November 2020 - Promises Healthcare
ENQUIRY
How Does CBT Help with Social Anxiety Disorder?

How Does CBT Help with Social Anxiety Disorder?

In Singapore alone, 10% of the population is plagued by anxiety disorders – one of which includes Social Anxiety Disorder, or SAD for short. And on a global scale, approximately 4.5% of the world’s population – 273 million people – are estimated to experience anxiety disorders as of 2010. Commonly misunderstood to be merely an over-exaggerated form of shyness, Social Anxiety Disorder is much more than that. Individuals with SAD experience symptoms of anxiety or fear under particular or all social situations, depending on the severity of their condition. For some, even doing the simplest day-to-day activities in front of others can cause extreme worry of being judged, humiliated or rejected. However, some research has also suggested that SAD may be especially manifested in individuals that have ongoing medical, physical conditions such as Parkinson’s Disease, obesity, facial or bodily disfigurement (including amputees), and any other sort of conditions that may cause one to look different from the norm.

What are the symptoms of SAD?

When people with Social Anxiety Disorder are surrounded by others or have to carry out a particular action around them, they may:

  1. Feel nauseous, experience an increase in heart rate, tremble, blush or sweat profusely.
  2. Be unable to make eye contact with others, move and act rigidly, or speak in an overly soft tone.
  3. Feel extremely self-conscious, as though others are judging their every move.
  4. Easily feel awkward, embarrassed and stressed out in social situations.
  5. Find it extremely difficult to be themselves around others, especially strangers.
  6. Have anxious thoughts such as, “I’m sure they won’t want to talk to me again,” or “Do I look plain stupid right now?”
  7. Apologise excessively, even when there is nothing to apologise for.
  8. Avoid conversations, such as by using their mobile devices or plugging in their headphones. 
  9. Avoiding situations where one might be placed at the centre of attention.

The list of symptoms above is not exhaustive, but we need to recognise that they may cause extreme distress to these individuals. For them, it can be tremendously helpful and relieving for them to seek treatment for their condition, more specifically through Cognitive Behavioural Therapy (CBT).

Cognitive Behavioural Therapy is a well-known form of therapy in the mental health profession. Considered to be a form of short-term therapy, CBT is usually delivered in a time-limited manner, often over the course of 8 to 12 sessions (although this may vary from person to person). Once the symptoms are reduced and the individual is well-equipped with the necessary skills to cope with anxiety triggers or social situations in general, treatment can be finalised. As it is not possible to change or alter emotions directly, CBT aims to tackle any maladaptive, limiting thoughts and behaviours that fuel or contribute towards agonising emotions. This, therefore, lowers the extent of anxiety that one goes through and instead, developing a sense of self-efficacy.

First off, CBT encourages individuals to open up and to be truthful regarding their automatic, instinctive (negative) thoughts so that they can work hand-in-hand with therapists to analyse the logic behind them. During the sessions, therapists will work to identify the assumptions (and their validity) that these people hold, which might be causing unnecessary anxiety or fear. Proper reasoning and clearing up of assumptions can be done by asking clients to do some self-assessment and to provide possible reasons as to why they maintain such assumptions. By doing so, therapists can then assess the situation and present evidence contrary to their beliefs. 

Another aspect of CBT includes ‘Decatastrophising’. One common thinking pattern found in people who suffer from anxiety issues is ‘Catastrophising’, which is the act of imagining the worst-case scenario and magnifying the bad in any given situation. CBT helps to counter such a mindset by helping these individuals prepare for the feared consequences, as well as to cope with their unhealthy ways of thinking. For example, therapists and clients will go through certain ‘Challenge Questions’, such as:

  • “Has anything this bad ever happened before? How likely is it to happen now?” 
  • “What makes you confident that your feared outcome will actually come true?”
  • “What is the best outcome that can happen in this situation?”

These are just a few examples of ‘Challenge Questions’, but they can certainly be beneficial in helping to ease feelings of anxiousness and to calm the individual. In some way, this can also decrease an individual’s inclination to avoid seemingly triggering social situations. 

