How to Diagnose Trauma and Stress Disorders in Kids

Written by Rob Lusk

You just started seeing a young client who has clearly been affected by trauma. You need to diagnose them, but where do you start? Is it PTSD? An Attachment Disorder? Is there a diagnosis that can capture all of their problems?  

That’s where the new DSM5® updates come in. Here are some tips that will help you wade through the new trauma diagnoses in the DSM-5® and help ensure you’re choosing the right diagnoses for your child and adolescent clients.

You’re probably aware that the DSM-5® created a new section focused on Trauma and Stressor-Related Disorders with our youth patients. There are essentially seven disorders in this new section: 

  • Reactive Attachment Disorder
  • Disinhibited Social Engagement Disorder
  • Posttraumatic Stress Disorder (PTSD; separate criteria are included for PTSD for children 6 years & younger)
  • Acute Stress Disorder
  • Adjustment Disorders
  • Other Specified Trauma/Stressor-Related Disorders
  • Unspecified Trauma/Stressor-Related Disorders 

Here’s a brief overview of this section, along with some tips on using these diagnoses with your child and adolescent clients.


Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) 

These both used to be subtypes of RAD. The former RAD, Inhibited Type has been expanded a bit and is now “just plain” RAD.

DSED is now used to diagnose youth who were formerly diagnosed with RAD, Disinhibited Type. 

Both disorders have the same criterion that the youth must have experienced “extremes of insufficient care” in early childhood that is presumed to be responsible for their relationship problems. 

In RAD, the youth tends to withdraw from caregivers, has limited social/emotional responsiveness in general, and has periods of irritability, fearfulness, or sadness. In general, these kids don’t get close to others – especially caregivers.

In contrast, in DSED (like the old RAD, Disinhibited Type) the youth has diffuse boundaries. They seem at ease with approaching and interacting with strangers, often violate others’ personal space, and don’t tend to seek security from their caregivers - who often feel like their relationship with the youth is superficial. In general, these kids seem to want closeness to as many people as possible, but often aren’t seen as having “genuinely close” relationships with others (again, especially caregivers).

These updates in the diagnoses are helpful in several ways. First, the criteria have been expanded and clarified, so it’s easier to figure out whether a child actually fits each diagnosis. Second, dividing these disorders is consistent with growing research literature that suggests that children with Disinhibited Social Engagement Disorder may be much more difficult to treat and may take somewhat different approaches, so they are probably distinct enough that it makes sense to separate them.

 

Posttraumatic Stress Disorder 

PTSD is still pretty similar to the “old” version, although in my opinion, the criteria fit youth better than they used to – and again, there are now separate criteria for children aged six and younger. 

The first three “core” criteria are:

1. Exposure to a traumatic event
2. Having intrusive/re-experiencing symptoms (like nightmares and flashbacks)
3. Avoidance of trauma reminders. Unfortunately, this often means they will want to avoid therapy with you – and kids are tough enough to engage without a symptom that makes it even harder. 

The DSM-5® added a new criterion (Criterion D) - altered thoughts and mood. 

This is helpful from a diagnostic perspective, since the criteria are spelled out more clearly and distinctively, making it easier to apply than the older version. However, this unfortunately means some of the most commonly used diagnostic assessments - e.g., the UCLA PTSD Index - no longer match up to the diagnostic criteria.

Finally, there are two additional criteria that carried over from the old diagnosis: alterations in arousal/reactivity and a one-month duration.

Another helpful addition is the specifier “with dissociative symptoms.” These are very common in traumatized youth, although the specifiers included – depersonalization and derealization – tend to be reported much more by older adolescents and adults in my experience.

While similar to the older version of PTSD, the new version is more helpful because it spells out the symptoms in better detail, adds the ability to include the “with dissociative symptoms” specifier, and the expanded criteria fit youth somewhat better than they used to.

 

PTSD 6 and Under

The PTSD criteria for ages six and under are much more developmentally appropriate for young children than the standard version’s criteria. 

The main criteria are exposure to a trauma, which can include learning a caregiver was traumatized - intrusive symptoms, avoidance/negative cognitions - combined for young children - arousal/reactivity, distress/impairment, and duration of more than one month (the same specifiers are allowed as in the “older” version of PTSD (e.g., with dissociative symptoms). 

The new criteria is easier to “fit” traumatized young children in this diagnosis, but it also means that two young children with a PTSD diagnosis can have very different specific symptoms. Overall, I think it’s an important addition because it recognizes that trauma symptoms show themselves differently in young children, and the flexible criteria make it much easier to fully apply a PTSD diagnosis to them.

 

Acute Stress Disorder

Acute Stress Disorder hasn’t changed much. It’s characterized by the development of severe anxiety, dissociative, and other symptoms that occurs within one month after exposure to an extreme traumatic stressor.

It’s essentially the short-term version of PTSD, but it’s diagnosed from three days to one month after the traumatic event. The main reason the disorder isn’t diagnosed before three days is that many people - including youth - have PTSD-like symptoms for up to two days after a trauma, but in most people the symptoms fade after a day or two.

