the Universe and it is impossible to imagine that our needs wouldn’t be met (Praper 1996). Here we talk about primary narcissism, where toddler doesn’t separate the mother from himself and he depends on her to satisfy his primary needs (Lasch 1979: 79). Both self and others are viewed immaturely-as idealizations (Vaknin 2003). Gradually toddler gains experiences that everything cannot be the way he wants. He realize that there are obstacles in the world, which brings him little disappointments and make him overcome primary narcissism (Praper 1996).
Secondary or pathological narcissism is a pattern of thinking and behaving in adulthood. It manifests in the chronic pursuit of personal gratification and attention, in social dominance and personal ambition, bragging, insensitivity to others, lack of empathy and/or excessive dependence on others to meet his responsibilities in daily living and thinking (Vaknin 2003). Lasch says that this type of narcissism tries to destroy painful disappointments in childhood and cover the childs rage towards people that hurtled him. (Lasch 1979: 79)
Manfield differentiates the exhibitionist type and cover narcissism, both belonging to secondary narcissism (Praper 1996: 178):
The first type is exhibitionistic type. Children during childhood get a lot of support in their grandiosity but there is no room for individuality and true feelings. This type is common for families with one child. Investment in one child raises grand expectations. The child should be born genius, and should use every opportunity to demonstrate this to others. When not acting as expected, he can be roughly rejected by his parents. Avoiding rejection, he continues to be brilliant, perfect, sweet. He also requires that others treat him as special (Praper 1996: 178).
The second type is the disguised type. The child has experienced that grandiose ideas are unacceptable. He learns to hide any such feeling and behaviors. However, he still develops perfectionism and hypersensitivity to criticism. The need for superiority is suppressed while suffering from feelings of inferiority. The truth is that he in fact doesn’t believe that he is inferior (Praper 1996: 179). The disguised type appears humble and modest, so impressively weak that it isn’t difficult to overlook the hidden grandiose self (Praper 1996: 223).
Also Millon distinguish 4 subtype of secondary narcissism in the following photo:

Table: Narcissistic Personality Subtypes (available at: http://www.millon.net/taxonomy/summary.htm)

  1. Origins of narcissism 

NPD has been considered as pathology of self as formation of pathological development of identity (Praper 1996: 175). Considering the work of Otto Kernberg, narcissism is an ego distortion. Ego functions enable us to observe our self and environment. With narcissism, the ego is unable to develop observations from environment in to cohesive picture of self (look Praper 1996: 176). Kernberg sees narcissism as a defense against feelings of individual anger and abandonment, stemming from the child’s rejection. As a result narcissists are distrustful and incapable of relying on others. Their relationships are marked by jealousy, control, and withdrawal (Žižek 1987: 118-119).
By Kerenberg, pathological narcissism originates from the serious frustrations in separation phase (Praper 1996). Kernberg points out that narcissism is a result of permanently cold parental figures, which express indifference or hostility towards the child. This inadequacy is reflected in their tendency to inflate their self-image (Otway and Vignoles 2006).
Kohut believes that narcissism is a normal aspect of infantile development. The child’s self-grandiosity is supported by mirroring and idealizing relationship between child and parent. If these needs are not met, the child as an adult may appear poorly adapted to adult forms of narcissism (Otway and Vignoles 2006). He also believes that the loss of the object that would allow binding and idealized mirroring force the person to direct fantasy only to himself. Therefore, the NPD is looking for a person who would idealize him. Hoping that through the binding with others, he will achieve the feeling of coherent self. In reality he is looking for mother’s admiration that was not there (Praper 1996, 177). The secondary narcissism happens because the process of archaic infantile narcissism to a healthy adult narcissism is interrupt. (Otway and Vignoles 2006).
By Winnicottu, the reason for narcissism is the lack of empathy and harmony between parent and child. Another reason can be overly intrusive behavior from the parent. Child develops a false self, which protects the true self from intrusion and damage. Therefore, narcissists always offer impeccable false self and protect himself against feelings of inferiority (Praper 1996:177).
Millon’s theory opposes to mentioned theories which believe that negative relationship between child and parent is reason for narcissism. Instead, Millon says that the reason is the excessive attention of parents, over-pampering, forbearance and admiration. Parents show unrealistic judgment of the child’s abilities, thereby increasing children’s self-image, which the environment does not necessarily support. Despite the differences in the theories, all believe that narcissism is a result of dysfunctional childhood experiences. (Otway and Vignoles 2006)