Tying in with ‘Decatastrophising’, another technique introduced during CBT is ‘Reattribution’. ‘Reattribution’ is a method which challenges the negative assumptions held by the individual by considering the possible alternative causes of events. This is particularly advantageous for people who, in most situations, perceive themselves to be the cause of problem events. For example, this can mean having a discussion on the evidence which proves that the individual is/is not the cause of the problem. Eventually, this will help to tackle ‘Automatic Negative Thoughts’, excessive self-blame and worry.

Of course, in order for the treatment process to be carried out more effectively, some therapists do assign “homework” to their clients. This is to say that clients are encouraged to apply CBT principles in between sessions, and are tasked to self-monitor and focus on implementing tips and processes when dealing with actual situations. By monitoring their emotions and making a conscious effort to calm themselves through methods discussed during sessions, these individuals will eventually develop the much-needed skillsets to cope with emotionally-draining social environments.

 A combination of cognitive and behavioural therapeutic approaches, CBT has been proven to be an extremely effective treatment method for anxiety disorders, including SAD. In fact, the skills you learn in CBT are practical and highly applicable, and hence can be incorporated into everyday life to help you cope with future stresses more effectively.  As such, if you or a loved one is struggling with SAD, do seek treatment as it will ultimately benefit you in the best way possible. 

 


References: 

  1. https://www.mentalhealthacademy.co.uk/dashboard/catalogue/using-cbt-with-social-anxiety-disorder/chapters/1 (Accessed 3/11/2020)
  2. http://psychcentral.com/lib/social-anxiety-overview (Accessed 3/11/2020)
  3. https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness/index.shtml (Accessed 3/11/2020)
  4. Photo by Luke Porter on Unsplash
Building the Bridge with Generation Z

Building the Bridge with Generation Z

Take a look around our workplace and you will likely see people from across different age groups, particularly as we now have many people working past the age of 60. In fact, it is not surprising to see at least up to four generations on the job today, from the Baby Boomers to Gen Z.  In case you are wondering what each of these generations refer to, here’s a rough guide:

Baby Boomers: They were born between 1946 and 1964, and are currently between 56 to 74 years old.

Generation X: Gen X was born between 1965 and 1980, and are currently between 40 to 55 years old.

Generation Y (also commonly known as Millennials): Individuals born between 1981 and 1996, and are currently between 24 to 39 years of age.

Generation Z (or Gen Z in short): Refers to the demographic cohort succeeding the Millennials, or loosely speaking, those born from 1995 to 2010. In other words, these people would be 10 to 25 years old at present. 

A flurry of potential labels has appeared that refer to Gen Z as well, including Gen Tech, post-Millennials, iGeneration, Gen Y-Fi, and Zoomers. It goes to show that this is truly a generation of digital natives. They have been born into a world of vast technological advances and innovations and exposed to smartphones, social media, virtual reality, the internet, and artificial intelligence from a very young age. This is where the gap has widened drastically between Gen Zs and those of Gen X, Gen Y, and especially the Baby Boomers. 

Unlike the older generations, the Gen Zs grew up during the rise of social media, smartphones and instant accessibility of information in a hyper-connected world. Gen Z individuals reportedly spend up to 3 hours a day on average on their computing and mobile devices. With that said, keep in mind that new technology is typically first adopted by the youngest generation before it is gradually adopted by the older generations. Baby Boomers in particular, still make up the largest proportion of traditional media consumers. While the younger generations have switched to digitalised news sources or other forms of online social media, quite a handful in the older generations is still sticking to the old-school television, magazines and newspapers. 

You might wonder, “So what exactly is the problem here?” Well, while it is true that generation gaps have long existed since time immemorial, the widening gap between generations is seemingly putting our interpersonal relationships under strain. Gen Zs across the world are well aware of the ways in which their childhood has been unique from their parents and grandparents. In the past year or so, the “OK Boomer” phenomenon has become increasingly widespread over social media. Albeit a little controversial, the term “OK Boomer” is often used by Gen Zs in a rather cutting and dismissive manner to a particular suggestion or criticism by an older generation person. As the term found its way onto the internet, the younger individuals found it to be an effective and all-encompassing manner of expressing their feelings, especially towards things that they find out-of-date. Even more so, Gen Zs and Millennials often use it whenever they want to direct our attention to generational conflicts – for example, expressing their frustration and critiquing the older generation for making judgements on issues such as gender expression, their financial choices, or their approach to job-hunting. 

