Issue 2: Acceptance – A Foundation of Coping

 
We all experience circumstances, thoughts and feelings that are uncomfortable and unwanted. For many the natural tendency is to either avoid them or to deny them. These strategies only serve to delay dealing with the unwanted conditions, which usually results in them getting worse. This often causes symptoms, most notably anxiety. Obsessive Compulsive Disorder, Panic Disorder, Phobia and even PTSD all have foundation in circumstances that are not being addressed. This blog will present an alternative coping strategy that is based on learning how to accept unwanted circumstances, so that they can be addressed most effectively.
            Avoidance and denial of circumstances, thoughts and feelings can take many different forms. Physical avoidance of circumstances that cause fear is called Phobia. Sometimes individuals avoid circumstances, thoughts or feelings by ignoring them. Some mask them with alcohol or other substances. Denial can take a direct form where a circumstance, thought or feeling is simply denied. Anxiety and other forms of discomfort come from lying to oneself. This is because lying to oneself undermines the ability to trust oneself resulting in self-doubt and feelings of vulnerability. Sometimes it is the significance of an event that is denied rather than the event itself. In such a case justifications might be offered such as “I didn’t really mean it”, “I was only joking”, “I had too much to drink”, “it only happened once”, etc. Avoidance and denial do not address the source of the discomfort. They are a form of procrastination, not effective problem solving or coping strategies.
       Some treatments focus on eliminating anxiety and other symptoms. This might include medications for subjective anxiety, insomnia, headache, etc. which are reactions to unwanted events in the patient’s life. These medications may relieve these symptoms, but they will not address the underlying causes. Similarly, some forms of psychotherapy endorse diversions, such as physical exercise, meditation, yoga, etc. to cope with anxiety or other symptoms. Some therapies focus on changing thought patterns to reduce unpleasant feelings. Once again, temporary symptom relief can be achieved this way but the discomfort quickly returns because the source of the discomfort has not been addressed. The following approach is not an approach to palliative relief of personal discomfort. Rather it is a strategy that involves directly addressing unwanted situations tactically.
 
Consider the following example that is a composite of my work with many individuals over the years.
 
Mr. X. is a management level employee of a large financial firm. He manages a lot of money and a lot of people and he makes a lot of money. He also spends a lot of money living an extravagant lifestyle. The first couple of weak earnings reports he ignored. Some variation in his industry is to be expected. He started to have difficulty falling asleep because he was worried about his business. He also began drinking more alcohol because it “helps me relax”. He visited with his family doctor, who prescribed medications for sleep and anxiety. He began massage therapy, which was also helpful in reducing muscle tension. Due to some irritability that Mr. X. expressed towards his family during this time, he was asked to go to “anger management”. There he learned how to suppress angry outbursts through mindfulness and self-control. This was successful in reducing the frequency of his angry outbursts.
            These interventions had no tangible effect on the cause of the problem: his work situation was changing. His increasing awareness that something unusual was occurring was increasing his stress and anxiety, which he was attempting to manage with the above palliative treatments. Once he accepted that things were changing for the worse at work, this empowered him to take actions to cope with the changing work situation. For example, he used flexibility, the coping strategy introduced in the previous blog, to change the way he approached his work. Accepting that there was a shift from cooperation to competition among his coworkers changed his focus from team success to individual success. He also became more defensive as he recognized that his superiors were becoming more critical. He also began to consider back-up options if the quality of his work experience continued to deteriorate.
 
Mr. Xs failure to accept the changes at work while pursuing palliative treatments for his discomfort prevented him from addressing what was happening at work. The necessary adjustments could only be made once he accepted that his work situation was changing and that he needed to adapt. The discomfort he was feeling is meant to compel him to address a situation that requires his attention. Suppressing these feelings prevented him from making the necessary changes at work. Another example where the failure to accept circumstances as they are prevents adaptation is described below.
 