  1. Personal attributes

Main personal characteristics which are normally found in NPD:
Sensitivity to criticism: patients with NPD feel injured, humiliated and empty when criticized. They often react with devaluation, rage, and defiance to any5 real or imagined criticism. They are incapable to tolerate setbacks, disagreement, and criticism. (Vaknin 2003)
In personal relationships narcissist is not capable of attachment to others. He depends only on recognition from others. He doesn’t t trust people because he has pathological fear of over-dependency on others. That’s why he usually have short love relationships that in his mind shouldn’t be too stressful or emotionally demanding (Žižek, 1987). The relationships are typically impaired due to their lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention (Vaknin 2003).
Narcissist is unable to enjoy because he connects enjoyment with others. Enjoyments starts when others notice his enjoyment. A narcissist is totally external, which indicates inner emptiness and loss of their identity.
Narcissist is incapable of mourning. They are not able to converting rage, because of the loss, to the mourning. He is only able to forget the lost object, or to determine that in fact he didn’t like them anyway. After that he directs his energy towards new person.
For narcissist, the availability of people is taken for granted. To this type of person you are not a person with feelings, you are a ‘thing’ to feed off and sustain their existence.
Narcissist use manipulation to get what he wants. He knows exactly which manipulative tactic is going to work best in which situation. When he wants something from us he pays attention to us but the moment he doesn’t need us anymore he acts indifferent toward us. Narcissists work within win-lose strategy. They believe their world is positioned to serve their insatiable needs. (Žižek, 1987; Tonia Evans 2008)
Being perfect: narcissist has a fear of failure, for example loneliness and aging. That’s why they take care of their body, trying to stay young  and be under the spotlight-so they won’t get lost in the crowd of average people (Žižek, 1987).  They are either “cerebral” (intelligence or academic achievements) or “somatic” (physique, exercise, physical or sexual prowess and romantic or physical “conquests”) (Vaknin 2003). Which means they are trying to be perfect in physical appearance or in intellectual accomplishments.
Narcissist in society: narcissist sees himself as some kind of an exception. He seems adapted to the social norms but he doesn’t take them seriously. He plays this game just to avoid punishment and be successful in the society. He is convinced that everybody else is doing the same-“everyone is wearing masks, social life is just a game” (Žizek, 1987). A narcissist sees the admired person as “an extension of themselves.” If that person refuses them, they “immediate experience hatred and fear, and devaluate previous Idol” (Lasch 1979: 155-156). A narcissist avoids intimacy and associates only with people who are, like himself-perfect (Praper 1996: 180). Žižek mentions three types of other people, separated by the narcissist:

  1. The ideal-other: they expect approval and recognition, he identified with them
  2. Enemies, who are preventing his narcissistic affirmation, so they must be destroyed
  3. All the rest, the mass of people, ”suckers”: a grey average, which is here only to take advantage off and then reject them (Žižek 1987: 111).

 

  1. Narcissist as a patient

Several different approaches to individual therapy have been tried with NPD patients, ranging from classical psychoanalysis to Gestalt therapy. The emerging consensus is that therapists should set modest goals for treatment with NPD patients. Most of them cannot form a sufficiently deep bond with a therapist to allow healing from early-childhood injuries as a matter of fact they rarely turn to therapy at the first place (Frey, 2010).
“As of 2002, there are no medications that have been developed specifically for the treatment of NPD. Patients with NPD who are also depressed or anxious may be given drugs for relief of those symptoms (Frey, 2010).
Kerenberg noticed that narcissistic patients shows excessive self-centeredness, over dependency on admiration from others, prominence of fantasies of success and grandiosity. They avoid facts that are contrary to their inflated image of themselves. A narcissistic patient due to the pain of isolation protects himself with a position of self-sufficiency. They don’t let people emotionally close (Kerenberg, 2007, 505; Praper 1996:223).
They suffer from inordinate envy, which is conscious and unconscious. They show greediness, exploitative behavior, entitlement, devaluation of others, and incapacity to really depend on others. But ironically they need the admiration of others. They show a remarkable lack of empathy, shallowness in their emotional life and lack of capacity for commitment to relationships and goals. Also their self-esteem is regulated by severe mood swings. They have chronic sense of emptiness and boredom which they try to escape through eating, drug and alcohol use. In addition, their tendency to criticize and devalue their therapists (as well as other authority figures) makes it difficult for therapists to work with them (Kerenberg, 2007, 505, Frey 2010).
Patients with NPD may present typical complications of this disorder, including sexual promiscuity or sexual inhibition, drug dependence and alcoholism, social parasitism, severe (narcissistic type) suicidality and parasuicidality (=their aim is not to die). For instance, a patient with NPD tends to become depressed when his feelings are badly hurt, when his defenses have let him down and when he believes his world is collapsing. When wounded, he is at the greatest risk of acting out, either against himself or others. A patient experiencing a narcissistic rage may become homicidal, particularly if he has a need to seek revenge. Under conditions of severe stress and regression, a narcissist can experience significant paranoid developments and brief psychotic episodes (look Kerenberg, 2007, 505; http://www.lmars.com/n-personality-disorder.htm).
Using Heinz Kohut’s self-psychology model, the goal of therapy is to allow the patient to incorporate the missing self-object functions into his internal psychic structure. This process is called transmuting internalization. In this sense, these patients’ psyches are “under construction” and therapy is their building time. Empathy is being the key for making changes in therapy. Without it, the patient whose self is too weak to tolerate more aggressive interpretation, would not benefit from therapy and in fact may suffer more damage (McLean, 2007).
Therapists can recognize narcissistic patients by contratransfer. By feelings of boredom and emotional desertion. The therapist may become sleepy, absent, experiencing shame. He can react as all-knowing expert on life, competing with all the therapists that client had left earlier. When the client devalues him, he feels inadequacy and helplessness (Praper 1996:223).
“The prognosis for younger persons with narcissistic disorders is hopeful to the extent that the disturbances reflect a simple lack of life experience. The outlook for long-standing NPD, however, is largely negative. Some narcissists are able, particularly as they approach their midlife years, to accept their own limitations and those of others, to resolve their problems with envy, and to accept their own mortality. Most patients with NPD, on the other hand, become increasingly depressed as they grow older.” (Frey 2010)