While the new update isn’t much of an improvement over the old version, it still fits the immediate/short-term aftermath of youth pretty well.

 

Adjustment Disorders

The diagnosis of Adjustment Disorders in the DSM-5® is very similar to the older version of the disorder, and typically doesn’t create issues for clinicians who are used to the “old” version.

Adjustment Disorders refer to when a youth develops clinically significant emotional or behavioral symptoms after experiencing identifiable stressor(s) that happened in the last three months. Functionally, the youth must either have distress that is clearly out of proportion to the stressor (this is often a judgment call) or significantly impaired functioning. Normal grief (bereavement) isn’t considered an Adjustment Disorder, and the symptoms can’t last more than six months after the stressor or its consequences have ended (so it’s time-limited in a sense).

The same “specifiers” are present in the newer version; the youth can show depressed mood, anxiety, mixed emotional symptoms, behavior (“conduct”) problems, or a mixed disturbance of both emotions and behavior.

Again, the criteria haven’t changed much from the older version, but this diagnosis is still useful for kids who haven’t had the “extreme” traumas usually needed for a PTSD or similar diagnosis, but are clearly reacting to a stressful event in their life.

 

Other Specified Trauma- and Stress-Related Disorder

This diagnosis is used when a client has trauma-related symptoms that cause significant distress or impaired functioning, but don’t meet the criteria for another listed disorder. 

I want to emphasize that this is a perfectly legitimate diagnosis, and should not be confused with terms like “not otherwise specified” or “provisional”. According to National Child Traumatic Stress Network data on youth in treatment for trauma, it appears that only around 25% of youth who receive trauma-focused treatment in the U.S. have ever met criteria for PTSD. 

Many trauma professionals believe that PTSD – and other specific trauma diagnoses, for that matter – usually don’t fit youth that well – especially those with chronic or complex trauma. 

Other Specified Trauma-Related Disorder is a valid way of dealing with this issue. It allows you to give a diagnosis for your trauma victims who simply don’t meet criteria for another disorder, but are clearly dealing with trauma-related problems. 

For communication purposes, I recommend noting what the problems are in parentheses after the diagnosis. In my experience, as long as you have the right code and name first, this doesn’t cause any issues with billing Medicaid or insurance companies.

For example, a youth at my agency is diagnosed with Other Specified Trauma- and Stressor-Related Disorder (Features of PTSD and Disinhibited Social Engagement Disorder).

As I’ve noted, this new diagnosis is extremely helpful; it allows you to make a “legitimate” diagnosis of a problem that’s clearly trauma-related, but simply doesn’t meet PTSD or other more specific criteria.

 

Unspecified Trauma/Stressor-Related Disorder

This option is used when you don’t have enough information to make a more specific diagnosis (e.g., in an emergency room). This should be specified further by the clinician in charge of the case as soon as possible.


When I learned that the new edition of the DSM® was going to have a section devoted to Trauma- and Stressor-Related Disorders, I was both hopeful and worried about what this new section would bring.

While there are still plenty of issues being debated about this section, in my experience (as well as that of the therapists I supervise and work with) it’s a significant improvement over the older versions. The addition of the “Other Specified” diagnosis in particular has made the practice of diagnosing youth easier – and arguably more valid – than it used to be.

The biggest concern about the current section among trauma professionals is probably that “Developmental Trauma Disorder” was not included. This term is probably the most common unofficial language used to describe the host of symptoms often seen in complex or chronic trauma victims. As a result, kids with complex trauma histories will often still meet criteria for multiple disorders in other areas (e.g., ADHD, Depressive Disorders, and Anxiety Disorders), even when these issues seem clearly trauma-related. Hopefully the next edition of the DSM® will address this.


Interested in learning more from Rob Lusk? See more of his courses here.

3 Tips to Help Your Patients Address Their Addiction

Do you treat patient with addiction issues? Many patients have a problem addressing their addiction, and treating them can often lead to confrontation or disconnect with the patient.

The question is, how do you help them without blatantly convincing them of something or forcing them?

The way you approach patients can define what type of therapist you will be, and how your patient responds to your course of treatment. Regardless if you have been practicing for 1 year or 30, hostile confrontations yield poor long-term results. Try these 3 ways to help your patients address their addiction when approaching the situation differently.

 

Help Your Patient Discuss

Usually, it’s hard for your patient to directly address their own addiction, so why not try to coax them to speak about problems associated with their drug or alcohol use? Using an approach such as this one can help your patients point out not only their own issues, but problems they’ve seen with it as well, inadvertently bringing up points for discussion.

You might try asking them how they feel about each of the issues they brought up or if they can relate. Developing discrepancy can also help distinguish their own behaviors to see if they’re similar or dissimilar from something they pointed out. This discrepancy can allow you to choose two statements or facts and point out the lack of similarity between them, thus focusing their attention on their own thoughts versus their actions.