Ms. Y is a single mother who lives with her 10 year old daughter and works full time. Each morning the mother tried to get her daughter off to school on time so that she could get to work on time. This was rarely the way it actually happened. Most mornings the mother and child would end up arguing about being late and their relationship deteriorated over time. Both the mother and the child suffered symptoms of stress. The child’s grades began slipping and she reported an increase in physical symptoms, such as stomachache and headache that made it harder for her to be in school on time, or some days to go at all,. The mother started to have difficulty sleeping as she often worried about the argument coming in the morning and then her having to get to work late. She often skipped breakfast which combined with the loss of sleep compromised her performance at work. The mother was offered sleep medication, but was reluctant to take it for fear that she would not be able to get up in the morning.
            In order to improve this situation, the mother and the child had to accept that the situation they had set up for school mornings was not working and had to be changed. Once again, the acceptance that situation is not working stops the frustrating behavior of trying the same routine each morning and failing, and creates the opportunity for the use of flexibility to change the routine to one that might work. For example, the mother might change her hours at work slightly so that she is not late. Another option might be for mother and child to go to bed earlier and begin their routine earlier, etc.
            In this issue of Coping Strategies That Really Work, I described the use of the coping mechanism, acceptance. The key role of acceptance as a first step in coping was illustrated in two different environments. In those examples, acceptance of the situation facilitated the use of flexibility, which was introduced in the first issue. In the next issue, I will introduce another coping strategy, utilization of resources and show how both flexibility and acceptance work cooperatively to support effective coping strategies that target improved outcomes in situations that cause discomfort and dysfunction.
 

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Issue 1: Coping with Frustration
 
This is the first of a series of blogs, each one describing a different coping strategy and its application to real life situations. In order to be most effective, coping mechanisms, or strategies, must be specific enough to improve the outcomes of challenging situations, while at the same time being broad enough to be useful in new situations that present themselves throughout your lifetime. This series of blogs will examine numerous coping strategies that have shown to be effective in very specific situations while at the same time being durable enough to be applied in very different settings and circumstances. Readers are encouraged to add coping mechanisms in the comment section of this blog that they have found to be most helpful.
Utilizing coping strategies effectively requires that you first define what it is that you are coping with. Many of my colleagues refer to coping mechanisms that help individuals cope with their emotions. For example, a vigorous workout, or listening to music or meditation may be suggested as a way to cope with anger or anxiety. These are healthy activities that help to temporarily relieve the discomfort of anxiety or agitation, but do not help with the underlying causes of the emotions. Tranquilizing medications may also be prescribed to help individuals cope with anxiety. When you stop engaging in these activities or taking antidepressant medication the underlying causes quickly restore the emotion. The coping strategies presented in this series of blogs are designed to help cope with the underlying circumstances that are causing emotions of different types. These coping strategies target solutions to the cause of difficulties or discomfort rather than relief of emotions, which is generally temporary.
            This approach to emotions does not treat emotions as symptoms which should be eliminated. In this approach we treat emotions as important signals and we seek to understand what they are signaling. Each emotion conveys information that is associated with survival and adaptation that is unhealthy to ignore. In this blog we will focus on frustration. We will discuss the causes of frustration and the best adapted coping strategy, which will be illustrated in three case examples.
 
FRUSTRATION
 
Individuals experience frustration when they feel blocked in pursuing a goal. The intensity of the feeling is associated with many factors including: the importance of the goal, the magnitude of the obstruction and the amount of time the individual spends in the frustrated state. Each individual has a frustration tolerance. This is the measure of the amount of frustration a person can tolerate without compromising function or sense of wellness. Additional frustration beyond this point, either in intensity or number of sources, is generally first experienced as irritability and short temper. Compromise of function comes as the irritability causes impatience associated with difficulty sustaining attention and sometimes impulsivity. Under conditions of intense frustration destructive behaviors are often reported. In very extreme situations, the destructive behaviors may target animals, such as pets, or even other individuals. The dreaded Shaken Baby Syndrome is most often caused by parents shaking an infant out of frustration.
            The irritability and destructiveness that is often associated with frustration causes it to be confused with anger. For many people, it is subjectively undistinguishable and people are often referred to Anger Management Programs, when they actually are frustrated. Interestingly enough, many of the techniques offered in these programs help with frustration. But anger is not the result of being frustrated in the pursuit of a goal. Anger is caused by pain. We get angry at others who have caused us pain, who are causing us pain, or who we think might cause us pain. Coping with anger requires getting rid of the pain. This will be discussed later in the series.
            One of the most powerful coping strategies for situations that cause you to approach or exceed your tolerance for frustration is called flexibility. Utilization of this coping strategy allows you to adjust the way you approach your goal when the primary method is unsuccessful. It also allows you to adjust your goal when you determine that the goal you initially selected is unattainable.
 