References

LOSS IN CHILDHOOD, LOVE RELATIONSHIPS IN ADULTHOOD, part 3

There is not a lot written on how beavered children form romantic relationships as adults. In the final section of the article we will take a look at behaviors in relationships that can occur due to the loss of a parent during childhood. When a child looses his/her parent the connection between love and loss is no longer separated. “Deep down I believed that all man will eventually leave me.” was wrote by forum user who lost her dad. Research showed that many bereaved children are more hesitant about forming romantic relationships in comparison to their peers. However most adults do find their ways of having a relationship despite the potential loss. Some ways are functional others dysfunctional. Here we will take a look only on the dysfunctions that may occur in a romantic relationship.

I am looking for a unicorn
Some of them are determined to find the love they once knew. They are desperately seeking and are determined to find unconditional love that will heal their inner child. “For some individuals, this search for “all-powerful” love can feel almost desperate. The individual believes not only happiness, but survival itself depends on finding the needed partner. “(Harris, 1995, p.155).
“We lost our father when I was 5 and my brother was 9. He has had very few relationships, while I have found that I was diving from relationship to relationship, hanging on to people who were bad for me – possibly looking to replace the male affection and protection I never received as a little girl without the father.”

I can’t lose you

Many form the relationship but the anxiety of losing somebody is persisting. “After 25 years of marriage I still pay careful attention if my wife will leave me for somebody else or die in a car accident.” People who have experienced the death of a parent early on can be sensitive towards experiencing future loss. They are also less resilient in facing the rejection. 
On the other hand fear of feeling the deep loss again can be controlled by not fully committing in the relationship. They are changing the partners quickly or leaving before they are left.

No love for me
Some don’t pursue romantic relationships at all. Although they can feel the need to be connected to another person they feel terror when they think about getting close to someone. It is also common that they are not able to feel their need for connection or they are denying it. “I don’t need anyone I am better of alone. I feel happy that way.”

BEAVERED CHILD AND SURVIVING PARENT, part 1

HOW DEATH OF A PARENT CAN TOUCH US, part 2

HOW DEATH OF A PARENT CAN TOUCH US, part 2

In the second article I will explore what an effect can the death of a parent have on our emotional and mental health. Consequences can occur shortly after the death or later in life. It is important to know that psychological effects of a parent’s death can occur long after feelings of grief are behind us and we seem to have adjusted to our lives.  Not everything is due to this one event but we can’t neglect the researches that show higher risk factor of developing disorders associated with a childhood bereavement.

Inner world
Feelings that can occur after the death of the parents also depends on the nature of their death. Sudden, unexpected death, slow death and suicide often arise different kinds of feelings in us. Feelings can continue for a lifetime if not addressed. Many don’t even connect them anymore with the death of the parent, because they got so used to them through the years.

  • Shame can be connected to the suicide death as well as feeling different from other children who have both of their parents.
  • Guilt is often present. We feel responsible for parent’s death although we didn’t have any control over it. Suicidal thoughts can occur because child wishes to reunite with the parent, although these are rarely acted upon.
  • One feeling that is not often talked about is a feeling of relief. That can arise from seeing your parent going through torture due to the disease as well as in cases where the parent was unloving or abusing. Their death brings peace to the child and the family.
  • Some detach form the enormous pain of the loss. They block out the feelings. They numb themselves even with a help of drugs or/and alcohol.
  • Feeling of profound emptiness that can come in waves or we feel it all the time. Some try to fill the emptiness while others accept it as a part of them. “I am filling my emptiness with reading obsessively, my siblings socialized excessively. Nothing bad, just in extremes. But it could as well go really bad because drugs are easily accessible.”
  • Feeling of being rootless and having no solid ground is shared by many.
  • Tendency to control/dominate in relationships. Control can occur due to a fear of loosing someone again. On the other hand others shy away from forming emotionally intimate relationships for the same reason.
  • Idealization of the lost parent. Children invent not only perfect, idealized parent, but also a parent who makes their every wish come true. On the other hand some block out the image of the parent completely or build unrealistic images of them to detach from the painful memories.
  • Adults who have experienced a childhood bereavement sometimes do not expect to live longer than their parent did. Some stop living after that point in their lives and they appear half alive. This connects them to the deceased parent. This dynamic can occur especially when the parent  of the same sex died.