 

Stay Neutral

The key thing to remember is not to try and convince the person in a way that interjects your opinion, pushes them beyond what they can handle, or argues. Don’t try to convince the person he or she is an alcoholic, and don’t argue either. Roll with the resistance and let them decide in their own time.

 

Emphasize Personal Responsibility

Personal responsibility is extremely important in the addiction healing process, but doing so in a subtle way may yield better results. Patients may react bad regarding this particular issue, but in time this aspect becomes clear. Try to emphasize personal responsibility in the issue, without contradicting what was mentioned above.


This article was created based on content from the course Depressed, Borderline, or Bipolar? Accurate Diagnosis and Best Treatments taught by Jay Carter.

If you’re interested in learning more and getting your continuing education credits, click here

5 Sex/Relationship Myths Therapists Should Stop Believing

 

First posted on PsychologyToday written by David Ley

 

You may find this hard to believe, but most therapists, psychologists and doctors have received no training in sexuality.

A minority of mental health, social work or medical training programs offer graduate-level training in sexuality issues, beyond covering the paraphilias and sexual disorders included in DSM-5. Some programs address sexual diversity issues, but not all. Few, if any, states require specific training in sexuality issues in order to qualify for licensure. Only a very few states (California and Florida when I last looked) require a license or documented training in order to call oneself a sex therapist.

Why and how this came to be is a long, socially-driven tale, and I’m not sure anyone has ever really documented the story. But, what this lack of training means, is that therapists are subject to the same sexual biases, misconceptions, and myths, which permeate general society. Most therapists learn about sexual issues from the general media – NOT from professional journals or research.  As a result, many therapists hold some dangerous myths and misconceptions, and use these mistaken beliefs in their practice.

Here are five of the most common ones, which I’ve encountered as I supervise, correspond with and train therapists around the world.

 

Kink is Rare and Unhealthy

Since the ideas of fetishes/paraphilias were first introduced in the late 1800’s, therapists have believed that sexually unusual behaviors and desires were just that: unusual, rare, and usually abnormal. But, the DSM-5 makes the distinction between paraphilic interests, and paraphilia disorders, now acknowledging that people can have unusual sexual interests, with no distress or dysfunction. In Scandinavia, they abolished the paraphilia diagnoses several years ago, with no regrets or reconsiderations in the time since. Recent research in Canada suggests that nearly half the population endorses interest in “unusual” sexual practices. Which begs the question if anyone really knows what “usual” or “normal” actually is. Numerous recent studies of people involved in BDSM show that they are often more emotionally healthy than the average person. And, the Fifty Shades of Grey Effect has shown that many, many "normal" people are interested in exploring their sexual boundaries.

 

Open or Non-Monogamous Relationships Don’t Work Long-Term

Therapists tend to be remarkably biased and judgmental about relationships that explore negotiated alternatives to infidelity. In a recent NY Times article, noted anthropologist Helen Fisher proclaimed that humans aren’t wired for nonmonogamy, and are fooling themselves if they pursue it. But, increasing numbers of relationships are negotiating these boundaries, and many researchers and therapists like myself are writing about the many kinky, polyamorous, swinger and gay male couples that we’ve seen establish and maintain very healthy relationships for decades. Several studies of nonmonogamous couples show that they tend to be more egalitarian, more open to sexual diversity, and more likely to practice safe sex. Given the incredibly high rates of infidelity and divorce in allegedly monogamous relationships, it leads one to wonder what exactly, therapists are thinking of when they say that monogamy works and nonmonogamy does not.

 

Porn Causes Divorce

I can’t turn around without hearing the statistic that porn use is involved in 50% of divorces. I’ve heard this from countless therapists, who write to tell me how wrong I am to suggest that porn use can be healthy. The origin of this seems to lie with two groups.

First, the Family Research Council has asserted that they conducted research, and found that porn was involved in over 50% of divorces, but the Family Research Council is a group founded by James Dobson, which promotes “traditional family values” and lobbies against divorce, pornography, abortion, gay rights, gay adoption and gay marriage. The FRC’s study of pornography and divorce was not published in a research journal, nor subjected to peer review.

The second origin of this mysterious statistic about divorce and porn is from The American Academy of Matrimonial Lawyers. In 2003, at one of their conferences, the Academy reportedly did a survey of 350 of their attorneys. About half of these attorneys reported that they had seen online porn play a part in divorces. Because the methodology is unclear, we don't know if they said they'd seen it in half of divorces, or if half of the attorneys had EVER seen it at least once. But again, this survey has never been published, and these data and methods never analyzed. I think it likely that therapists do see porn use in men  involved in divorce – because men increase their porn use when they are lonely, depressed, and when they are not having enjoyable sex in their relationships. But therapists are mistaking a symptom, an effect, for a cause, when they blame porn for divorces.

 

Trauma Causes Unwanted Same Sex Attractions 

Many therapists, especially within the sex addiction field, argue that childhood sexual trauma can lead males to engage in homosexual behaviors that are inconsistent with the man’s sexual orientation. This belief ignores a few important points:

·         First, gay and bi males are at higher risk of experiencing sexual abuse, not because abuse made them gay, but because gay/bi youth are often isolated and vulnerable.