FLEXIBILITY
 
Below are three case examples that demonstrate use of flexibility as a strategy to cope with frustration. These examples are composites of my years of clinical experience that were created to illustrate the applied use of coping strategies.
 
Case 1
 
A professional middle aged man came in seeking “Anger Management”. Although generally a mild mannered man who was well liked by family and peers, he suffered periods of impulsive behaviors around others involving very aggressive verbal battering and occasionally destruction of objects, such as punching holes in the wall. He felt that his behavior had gotten out of hand when he was removed from the counter of an airline for verbally harassing the staff. He described it as follows.
 
“I had to travel down south for business, which I hate to do. I tried to satisfy this customer over the phone, but they insisted that I come down in person or I would lose their business. I spent three days in negotiations and all I wanted to do was to go home, have a nice dinner and read my book. When I got to the airport, don’t you know, it was shut down due to the weather. A three hour delay. That’s when I lost it. I felt like I was going to explode. I went to the airline counter and started yelling uncontrollably that I paid for my ticket and am entitled to get home on time. I was so embarrassed when security showed up but I couldn’t calm down”.
 
We determined that his frustration in the above example was being caused by his not being able to attain his goal of getting home, having a nice meal and reading his book, all on his schedule. He was able to see that the existing strategy was having a negative effect – moving him away from his goal. Using flexibility he was able to see that with some minor changes in methods and goals, he could attain a significant portion of his goal. We found that he could have a nice meal and read his book in or near the airport and then rest on the ride home so that he would get home refreshed instead of exhausted. Learning to see situations that are not going his way as potentially malleable with regard to both method and goal, helped him with other frustrating situations in his life.
 
Case 2
 
A mother argued with her child every morning because he resisted getting up and going to school. The arguments were on occasion so severe that the frustration caused both of them to engage in destructive behaviors. The child eventually became assaultive towards the mother. The mother was looking to cope with the child’s behavior.
 
“The child is ruining my life. I can’t believe that I am thinking this but I don’t think that I can do this anymore. I have run out of ideas and energy, I cannot get him to school on time anymore”.
 
The mother initially stated that her goal was to get the child to school in the morning on time “no matter what it takes”. Based on the mother’s observations we agreed that the child was not well and so we decided to adjust the goal to be the child’s wellness. Rather than forcing the child to go to school and stay in school against the child’s persistent resistance, we agreed to instead find out what is wrong with the child. This ultimately revealed some metabolic problems that were successfully treated, resulting in the child’s being able to get up in the morning and be productive. Conflict between mother and child decreased as the mother was able to incorporate more flexible strategies into her parenting.
 
Case 3
 
An obese middle aged man lost his job in the financial sector due to a code violation. He unsuccessfully fought against litigation against his license and had become immobilized upon the realization that he would never be able to work in the financial industry again. He acknowledged thoughts of suicide. He expressed the following.
 
“I’m done now. There is nothing I can do. I have a family to support and I cannot get a job because I lost my license. I am a total failure. Oh sure I can get a job flipping hamburgers, but my income will plunge. We will lose our house and the children will have to leave school. It’s all over”.
 
The man initially stated that his goal was to get a job that would support his family as close as possible to the way they were accustomed. He had determined that this goal was impossible. Before abandoning the goal of supporting his family well, I encouraged him to examine his methods. He believed that the only way he could support his family at an acceptable level was to work in the financial field, which he was now prohibited from doing. The only alternative he considered was unskilled, minimum wage labor. I encouraged more flexibility in his exploration of his skills, qualities and experience that might be of value in the workforce. Within a year he was successful in replacing his previous income utilizing his skills in a different industry that did not require licensure. He was later able to use a more flexible approach to coping to change his eating and exercise habits resulting in improved health and loss of 100 pounds.
 