Higher vulnerability

Studies have revealed many negative outcomes associated with a childhood bereavement:

  • Increased likelihood of substance abuse.
  • Higher risk of criminal behavior. Parents are not only mentors but serve as a safe net. They set the boundaries to the child when they are in their experimental phase. In the absence of a parent some children find themselves running wild. They don’t know how to control impulses and moderate behavior. At first the lack of a parent feels like freedom but it soon become overwhelming. Rebellious behavior can include anger, violence, criminal behavior and sexual promiscuity.
  • Academic underachievement and lower employment rates. Almost all kids will have some trouble in school after the death of a parent. But for those already struggling, the crisis can be devastating to their performance. On the other hand child can become driven to over achievement. Keeping themselves extremely busy to avoid painful emotions.

The following factors increase the risk of psychological disorders (anxiety, depression):
-loss occurred before child was 5 years old or during early an adolescence,
-loss of mother for girls before age 11 and loss of father for adolescent boys,
-conflictual relationships with the deceased preceding the death,
-psychologically vulnerable surviving parent who is excessively dependent on the child,
-lack of an adequate family or support by a community (supports),
-unstable, inconsistent environment. Including multiple shifts in caretakers and disruption of familiar routines,
-experience of parental remarriage if there is a negative relationship between the child and the new partner,
-lack of prior knowledge about death,
-unanticipated death (suicide, homicide)(Source: https://www.ncbi.nlm.nih.gov/books/NBK217849/)

BEAVERED CHILD AND SURVIVING PARENT, part 1

LOSS IN CHILDHOOD, LOVE RELATIONSHIPS IN ADULTHOOD, part 3

BEAVERED CHILD AND SURVIVING PARENT, part 1

In this article we will touch very deep loss-the loss of a parent. It is hard to imagine how deep it cuts if you haven’t experienced it on your own skin. The best comparison I found was a comparison with a mountain climbing. Imagine that it is your first serious climb and you are accompanied by the professional climber. You rely on him with everything. He will show you the way, he will make sure that the way is safe, that you stay hydrated. In the middle of the mountain, your company dies. You are left alone. Chaos! Fear! That is exactly what a child who lost a parent feels. If a parent can disappear forever then nothing is safe and predictable anymore. Experience of the loss brings destruction to the family as a whole which often stops function as such and breaks down to individuals in the family.

Most people remember the day of the loss as being the end of their childhood. It marks a point before and after the life changed drastically. How was your experience like?

Grief
There is no universal face of grief. Children watch responses of the surviving parent and learn how they are “suppose to” mourn. “Is it O.K. to cry or I need to be strong and tough?”
The way someone grieves also depends on the age of a child. For example, those under the age of two may show loss of speech, while children under the age of five can respond by eating, sleeping, and urinary disturbance. School-age children may become phobic, preoccupied with body functions, withdrawn, or excessively care-giving. Especially in boys sadness may be replaced by aggression. Adolescents may respond similar to the adults, but they may also be reluctant about expressing their emotions due to the fear of being different.
Children who lost a parent when they were infants can feel absence instead of loss. “I don’t know what a “father” means. When I started school, I remember feeling different from other kids who had a mother and a father. /…/ There were no image (of father), just me, my brother, and my mother.” (Harris, 1995, p.18).
“My oldest brother was 13 when she died, and all he can talk about is what life would have been like if Mom had lived because he knows what life was like with her, he can really miss her. I never had her, so I don’t feel the loss. “(Harris, 1995, p.18).
Grief may continue on and off for many years, although it may get less intensive.



How did you and your family grieve? Did you grieve at all?

What a surviving parent can do for their children?

  • After such a traumatic event the best you can do is to keep child’s routines as regular as possible. That will lessen his anxiety and eventually bring back feeling of stability and security.
  • 
It is important for a child to have an adequate information about the death, suitable for their age. They are often afraid that a living parent can die as well. It is important to talk about their fears and reassure them that they are not to blame.
  • It is best to avoid any additional changes, such as moving homes, changing schools. Changes makes parental death significantly more difficult to deal with.
  • Sometimes the child lost not only one parent but has also lost the one who is still alive. They are (understandably) in such a pain themselves that they can’t manage keeping a family together. It is very important for a surviving parent to seek help form the community and/or professional therapist. Some surviving parents can respond to loss with abuse, neglect and anger towards their child. They can also make the child their “partner” or fall in such a deep depression that they withdraw from a child’s world completely.

How was it in your family? How did surviving parent manage to keep the family together in a long run? Did the surviving parent seek help?

Don’t talk about it

In some families the parental loss could not be talked about at all. Children can deliberately hide their feelings in order to protect the surviving parent. In my clinical experiences clients had little space to talk about their loss. Not that it was particular forbidden to talk about it but at the same time the topic was not mentioned because they wanted to save their family form any further pain.
It is essential to go through the painful feelings when grieving. Talk to your child about your feelings and encourage them to express theirs. You can also start some rituals that encourage family members to express their feelings. For example make a family gathering at the grave a yearly event where everybody can express their feelings and remember the deceased. Celebrate their birthdays or visit their favorite restaurant together every couple of months. Create a space where it is O.K. to express emotions about the loss for years to come.