·         Secondly, Occam’s Razor suggests that these men experiencing “unwanted same sex attractions” are actually not as heterosexual as they may want to be, reflecting the moralistic and homophobic attitudes of the families/religions they were raised in. Blaming abuse for the sexual desires is a distraction. 

·         Thirdly, the idea of “unwanted same sex attraction” ignores the important theory of sexual fluidity, which is now helping us to recognize that sexual orientation is not the rigid concept that therapists once believed.

·         Finally, I always like to ask therapists who believe this concept of “trauma-induced same sex attraction” if they believe that a woman sexually abusing a homosexual male could lead that male to experience “unwanted heterosexual attractions”? If a therapist doesn’t believe that this mythical effect could go both ways, then they are really just voicing stigma against male homosexuality.

A therapist helping these men to suppress their same sex attractions is dangerously close to conversion treatment, and further, is unlikely to be effective or therapeutic.

Patients experiencing distress at such desires deserve education, support and affirmative treatment to help them understand and normalize their desires – treating sexual attractions as symptoms of trauma is inherently labeling them as abnormal and unhealthy, directly contrary to best practices and ethical standards.

 

Casual Sex is Unhealthy

Many therapists believe that casual sex, sex outside an emotionally-committed relationship, is inherently unhealthy. It’s not hard to understand why therapists think this: our society promotes the idea that casual sex is less meaningful, and is cheap, compared to the ideal, of emotionally-committed bonding sex. Further, the research on casual sex is nuanced, and a bit difficult to parse out. Some research has shown that many women experience depression after casual sex, and are less likely to have orgasms.

Further research on casual sex suggests that it is people’s attitudes towards the activity which predict their experiences. If you think casual sex is cheap and unhealthy, you’ll probably feel bad afterwards, if you have sex with someone you’re not in a relationship with. But, it’s likely that it’s the people who feel bad after casual sex who are telling their therapists about it, not the people who enjoy it and feel fine about it. So, it’s easy to understand how therapists could end up thinking that casual sex is unhealthy for everyone, in spite of what research is now revealing.


Therapists who believe these myths aren’t being intentionally biased. As said, they’ve rarely had training on dealing with these sexual issues. They are inundated with the panicked, sex-negative information that abounds in general media. They see a limited sample of people struggling with these issues, and don't understand how sample bias affects their judgment.

Many therapists endorsing these myths identify as Christian counselors, and these misconceptions are consistent with the sexual morals promoted in conservative religious beliefs, but licensed clinical practitioners are held by their ethics to practice based on the best, most current clinical information available. They are also prohibited from engaging in stigmatizing treatments, regardless of the therapists’ religious beliefs.

Patients - If your therapist tells you any of these myths, know that they are likely doing so out of ignorance. Feel free to share this article with them. But, if they refuse to consider that their beliefs may be evidence of bias or stigma, you may need to consider finding another therapist, one who is interested in providing treatment based on evidence, rather than bias and assumption.

More folks are now recognizing this need, and offering training to therapists to help them understand modern sexuality.


What are some sex/relationship myths you've heard?

How do you help your patients move past these myths?

8 Way to Help Your Patients Understand & Avoid Drama

Excerpt taken from "Tired of the Drama" eBook by Alan Godwin

Unreasonable people relate by enticing others into the dramas they stage. That’s
the only way they know how to make relationships “work”. The trouble is, drama
participation makes us sick, drives us crazy, and wears us out. To avoid dramas, we
must be sure to do several things:
 

Understand Your Vulnerabilities

 

Naive Relational Expectations

Normally functioning people like to think that most people function normally— and many do. But unreasonable people don’t. Lacking the necessary reasoning abilities to problem-solve, they relate by enticing others into their obligatory drama roles. One form of enticement is to exploit the target’s naive relational expectations. 

Some of these stem from culturally embedded maxims that work just fine with normal people but not with unreasonable people. When we fail make the distinction, we become vulnerable to the exploitation.

“Give people the benefit of the doubt.”

Giving someone the benefit of the doubt is a good thing—as long as that person deserves such benefit. But a manipulator doesn’t deserve it due to his proven track record of exploitation. 

In fact, he deserves the opposite:

Don’t give him the benefit of the doubt unless he’s establishes a new and different track record. Giving it to him when he doesn’t deserve it opens a door through which he’ll step to perform his exploitative activities.

“Don’t think badly of people.” 

We’ve all heard this statement or its positive variation: 

“You should think the best of people.” It’s often the case that unreasonable people have stellar positives alongside glaring negatives and it’s that mix of conflicting traits that makes them so difficult to understand.

Staying aware of people’s negatives is not synonymous with thinking badly of them and failure to keep those negatives in view can increase a person’s vulnerability.

“Treat people like you want to be treated.”