We interviewed a fellow Gen Z, Himanshi, a current student at Nanyang Technological University pursuing a Bachelor of Communication Studies.  Here is what she has to say: “Social media certainly contributes to the widening gap due to the disparity between the types of communication and information mediums that we are engaged in. But at the same time, it is a natural occurrence simply due to the sheer difference in trends, preferences and eras.”

This brings us to what we can do to bridge the generational divide. For sure, we can’t stop the rapid evolution of how people communicate and interact, but perhaps it would be useful for us to have a better grasp on the Gen Z’s internet slangs and their way-of-speech, to narrow the communication divide at the very least.

“It may seem a little unfair to expect the older generations to pick up on our slang, especially since we don’t do much to understand their differing experiences and their perspectives either”, Himanshi added. “It’ll probably be a little awkward for us too if they were to start using them, but we cannot deny that it would certainly help in breaking down the communication barrier between us,” she laughs.

As much as we would like to include all the various slangs in this miniature guide, there are, frankly, way too many. However, we’ve picked out some of the most commonly used internet slangs adopted by Gen Z individuals. While this list is, for the most part, universal due to its online exposure, the usage of some phrases could vary depending on region and age group.

“Sus”
Popularised and widely used after the release of the game “Among Us”, this term is short for “suspicious”. 

“Oof”
Another term for “yikes”.

“Mood” / “Same” / “Me”
These are just various ways of saying “I can relate to that”.

Sksksksksksksks”
Although tough to pronounce it verbally (hence mostly used online), this internet slang is basically the new “hahahaha”. 

“Slaps”
This term does not actually refer to an actual slap. Instead, it is used in a positive light to describe something cool, or even praise-worthy. For example, Gen Zs may say, “This song slaps!’” 

“Thirsty”
Again, this term does not reflect the innate need to quench your thirst. This term is used to describe someone who is desperate for attention, especially from a romantic interest. 

“Shook” / “Shooketh”
Another way to express surprise or shock.

“I’m dead”/ “Dead”/ “Ded” / “I’m deceased”
These are various ways of reacting to something hilarious. These are sometimes replacements for terms such as “LOL”.

“No Cap”
A way to convince another person that you’re not lying. In other words, it is to convey authenticity and truth. For example, a Gen Z might say, “No cap, you look gorgeous.”

“Spill the tea” / “Tea”
“Tea” here refers to gossip or the latest scoop. When one says “Spill the tea”, they are asking you to let them in on the gossip. 

“Flex”
To show off. This can be applicable to possessions, or sometimes even knowledge and other intangibles. 

“This ain’t it, chief”
A humorous way of signalling to someone that their statement or opinion is wrong or stupid. 

“Salty”
A sense of jealousy, bitterness or sadness.

“Shade”
To “throw shade” at someone is to trash talk him with rude comments. 

“Highkey”
“Highkey” is often used in replacement of “very”, “really”, or “clearly”. It is used to express something straight up and openly. For example, “I highkey want that shirt!”

“Lowkey”
“Lowkey” is the opposite of “highkey”, and it is usually used to express something in a rather secretive and restrained manner. For example, “I want to keep this issue lowkey,” or “I lowkey hate that guy.”

As more and more Gen Zs are entering the workforce and infiltrating our offices, perhaps it’s highkey time for the older colleagues to study up and grasp these slangs. 

 


 

References:

https://www.vox.com/2019/11/19/20963757/what-is-ok-boomer-meme-about-meaning-gen-z-millennials (Accessed 27/10/2020)

https://www.kasasa.com/articles/generations/gen-x-gen-y-gen-z (Accessed 27/10/2020)

Photo by Nathan Anderson on Unsplash

Healing from being with a person with Narcissistic Personality Disorder

Healing from being with a person with Narcissistic Personality Disorder

Written by: Winifred Ling, Couples Therapist & Relationship Coach

Happily-ever-after is an ideal that many believe and pursue and numerous studies have suggested that the key to happiness lies in a thriving marriage. I am also convinced that when couples come together and decide to get married, they do not have the thought of a divorce on the horizon.  