Did you talk about the loss in your family? It is still O.K. to talk about it now as an adult?

-About 4% of children in Western countries experience the death of a parent.
-1 in 9 adults in a survey said they have lost a parent before they were 20 years old.
-40% recall frequently pretending to be O.K. not to upset their surviving parent.
-63% feared their surviving parent would also get sick and die.
Source: Poll by Greenwald & Associates for New York Life Foundation and Comfort Zone Camps.

HOW DEATH OF A PARENT CAN TOUCH US, part 2

LOSS IN CHILDHOOD, LOVE RELATIONSHIPS IN ADULTHOOD, part 3

AFTER BIRTH SUPPORT OPTIONS IN BERLIN

In the spirit of my article Postpartum care and Eastern concept of “doing the month” in this article I am listing different types of care/help you can turn to during the postpartum period.

  • Partner: Talk to him. Let him know what you need from him and were he needs to take over after the baby is born.
  • Friends and family: If possible ask your family or friends to help you with cooking, cleaning and taking care of your older kids. Sometimes family can stress us out. It is important to think through who you would even ask. You don’t need extra stress, you need an understanding hand.
  • Online community can represent a great source of information and support. In Berlin there is a great Facebook group for Expats “ExpatbabiesBerlin” also “Supermamas Berlin” whose concept is to bring new mums in touch with more ‘experienced’ mums who live in the same neighborhood. Mums bring food, gift, and support to new mums. The new mums returns a favor to another new mom in the neighborhood at a later time.
  • Hebammen (midwives) offer pre and postnatal care. During the postnatal period (“Wochenbettbetreuung”), insurance will cover up to 26 visits for up to eight weeks after the birth. During these visits, she ensures that both the mother and baby are doing well. She will answer all questions regarding baby and you and will give suggestions if you will need specialized help. Here you can find the Hebamme list. In the search engine you can enter wanted area, language and type of care.
  • Familienzentren: All round Berlin there are Familienzentren. Each Zenter offers a variety of activities, support or help to young parents and families. Write to Zentren in your neighborhood to find out what they can do for you. Here you can find a list.
  • Aufsuchende Elternhilfe is meant for Families during the pregnancy and untill the child’s 1. year. The staff members of the Aufhilfe Elternhilfe provide support and health advice, social counseling, they can run errands, take care of older kids, accompany to the pediatrician and assistance in dealing with authorities. Help is free of charge. For more information turn to Kinder- und Jugendgesundheitsdienst des Gesundheitsamtes in your districts or contact organization directly, HERE.
  • Help through volunteers: Various projects, such as „Wellcome“, „Känguru“, or „Berliner Großelterndienst“ offer families help by trained volunteers. These offers are mostly free. For more information look at their webpages.
  • Home help as a health insurance benefit (“Haushaltshilfe als Leistung der Krankenkasse”): If the discomfort exceeds the normal level after birth (caesarean section, a multiple birth, premature birth, postpartum mental health issues, problems with breastfeeding) there is the possibility that your health insurance company will cover the costs of household help. You need to go to your doctor (Hausartz) and get a prescription where they state why and to what extent support is needed. You will need to pay 10% of the daily fee yourself – but not less than 5 euros and not more than 10 euros per day.
  • Paid help during pre/postnatal period: cleaner, babysitter, doula, sleep consultant, lactose consultant, pelvis floor consultant.

POSTPARTUM CARE

After the baby comes, attention shifts from you to your baby. In most cases even mom can only focus of taking care of the baby, but who is now focusing on her? It is very important that after birth you are your own number one advocate and you take good care of yourself. You don’t need anyone’s permission, that is your right. Taking great care after birth helps prevent postpartum depression, anxiety and obsessive compulsive disorder. Furthermore, it helps your body to heal fully.

I heard so many times from my “after birth support system” that you are not allowed to donate blood 1 year after giving birth because birth is the same as going through a major surgery. Even if you don’t feel it, it doesn’t hurt to realize that your body is going through its own demanding processes during the pregnancy and also long after birth.

I believe many mothers don’t realize how important it is to take at least 3 months to nurture themselves after birth. I took a whole year. To me, my only job the first few months was taking care of myself and the baby. Meaning breastfeeding, being close to her and snuggling.

How to nurture yourself? Sleep, rest and eat well. Make sure that you are getting enough vitamins, minerals and amino acids through nutrition into your body. A lot of the nutrients will go through breastfeeding to the baby. You need to have enough for both of you. Seek advice from your doctor about supplementing if needed.