The danger here is a one-size-fit-all application of the biblical Golden Rule concept. But even the Bible warns against manipulators, sometimes referred to as “fools” or “wolves in sheep's clothing." 

• “Try to find the good in everyone.”

Again, unreasonable people aren’t usually devoid of good qualities and if we’re looking for positive aspects, they may not be that hard to find. But we must remember not to allow the positives to cancel out their important-to-stay-aware-of negatives.


Attempting to Reason With the Unreasonable

Unreasonable people can’t be reasoned with because they are un-reason-able. Lacking reasoning abilities, they have neither the ability nor willingness to work through relational problems. Consequently, they resort to manipulation (drama) to make relationships “work”.

But here’s the thing - despite what we know about them, most normal people are prone to engage on the level of reason in hopes that they will—at long last—see the error of their ways and change. But this won’t and can’t work because they lack the very equipment needed for reasoning to succeed. Here are some common reason-based appeals often made to unreasonable people:

• “Let’s sit down together and talk this out.”

This fails because it requires humility: I could be wrong, you could be right, let’s talk.

• “I’ll let him know that I see what he’s up to.”

This fails because it requires awareness: I see where I’m wrong.

• “If I treat him well, he’ll treat me well.”

This fails because it requires responsibility: It bothers me when I’m wrong.

• “I’ll set him straight and tell him I won’t take it anymore.”

This fails because it requires empathy: It bothers me when I hurt you.

• “I’ll confront him and let him know he’s got to get help.”

This fails because it requires reliability: When I’m wrong, I’ll change.

You can see why trying to reason with an unreasonable person is an exercise in
futility.


Confusion

Unreasonable people operate in a cloud of confusion. We can feel confused for
one of several reasons:

• There is often a disturbing discrepancy between the public image the unreasonable person portrays and who he actually is in private. Attributes, which may be positives in public, are the same ones that have such a negative effect privately. For instance, a master who has to be in charge may excel in commanding a military campaign but be a controlling jerk at home. 

Frustratingly, he’s lavished with praise for his accomplishments by people who think he’s wonderful. And those same people may think something’s wrong with us for not agreeing with them. How can someone be such a winner in one realm and simultaneously be such a loser in another? That’s confusing.

• We may feel confused because unreasonable people stage dramas on some occasions and not on others. And when they’re not staging dramas, they can be very pleasant to be around. For instance, a messiah may be happy and normal as long as she is receiving sufficient amounts of gratitude for her caretaking activities. So, who is she? The happy normal person or the shrew who makes us feel guilty for failing to appreciate her?

That Jekyll and Hyde split is confusing.

• He creates a smokescreen by highlighting our flaws and calling us hypocrites for criticizing him. “How dare you judge me when you’ve got your own shortcomings” is the thought. If successful, we’ll think, “Maybe I am being too hard on him. He’s right, after all, I do have problems.”

• He has mastered the art of projection. Unable or unwilling to tolerate personal wrongness, he projects his negatives onto us so that we become the possessor of them. He accuses us of the very things that are true of him. When we look at what’s being projected, believe that the negatives are true of us and have emotions about them, we’ll think, “Is it me or is it him? It must be me.” At that point, the lies have accomplished their confusing purpose.


Understand Your Antagonist

Coaches study game films to understand the opposing team’s strengths and weaknesses. Wise generals study the enemy’s assets and liabilities before sending troops into battle. For conflict with unreasonable person to have a good outcome, we must accurately assess what we’re up against.

But a word of caution is in order. We should form conclusions tentatively and hold conclusions loosely. I knew a lady once who read a book suggesting that all people belong to one of four personality groups. She routinely referred to individuals by category as when she would say, “Oh, well, what do you expect from Joe. He’s a _____. Brenda, on the other hand, is a _____. No wonder they clash.” Her discomfort with complexity led to errors of oversimplification, and her dogmatic pegging and labeling of people caused her to often misunderstand them.

Labels can be helpful but woefully inadequate when it comes to explaining the intricacies of
human behavior. That danger exists here as well.

Remember, people in react mode are at their worst.

Since all of us look and sound unreasonable when reacting, we should avoid rushing to judgment. Just as we an’t legitimately critique a movie after watching one scene, we should avoid quickly categorizing someone as unreasonable unless we’ve observed a pervasive pattern of behavior over time. “Are we observing transitory manipulative behavior or is this a persistent pattern of manipulation?” is the question we should ask ourselves. Once conclusions are formed, we should be willing to alter them should subsequent evidence suggest otherwise. Additional pattern observation in different settings can result in pleasant surprises or disappointments. Sometimes, an unreasonable turns out to be reasonable after all or the other way around. It can go either way.
 

Avoid Button Pushes

Unreasonable people push our buttons hoping for a reaction. We must expect attacks and learn from our mistakes.
 

Expect Attacks

The unreasonable person may push our buttons in predictably obvious ways or ambush us in unpredictably subtle ways, such as:

• Exploitation of Weaknesses. Sniffing them out and attacking us there.

• Projections. Taking his negatives and projecting them on to us.