 
This blog demonstrates the
 use of flexibility as a strategy for coping with situations that cause significant frustration. Flexibility was applied successfully both to ways in which goals are approached and also to reconceptualizing the goals themselves. We also discussed the need to discern frustration from anger, as the two emotions benefit from different coping strategies. The next blog in this series will discuss coping strategies for anger.

​Healthy relationships are based on behavioral boundaries that are understood and respected by both parties. Individuals who suffer from BPD are offended by your efforts to set boundaries with them. Their resistance to this process is a major factor in causing their relationships to be unstable and unsatisfactory to them. Understanding why this is the case requires an understanding of how having BPD inhibits the ability to understand boundaries and to use them to strengthen relationships.
 
Boundaries are expressions of what we need to feel safe and comfortable in relationships. This may include how you feel about being touched by another person, what you like to be called (e.g. Robert, Rob, Bob or Bobby, etc.). Safety and comfort are necessary for intimacy. The wish to be intimate is a motivation for respecting boundaries.
 
Healthy individuals understand that setting boundaries is a process of relationship building and they appreciate the opportunity to make you feel comfortable. They do not mind, not smoking in your house or not calling the home phone after 10 PM on weeknights. They feel privileged when you say “My friends call me Bobby” and are happy to comply with these boundaries.
 
Sufferers of BPD see your setting boundaries with them as a form of rejection. It makes them feel bad about themselves; less than. They believe that if you love them you will tolerate any and all behavior on their part to prove it. BPD causes sufferers to need constant reassurance from others that they are loved. This need causes them to test others in various ways to get them to prove their love and commitment. One core testing behavior is the challenging of personal boundaries. Seeing if you will speak to them at 2 AM because that is when they want to talk, even though you asked them not to call that late because you get up early for work in the morning, is such a test. The first part of the test is whether or not you pick up the phone. If you pass the first part, then the second part is whether or not you are angry. If you fail the first part you will be punished the next time you do speak. You will be accused of not being available in an emergency and of not caring. If you do pick up the phone and you are angry, you will be accused of being unloving and unsympathetic. The only way to pass the test is to allow them to violate your boundary and be nice about it!! Once you do this, the boundary will be retested. It will be assumed that since you relaxed the boundary once that you will relax the boundary whenever they wish to talk. They will then assume that you will relax other boundaries as well, leaving you feeling like you have no ability to set any boundaries at all.
 
Setting boundaries with individuals who suffer from BPD requires your understanding that boundaries will be tested and preparing for this to occur. Setting boundaries successfully with sufferers of BPD will require the following elements:
 

• The boundary must be clear. Individuals with BPD must be told that calls are not taken after 10 PM on weeknights. It is not sufficient to ask them not to call “too late”. They will argue that 2 AM is not too late for them.
• The boundary must be consistent. Since the boundary will be tested, it must be made clear that there are no exceptions. If asked about an emergency, you tell them to call 911 in emergency. That is what you would do anyway. Other matters can wait until morning.
• The boundary must be presented without anger. If you express anger towards them it will allow them to feel victimized and they will use it to justify both their breach of boundary and their reacting by punishing you.

 
The following dialogue will illustrate how to set a boundary around calling your home too late. The friend with BPD was asked not to call after 10 PM on weekdays but did so anyway to “test” your love and commitment.
 
Friend: “Why were you so nasty with me on the phone last night?”
You:    “I asked you not to call after 10 PM on a weeknight.”
Friend: “It was only 11:30.”
You:    “I just need to get some sleep before I go to work in the morning.”
Friend: “Oh, I am sorry I interrupted your precious sleep. I won’t call again without an appointment.”
You:    “That is not what I said. I am simply asking for some consideration.”
Friend: “Don’t worry, I won’t be calling you anymore. You can sleep as much as you like and call me if you want to speak to me.”
 