A wonderful concept that convinced me was so called “doing the month” (zuo yuezi) that derives from Chinese culture. While exploring this concept I figured out that a lot of eastern countries follow the similar idea. Of course, this is an old concept so some of its directions don’t apply to today’s mothers, but let me pinpoint some of the guidelines that are followed after the birth in different cultures:

  • In these cultures, the postpartum period is a time when the mother is supposed to recuperate, her activities are limited, and her (female) relatives take care of her. How long after birth this period last varies a little bit from culture to culture but mostly its lasts somewhere between 3-6 weeks, and in Korean culture up to 100 days.
    During those weeks, visitors are prohibited, and new mothers and newborns are not allowed to go out unless it is really necessary. The reason behind it is to avoid contact with a possible source of infection. Mothers are encouraged to abstain from chores, food preparation and cleaning. This time is meant for rest and being with a newborn.
  • As mentioned above, women who practice this tradition are not alone, and that lowers the anxiety and stress of motherhood. In these cultures, friends and relatives provide the family with meals and take care for other children.
  • Cold/hot concept: One common belief is the necessity of maintaining a “hot-cold balance” within the body and with the environment after the birth. Cold and wind are pathogenic factors in Chinese medicine, meaning they can trigger a disease process. In many non-Western cultures, blood is considered “hot.” During the birth women losses blood and it is considered to be in a cold state. Consequently the goal is to keep the mother warm after birth. This is achieved through various ways: food, warm environment, clothes, and baths. In China there is “no shower” rule after this period. This rule made sense in the past because there was an absence of proper shower systems and hair dryers. Back then, new mothers could have easily gotten a cold after a shower. Nowadays this doesn’t apply anymore, but some still follow this rule.
  • Food: Mothers are fed very simple but special foods and a number of herbal drinks to promote healing and recovery, boost their immunity and improve their milk supply. It is advised to eat warm and cooked foods. Cold food in Chinese medicine means that food has a cold (or hot) characteristic and not that is physically cold. For the list of cold foods according to Chinese medicine look here.
  • Pampering during this time is also very important. In India mothers are given massages with warm oils daily.

The most common underlying theme throughout this concept is protecting the mother and newborn from exposure to pathogens and extra stress. This may quicken recovery time, potentially preventing postpartum mental health issues and other health problems, while promoting healthy milk production and a healthy immune system for both the mama and baby. If this concept felt close to you try to apply it as much as possible after your birth. You can also read the article “Where to find extra help in Berlin, Germany” HERE.

EMOTIONAL AND PHYSICAL DIFFICULT PREGNANCY

This is an article for future moms who struggle with their pregnancy. I wanted to open up about a topic that is both close to my heart, and at the same time seems to be a taboo for pregnant women to talk openly about it. Although I don’t know about your experience, but when I was going through mine, many people “allowed” just one experience of pregnancy – the experience of joy. Every time I went off this script, I could see it in their faces – worry. Looking at me with the thought in their mind: “Will you be a loving mother?” or they try to advise me on how to help myself become a happy pregnant lady. No, I wasn’t  imagining my feelings, and my hormones also didn’t trick me to feel something that was not there. Many people start to feel uncomfortable when you describe your pregnancy as unpleasant, having doubts, having no feelings towards your baby, etc.

My pregnancy wasn’t planned, and I was experiencing a state of shock and a lot of deeply negative emotions deeply into 5 months of being pregnant. Some of them could be connected with my really bad physical state until the 19th week, but not all of them. I dealt with life struggles the same as I advised my clients. I talked about how I feel. Consequently, I was getting different responses from people around me, but only a few had a sympathetic ear.

Even if you were planning to have a baby, you still can be shocked when you find out. Being pregnant can be something that is hard to comprehend at times. A lot of pregnancies are unplanned, or women feel society’s pressure to have a baby. However, even if you planned it, you can still experience negative emotions while pregnant. And you have every right to feel this way.

There is a range of feelings that can occur here, and I will write about a few of them: Doubting if you will manage to handle it, doubting if you will love your baby, not wanting to have your baby, not feeling connected, being deeply disappointed about the gender of your baby, feeling sad about becoming a mother, hating your pregnancy, hating body changes, worrying that your life will end, worrying that you will have no freedom, etc. Also, some of your dormant traumatic memories can awake while pregnant or postpartum. It is not uncommon that we remember our childhood trauma while becoming a parent.

All the feelings that you are experiencing while pregnant don’t tell how you will feel as a mother. For example: you can be looking forward to your baby but once it’s born, you can feel resentment or have trouble to connecting with it or . It can happen that you will have intrusive thoughts about you or your baby. What kind of thoughts? Killing you baby, hitting it, throwing it. You can find a little bit more about different pre/postnatal mental states HERE.

The medical environment can brush off these things too easily. In my experience nobody asked me if this pregnancy is planned and how I feel about being pregnant and becoming a mom. Probably they assume that all is well because of my age. Furthermore, so many doctors shared with me that this is really happy occasion. I believe we should be more careful in the medical field about how we approached someone. It is safer to ask a person about their feelings then just assuming happiness.

My belief is that it is important to talk with people who aloud you to feel how you feel and/or to seek safe therapy space were you can discuss your feelings no matter how “negative” they are. I am not here to give you advice or to have therapeutic goal to put you “on the right path” so that you would feel joy about this time of your life. I am here to listen, to hold your emotions and to create a nonjudgmental, safe place for them in case you decide you want to deal with your emotions in psychotherapy.