• Presumptions. Presuming upon our good graces.

• Role Shifts. If the unreasonable person can’t entice us into playing the required part, he may shift roles in hopes that, when the drama ends, he’ll be back in his preferred role. Here are some different forms of role shifting:

• If the master role is preferred. A master needs us to submit. If we don’t, he may shift into the messiah role, one rescuing a person in need. He gives us something, but the gift has “strings attached.” At that point, the giver is no longer a helper but a controller, the assistance being accompanied by an obligation to submit.

• If the martyr role is preferred. Martyrs are either saved by messiahs or persecuted by masters, the roles we must play for the martyr role to succeed.

If we don’t, she may become a master and strike at us, hoping that we will strike back. If we do strike back, she can once again assume the role of a martyr who suffers at the hands of others—“I can’t believe you would treat me that way.”

• If the messiah role is preferred. A messiah is a sacrificial giver and needs us to be grateful recipients. If we aren’t, she may slip into the martyr role, saying things like, “After all I’ve done for you, this is the kind of treatment I get. Thanks a lot.” If it works, we’ll allow her to resume the messiah role just to escape the guilt trip discomfort.
 

Learn From Your Mistakes

Pickpockets can pick our pockets because we’re not expecting our pockets to get picked. Remember, unreasonable people are good at enticements, but reasonable people are not naturally good at resisting enticements and get easily caught off guard.

We will make mistakes and slip-ups are probably inevitable, but it’s important to learn from our mistakes and avoid repeating them. As the saying goes, “Burn me once, shame on you. Burn me twice, shame on me.”

Beating ourselves up about it doesn’t help but safeguarding ourselves against further enticements does.
— Alan Godwin

Respond vs. React

Unreasonable people want us to react, they take “snapshots” of our reactions, and then they use those pictures to indict us. We can help clients minimize the likelihood of reacting in two ways:
 

Plan Your Response

Reactions are impulsive; responses are intentional. To plan responses, we need to know what role is being required of us. If our manipulator is a master, we’ll need to plan ways to avoid subservience. If the person is a messiah, we’ll need to avoid the obligatory role of gratitude. If he is a martyr, we’ll need to find ways to avoid being guilted into rescuing behaviors.

It’s usually best to refuse our roles quietly rather than confrontationally. If we say, “I know what you’re up to and I’m not going to allow you to dominate me,” that statement alone makes us drama participants. Better to refuse quietly, disallowing him the gratification of observing a reaction. If we don’t react, the manipulator will likely think his emotional remote control is broken and try to fix it by pushing the buttons harder. In the short term, he may become a worse version of himself if he thinks his strategy is failing. If we don’t remember this, we’ll find ourselves thinking, “This isn’t helping; it’s hurting.”

Actually, more vigorous button pushing on his part shows that the plan is succeeding.

 

Display No Reaction

This is what we need to do with unreasonable people who push our buttons, hoping desperately for a reaction that can be used against us. It’s not that we won’t have reactions but that we choose not to display them. We need to restrain externally what we feel internally. This idea has been expressed through phrases like, “Never let ‘em see you sweat” or “The best response is no response” or “Don’t feed into it.” 

Poker players learn to wear “poker faces” for this very reason. The phrase, “Kill em with kindness” applies here because displaying kindness versus agitation disallows the drama enticement. Displaying no reaction keeps us out of the drama. And that’s not being passive; it’s being powerful.
 

Don’t Push Buttons

Another way to resist the drama is to avoid pushing the unreasonable person’s buttons. If we follow our natural inclinations and react by pushing those buttons, we stay in the drama. The idea of not pushing buttons is expressed through statements like:

• Leave well enough alone

• Let sleeping dogs lie

• Don’t stir the pot

• Don’t poke a hornet’s nest

There are two common thoughts that occur to reasonable people arguing with unreasonable people. One is, “How can he possibly believe that nonsense? If I could just get him to understand the sensibleness of my position, we could resolve this problem.” There, we’re attempting to establish reason, but remember, he’s not interested in reason, only in rightness.

The other common thought is, “I’ll teach him a lesson and make him see the error of his ways.” There, we’re attempting to establish justice. But he won’t see those errors because he admits no wrongness. Expecting either reason or justice “pokes the hornet’s nest” and keeps us caught up in the drama.
 

Don’t Expect Reasonableness

The common temptation when arguing with an unreasonable person is to make our case more vigorously, hoping that he’ll eventually get it.

What we discover, however, that it no matter what we say or how well we say it, he won’t get it. He’ll not listen to, understand, or validate our position. If we react by arguing harder, we’re right back in the drama.

We lose, simply by becoming engaged in the conversational tug of war.

So, remember this rule of thumb: To solve conflict problems with reasonable people, we should talk more. To solve conflict problems with unreasonable people, we should talk less and act more.

They “win” by keeping us frustratingly embroiled in the verbal battle

 

Don’t Expect Justice

Attempting to establish justice puts us into the thick of the drama.