At this point the topic should be ended. The point should not be argued, because this suggests that the point may be negotiated. Boundaries must be consistent and therefore cannot be negotiated. You can try to change the topic and continue the conversation, but if the friend continues to try to punish you then you must end the call and try again at some other time to have a conversation with this person. If the friend subsequently calls during daytime hours you should pick up the phone and be pleasant. If they call late again you should not pick up the phone. Eventually, the friend will understand that they must respect your boundary if they want to have a relationship with you. Healthy individuals accept boundaries respectfully. Individuals with BPD must be forced to respect boundaries.

This is the launch of the Borderline Blog. This blog is dedicated to those who suffer from Borderline Personality Disorder and their families. Feel free to post your thoughts, feelings and questions in an open forum.

​If you have a child struggling with Borderline Personality Disorder (BPD) then you have probably had the experience of being told that you are hurting your child as you try to help them. A typical exchange might sound something like this:
 
Parent:             Would you like me to help you pick out your clothes for your wedding?
Child:              Why, you think I can’t dress myself?
Parent:             I just thought it would be a nice activity for you and me.
Child:              So you pick an activity that makes me feel incompetent. A great parent you are.
Parent:             I am just trying to be involved as a parent.
Child:              Just like my therapist said, you refuse to see me as an adult. You want to keep me a child forever.
 
For many parents of children with BPD this has left them unsure about how to respond to their child in almost all situations. Many experience a total lack of confidence in their parenting ability. This is not due to bad parenting on your part – this is due to a symptom of the disorder that requires specialized parenting techniques. Understanding this symptom and the techniques will make you a more confident and effective parent of your child with BPD.
 
Sufferers of BPD struggle with an underlying sense of self-loathing that they project onto those that they are close to. This causes them to feel that others are overly critical and disapproving of them. They listen for slights and put downs from you, often resulting in the self-fulfilling prophesy that you are demeaning them, although you have no such intent. In the example above the child may have convinced the therapist that the parents are demeaning and inhibitive of the child’s emotional growth.
 
This contrasts with the behavior of the typical sufferer of BPD who is demanding of others and frequently asks for favors or insinuates entitlements, such as for money, rides, child care, etc. Reconciling their demandingness of others while at the same time being disposed to seeing themselves as a victim requires an understanding of a form of codependency that occurs frequently in those who suffer from BPD. This type of codependency involves resistance to independence rather than embracing it. They see you doing things for them as affirmation of their worth. They see helping them as demeaning because it implies that they are flawed. An exception is areas that the child has no exposure to and hence does feel the need to defend their competence.
Your understanding of perceived victimization and codependency in sufferers of BPD will enable you to parent more confidently and effectively utilizing specialized techniques. In trying to help your child with BPD effectively you first need to determine if the help you are giving is helping the child become more functional and independent or whether you are enabling your child to avoid pursuing independence. This will allow for Selectively Supportive Parenting. This involves offering help only if it supports independence. Examples include facilitating education, skill acquisition, pursuit of health services, including mental health services, etc. Because your child has a condition that inhibits independence and encourages codependency you should never offer to help your child with anything that they might be able to do on their own. If you decide to offer help in a situation that does not inhibit independence, such as helping with a basic manual task, you would be best to phrase the offer as “may I help you___?”. This will minimize, but not eliminate, the chances that it will be perceived as a slight.
 
Parents of children suffering with BPD often find that conventional supportive parenting: offering support without scrutiny for codependency, is often ineffective or counterproductive due to the child’s resistance to independence. Parenting techniques are most effective if crafted specifically for use in families affected by BPD. Selectively Supportive Parenting is one such techniques. In addition, the following considerations will also be helpful in guiding parenting of a child with BPD.
 

• Do not offer to help the child with anything the child attempts independently.
• Avoid offers of help that can be interpreted as a challenge to competence.
• If your child has a therapist consider having direct contact with the therapist in order to insure that the therapist has a balanced view of the child’s functioning.

 
Introduction of these techniques into parenting style will be most effective if applied consistently and transparently. Reasoning should be clearly explained as to how resources offered are to be used and as to why resources are being denied when necessary.