DESTRUCTIVE RELATIONSHIPS

In my office I meet a lot of wonderful people. They often come to me because they are in a destructive relationship they aren’t able to get out of. Although they know pretty well that the relationship is not good for them. The combination of their nonfunctional behavior with partner’s destructive patterns create toxic codependent relationship.
Codependency doesn’t only happen in a romantic relationship. It can occur in any type of a relationship, including family, work, friendship, community etc. Although in this article I write from women’s perspective men find themselves in this type of relationships as well.

Why are we attracted to the codependent relationships?
Destructive behavior is learned. Typically we find ourselves in dysfunctional relationships because we come from dysfunctional family, where we haven’t recited enough nurturing.
In general people who are raised in a dysfunctional family environment are used to chaos, unpredictability, fear and drama. Being in such a love relationship feels right to them because of familiarity. As adults we are compelled to recreate similar situation throughout our lives, in an unconscious drive to finally change the outcome and brake the pattern.
As a child you were unsuccessfully trying to please your parents in a hope that they will finally give you the love you need. In a codependent relationship you are a slave to the same dynamic. You are willing to wait, hope, plead, change and help just to maybe someday get a love form your unloving, avoidant, addicted, uncaring and inappropriate partner. The more he refuses you the more you want him.
Even though often we see the real problem in our relationships, we still look for excuses and “reasonable” explanations. An often occurrence is blaming his past for all the problems. We are determined to save him from his own demons through our love. Sex is one of the primary ways of trying to bringing him back to health.
We stick to the same partner because we want to prove we are not like “the others” and we would never leave him. We are much more in love with his potential “what it could be” then we are in touch with the real situation.
Also we can be addicted to the emotional pain that is a part of the codependent relationship. Consequently we find a good man who treats us well boring.

Codependent dynamic in relationship
A common theme in these types of relationships is that the beginnings feel like we have known each other for a long time. We fall head over heels in love with each other and everything is starting to happen really fast. “On my first date with him, I felt it in my guts, I met a soul mate. I did everything to stay with him, even loose myself in the end.”

There are different dynamics in relationships that reflect codependency:

  • One of them is passive-controlling behavior were one person is submissive, can’t make decisions and tries to please their partner. Other is controlling, makes all the decisions and tries to change their partner.
  • Some find themselves in a role of a rescuer. That is especially evident in relationships where one of them is addicted because the rescuer makes everything instead of the partner. Partner can remain irresponsible, negligent and addicted. At the same time the rescuer focuses so much on other person and avoids taking responsibility for her own actions. We avoid our own pain, emptiness, fear and anger. We use our relationship as a drug to do that.
  • Another occurrence is that both partners are having people pleasing behavior. It feels like they are glue to one another in a great harmony without any fights in relationship. Both of them can’t really function without the other. There is no place for individuality.

Bringing focus back to yourself

The way of breaking the cycle that started in our childhood is bringing the awareness back to ourselves. It takes a long time before new, healthier ways of living feel right instead of forced. Despite all the chaos in this types of relationship they can be pretty hart to end untill we don’t take time and do some serious work. There are some areas which are often problematic amongst people who find themselves in codependent relationships. Focusing on them play the important role in psychotherapy:

  • Fear of being alone: Our fear of ending up alone is so big that we rather stay in codependent relationship. If the relationship somehow ends we tend to find another partner right away or even before the old relationship ends. The fear of being without a man can be so severe we experience some of the same symptoms as during drug withdrawal. “When the relationship is over I can’t sleep, I start to shake and feel cold. I get depresses and neglect my kids. The fear of these symptoms makes me rather stay in the relationship that I know is not right for me.”
  • Deep feelings of emptiness: We stick to the relationship just to avoid the emptiness we feel deep inside. We believe that when we will be with someone the emptiness will go away and the life will have the meaning again. Sadly most people in codependent relationships feel alone and empty most of the time.
  • Low self-esteem: We don’t see our self as someone worth of love, success and happiness. We believe that we need to earn love. Perfectionism goes often hand in hand with low self-esteem. If everything is perfect, you can’t feel bad about yourself. On the other hand everything that is not perfect brings feelings of guilt and feels like people will stop loving us.
  • Poor boundaries: We don’t develop the feeling for our own as well as for other person’s boundaries. We can’t say no just as well as we have trouble hearing the other person’s boundaries. Setting boundaries would put the relationship at risk or it would mean that it needs to end.
  • Control helps us feel safe and secure due to the little control we’ve had during our childhood. Some mistaken control as being helpful. With controlling others close to us we are not facing our own pain. We can also find ourselves on the opposite side of the spectrum and we are the controlled one. Which can feel safe at first but soon turns to drama. Self-blame also give us feeling of the control. By blaming ourselves we have a hope that we will eventually figure out what we are doing wrong, correct it and stop the pain.
  • Care-taking: We put others ahead of ourselves. This can be the role we have learned while emotionally and/or physically taking care of incompetent parent. We lean towards people pleasing behavior but at the same time can be offended if somebody doesn’t want our help. This is the only way we know how to show love and hope for love in return.
  • Obsessions: The root of obsession in fear. Fear of being alone, unlovable, unworthy, ignored or destroyed. We hope that the man whom we are obsessed with, will take care of our fears. We are occupied with thinking about him or our own mistakes in the relationship.
  • Denial: We are in denial about the problematic relationship and our own responsibility for it. What all unhealthy families have in common is their inability to discuss root problems. Which is reoccurring in romantic relationship.
  • Intimacy: We have trouble being in healthy intimate relationship. We fear true intimacy because we feel that if person would truly know us they would reject us. We take control of that through controlling how close we get to others.