It’s very tempting to say, “I’ll teach him a lesson and he won’t do that anymore.”

The problem is that unreasonable people learn no lessons because learning lessons requires the use of muscles they’ve allowed to atrophy. Trying to get them to admit wrongness won’t work and, if we display frustration, we’ve become drama participants.

Trying to establish justice, to force an unreasonable person to acknowledge personal wrongness against his will, has a button pushing effect and provides a way for him to keep us wrapped up in the drama.

 

Set Your Boundaries

With reasonable people, we solve problems by working together to reach mutually
satisfying solutions. Reasoning with reasonable people works, which makes for good
conflict outcomes.

But that doesn’t work with unreasonable because they don’t have the necessary abilities. And if we attempt it, the frustration we experience puts us right back into the drama. Reasoning doesn’t work but a limited substitute does— setting boundaries. Boundaries accomplish what reasoning can’t. They restrain the problems in such a way that they no longer dominate the landscape of our lives.

For instance, Mr. Jones had an obnoxious neighbor with an obnoxious dog, who regularly dug up his flowers and made unwelcome deposits in his yard. All efforts to persuade the neighbor to leash his dog failed and it became clear to Mr. Jones that he was attempting the impossible—trying to reason with an unreasonable person.

Finally, Mr. Jones put up a fence, which kept the canine terrorist from terrorizing his existence. In this example, no mutually agreeable resolution was reached because the neighbor’s unwillingness to reason made that impossible. But Mr. Jones did find a way to keep the dog out of his yard. The problem was not actually solved but his boundary enabled it to be restrained. He improved the dog situation by putting up a fence. In this case, the solution that couldn’t be achieved through reasoning was achieved through boundaries. Yes, it cost him something but it worked.

With reasonable people, problems are fixed when both sides participate in the reasoning
process. With unreasonable people, problems are restrained, not when both sides participate, but when the reasonable person does a good job of setting boundaries.

• Boundary Goal for Level 1 Unreasonable People: (Growth)

• Boundary Goal for Level 2 Unreasonable People: (Containment)

• Boundary Goal for Level 3 Unreasonable People: (Protection)

 


Lean on Your Connections

All aspects of dealing with the unreasonable are challenging.

So challenging, in fact, that we won’t succeed without the support of others. They can be so confounding, so determined, and so frustrating that we’ll most likely fail if we try to go it alone. The understanding and reinforcement of other reasonable people is not a luxury but a necessity.

Slaves in the pre-Civil War South understood this all too well. For all practical purposes, their masters operated under this unreasonable set of assumptions: “We’re good, you’re bad, and you exist for us. If you submit to our control, we’ll all get along just fine.” Lack of submission could—and often did—lead to physical harm. Their sufferings under that system of chattel slavery were eased somewhat by singing songs which came to be known as “Spirituals.” Through the lyrics, they could express thoughts and feelings to each other about their trials, their tribulations, and their hopes. Thus, the ability to endure was enhanced through mutual encouragement.

We may not be literally enslaved by unreasonable people, but the need for support is just as essential. Remember, his survival depends upon getting us to believe, “There’s nothing wrong with me but there’s definitely something wrong with you.” 

Without reference points for our sanity that others provide, it’s very easy to get swept up into that distortion and to become discouraged. Handling manipulators is achievable only with the support of reasonable people relationships.

• Encouragement with Level 1 Unreasonable People: (To stay with it)

• Encouragement with Level 2 Unreasonable People: (To stay sane)

• Encouragement with Level 3 Unreasonable People: (To stay safe)
 


Accept Relational Limitations

A relationship with a manipulator may require coming to terms with certain limitations:

 

A Relationship with Limited Depth

Our relationships with some unreasonable people may be workable only if the level of relationship is limited. It may be more superficial than we’d prefer, but superficial and civil is better than close and contentious.

If drama enticements are resisted, the relationship changes. In some cases, refusing a role in the drama ends the relationship but more often, it changes the level of closeness. Relating in this way may feel disingenuous to some of us, like we’re pretending to get along when we’re really not. Actually, it’s more honest to be superficial if relating more deeply requires drama
participation.


A Relationship with Limited Value

It’s not unusual to have relationships with unreasonable people with whom we experience a dilemma.

On the one hand, we greatly value their gifts, talents, and abilities. On the other hand, they drive us nuts. We treasure their talents but deplore the drama. It’s like having a brilliant physician with a horrible bedside manner. We can’t stand him personally but wouldn’t want anyone else to perform the surgery. And we may have unreasonable people relationships that are valuable to us in some ways but detrimental in others.

When this is the case, we need to re-structure the relationship in order to make use of its limited value. We can’t “make a silk purse out of a sow’s ear,” as the saying goes, but we may be able to “make a pretty good tote bag” as a friend of mine says. The relationship may not be all that we desire, but it has value to us nonetheless.

 

A Relationship with Limited Growth

One of the outcomes of handling unreasonable people well is that we grow whether they do or not. We become better versions of ourselves while they remain unchanged or become worse versions. The growth is limited to us.

When a reasonable person has good conflict with an unreasonable person, the reasonable
person grows even though the person fails to do so—unless he’s a Level 1.

Handling a manipulator well contributes to the growth of character and identity. It brings out
our best and we become better versions of ourselves.
— Alan Godwin

Want more information on how to treat manipulators and drama?
Check out Alan Godwin's courses here. 

Interested in a particular subject? Leave a comment below.

5 Pieces of Advice when Treating Social Anxiety Disorder

Written by Eli Lebowitz

Social anxiety disorder is more than occasional shyness or social discomfort. Social anxiety will cause them to avoid at least some social situations. In most cases there will be many situations they avoid such as conversations with other people, eating or drinking in public, answering the phone, or speaking in class. If they cannot avoid the situations they fear and have to endure them, people with social anxiety will experience these situations as extremely distressing.

Here are a few pieces of advice to help your patients deal with social anxiety.

 

Social Anxiety Disorder vs. Occasional Social Anxiety

If the anxiety is taking a significant toll on their life, limiting their ability to function academically or otherwise, then that may be social anxiety disorder. People with social anxiety disorder will experience a lot of anxiety, distress, and worry about how they are perceived. They’ll usually be very worried about embarrassing themselves, and they may fear that their anxiety is making them look silly, for example by blushing or trembling. Psychologists will generally not diagnose social anxiety disorder unless the condition has lasted at least six months.

If a person feels uncomfortable in new situations, or takes time to ‘warm up’, or just prefers small groups, that is not social anxiety disorder.

 

How to Help Patients & Their Support Systems Be Successful

Support

Help your patient get support by encouraging the people around your patient to be there for them and advise them not to tease or mock a person with social anxiety disorder.

We all have things we are anxious about and what is easy for you may seem terrifying for somebody else. Most people with social anxiety disorder already know that their fear is irrational and excessive, so just telling them that again and again is not likely to help. 

Remind Them

Help the patient’s support system remember that having social anxiety disorder does not mean that patients don’t want friends. Most people with social anxiety disorder feel lonely and would like to have friends and social interactions. They’re just anxious about them. 

Be Patient

Don’t give up and try to find ways to create social interactions that feel ‘safe’. A frat party may be out of the question, but a coffee with a friend or two might be doable. Or for some people it may be the other way around. Let your friend know that you won’t judge them and just want to be their friend. Give them time. If you asked a question and did not get an answer right away, wait before you jump in or give up. 

Relate

Talk about what helps you when you feel uncomfortable. Many people with social anxiety disorder worry about ‘having something to say’ or ‘how to start a conversation’ so offer tell the support system for the patient to share their own best tips. And that they should be prepared for their loved one with social anxiety not to accept them right away.

Encourage Them

Tell the families and friends of your patient to encourage them to get help when they need it.

Therapy and medications for social anxiety disorder can be very effective. Find out about resources and offer to go along for a first visit if they want support. Respect their privacy but make it clear you want to help. 

 

How Cognitive Behavioral Therapy Can Help

Cognitive behavior therapy (CBT) is an evidence-based treatment for social anxiety disorder. In CBT patients learn to identify their anxious thoughts and to challenge them. They learn skills to help themselves feel less anxious so they can cope with stressful situations rather than avoiding them, and they practice gradually and systematically facing their fears.

Starting small is best.

Perhaps doing something that is only a little stressful, and practicing it until it becomes easy for the patient. They’ll learn how to recognize how their brains and bodies react before they move on to more difficult tasks. They’ll practice coping until they are no longer as anxious about social situations and the disorder is no longer impairing their lives in a meaningful way. 


Dr. Lebowitz helps mental health professionals build treatments that work. Check out his current courses here. 

What's one issue you face when working with anxiety or CBT?
Leave us a comment so we can help.

5 Benefits of Learning Sign Language

Originally posted on LinkedIn by Jill Eversmann

When looking for another language to learn or to teach to children, consider the benefits of learning sign language. Here are 5 benefits, there are many more:

 

ASL is a true language

Knowing the basics will help you communicate with members of the Deaf community.

 

ASL is a World Language

It's accepted as a World Language for High School credit in many states (including South Carolina) and is easier to learn than other spoken languages for those children who are not primarily auditory learners. Sign language provides auditory, visual and tactile cues when learning.

 

ASL encourages early communication

Using ASL vocabulary with pre-verbal and non-verbal children can give them a way to communicate that is easier for many children than speech and it encourages speech and language development.

 

ASL improves bonding

Teaching Sign Language to babies and toddlers can improve parent-child bonding and decrease frustration and tantrums due to being unable to communicate basic wants and needs.

 

ASL improves other skills

Introducing sign language (ASL vocabulary, fingerspelling and numbers) to preschool and elementary school children has been linked to improved reading, spelling and language skills.


Interested in learning more from the wonderful Jill Eversmann? Click here to gain pivotal ASL skills for any healthcare field AND get your continuing education credits.

What ASL signs are you interested in learning?