 

TWO LAYERS OF ANXIETY*

*the article is based on my private practice observations

Anxiety is often a reason why people knock on my door. It is also the subject that I am most drawn to. That’s why I would like to write a short article based on my work experiences about dealing with anxiety.

In short, I approached anxiety in two levels:

  1. Dealing with symptoms: In the Internet era, people educate themselves about panic attacks and how to ease symptoms. Consequently this level is the most accessible for self-help. Cognitive-behavioral psychotherapy is mainly focused on this level. Many people come to psychotherapy equipped with the knowledge and exercises how to help themselves with panic attacks. But why do those people still come to therapy? I believe focus in this level is not enough for the long term anxiety relief. In my practice, I focus 80% of my time on second level:
  2. Deeper approach: Psychotherapeutic relationship offers safe, understanding, trusting environment which is especially important for people with anxiety. For them, knowing that they have safe place, whit expert who they can trust, play enormous role. I notice that people with anxiety often keep their fears and worries to them self, they are overly consider with other people’s emotions and are on the mission not to hurt others, their true content is locked inside them which one day explode into panic.
    In time, the therapeutic relationship is safe enough for all the hidden content to come to light, having somebody to talk about it, relieves the burden that is kept inside and coses stress. Often we are so used to carrying a burden that we don’t realize how anxious our mind and body are feeling.

What (not) to expect in therapy

A lot of people believe that there is some kind of recipe for panic attacks solution. And they expect to get it from therapist. There is not just one anxiety, I see different kinds of it, some overwhelming others »just« as symptom form some other mental disorder. Therapy needs to get to its core and there is no recipe for that.

I don’t believe that you can cure anxiety response 100%. Let’s not forget that no matter how unpleasant it is, it is still a normal human response. The only difference it is that by people with anxiety, the centers for danger are triggered where there is no actual life threatening situation. The difference after therapy is that less things are causing us stress. Before it was stressful to go to the grocery store, now it would be stressful when having an accident. That’s a normal body/mind response.

HIGHLY SENSITIVE PERSON (*HSP)

In this article I will summarized the work of Elaine N. Aron, Ph.D. book, The Highly Sensitive Person. In her psychotherapy practice she worked with HSP for decays and come to an interesting conclusions.

In connection to anxiety: HSP often treats his high arousal as anxiety. He got false messages form the environment that unpleasantness he is experiencing (due to high arousal) is actually fear. Consequently when they get aroused (annoyed, tired…) that automatically triggers fear.

Twenty percent of the population is born with HSP, 30% of them are extrovert and it effects women and men equally. The author distinguish between two subtypes:

First one is calm, quiet and satisfied quickly the other is slightly contradictory, for example he is curious but careful, cheeky but scared, he gets bored very quickly but at the same time, he is quickly overstimulated.

Hypersensitive nervous system
HSP have a hypersensitive nervous system. Exposed to the same amount of stimulus, they tend to absorb more and consequently they get aroused faster. Also they process everything very deeply and get easily overwhelmed.

They pick up the stimulus form the environment that many others would normally overlook. Some people call that good intuition. Their delicate sense make them a good writers, historians, philosophers, judges, artists, researchers, theologians, therapist, teachers, conscious parents and citizens.

Main characteristic of HSP Person:

  • Creative (unusual imagination), very empathic people.
  • They tend to have more vivid dreams and nightmares then others. Even if they didn’t have any traumatic experience it is not unusual for them to fear the dark. No wonder many of them have trouble sleeping.
  • They feel hunger very strongly.
  • They have hart time making decisions, especially because they are being more aware of consequences, wanting to make right by everyone and paying great attention to details.
  • If they had many negative experiences in life, they are more prone to anxiety or depression. HSP children can get criticized for their sensitivity, often the environment doesn’t know how to react to it. That’s why many of them feel like there is something wrong with them. In the environment that is in tune in with their sensitivity, they flourish to a confident person, viewing their sensitivity as a gift.
  • They react to criticism more intense than others which can result in avoiding criticism all together, by trying to please other people and putting others first.
  • They have lower pain tolerance. They feel changes in their body more profoundly, that’s why they are having trouble to brush the painful sensation off their mind.
  • They tend to be more sensitive to violence in the movies and real life. Due to their great imagination, they can vividly imagine what it would be like. The images can linger with them for weeks or even years.

Are you a HSP? Find out in these questioner: http://hsperson.com/