To many, marriage is not a frivolous decision but one where he or she has deliberated and decided to entrust oneself to the other legally. Imagine the horror when shortly after the wedding bells, you discover that your spouse turned out to be someone that you don’t recognise and ends up hurting you so deeply that you wonder how you even got to this point: being romanced to being discarded. This is what it is like to be in a relationship with a narcissist. 

Let’s explore the traits of a narcissist. 

The following are the 9 official criteria for Narcissistic Personality Disorder (NPD):

  • grandiose sense of self-importance
  • preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  • believes they’re special, unique and can only be understood by, or should associate with, other special or high-status people or institutions
  • need for excessive admiration
  • sense of entitlement
  • interpersonally exploitative behaviour
  • lack of empathy
  • envy of others or a belief that others are envious of them
  • demonstration of arrogant and haughty behaviours or attitudes

In essence, a narcissist has an excessive sense of self-importance over and above the needs of others. There is a sense of grandiosity and arrogance; and a lack of ability to empathise and experience reciprocity within intimate relationships. They are typically charming and charismatic. The early stages of the relationship are almost always exhilarating, romantic, powerful and intense. Love-bombing is a tactic where NPD makes you feel so special and loved that you can’t help but fall deeper in love with him or her. Most narcissists only reveal their true colours when they are in conflict. And when you no longer serve their needs, they discard you from their lives or make it a living hell for you. 

Imagine the adverse and trauma that one experiences when you wake up one day and realises that the love you’ve received is not real and permanent. 

The following are the lasting psychological and emotional impact of being in a relationship with a person with NPD: 

  1. “I don’t know what is real anymore.”
    Survivors of persons with NPD have the inability to trust their own judgment. Because gaslighting is a key feature in this toxic relationship, they lose touch with what is the reality. Gaslighting is defined as a form of manipulation, emotional and psychological abuse that results in a slow dismantling of a victim’s self-trust and judgment.
  2. “It is all my fault. Everything I do is wrong. I trigger him/her. I deserve his/her anger.”
    Because a person with NPD will never assume responsibility for anything (they believe they do no wrong), they turn it around and project their emotions on the survivor. The survivor is the one who is over-sensitive and would ask irritating questions that trigger them to react. The consequence of this is that the survivors feel powerless and start to blame themselves for not being good enough for their partner.
  3. “I am worthless and deserve nothing
    From the constant criticizing and undermining from a person with NPD, the survivors begin to accept the narrative that they are the problem and suffer from low self-esteem. They may start to withdraw from their family and friends who are concerned and question the relationship. They also hide their partner’s behaviour and lie about it.
  4. “I am going crazy”
    This is related to point #1. Because a person with NPD constantly lie and intentionally say things that make the survivors question their reality, they start to think that they are crazy for having those questions. They feel confused and lost all the time.
  5. “I don’t know. I can’t decide. It will be wrong anyway.”
    They have great difficulty in making decisions because they start to believe that they can’t do anything right. This is the message that is drummed into them persistently and this could extend into other aspects of life, such as in their work.

 

One of the common frustrations that my clients, who have survived persons with NPD, have often expressed: ‘how is it possible that they missed the warning signs’. Because of the suffering that they have been through, they have asked for the warning signs to be shared so that more can be aware and watch out for them in their relationships. 

  1. Self-centeredness
    They believe that the world revolves around them. They are not able to empathise and therefore can only see from their point of view. When things do not go their way, they get very upset and may threaten to end the relationship. Everything is on their terms. For example, my client shared that when they were dating, the partner dictated when to meet according to his schedule. Not knowing better, she accommodated. That is a red flag. Also, when they no longer have use of the partner, they have no qualms to simply discard them by being emotionally unavailable, refusing to communicate and abandoning the partner.
  2. Frequent threats and emotional blackmail
    If you feel like you are perpetually walking on eggshells not knowing when your partner will explode on you, chances are he/she has NPD. Threats and emotional blackmail are their tools to control and get you to submit to their wants. E.g., Go ahead and leave, I never needed you anyway. I’ll tell everyone what a mean person you are.”
  3. They act entitled and rules don’t apply to them.
    They believe that their needs are more important than their partner’s. There will be no reciprocal gestures unless there is an ulterior motive to get what he or she wants. Because of the self-importance and arrogance, they believe that they can do as they please as long as they don’t get caught. They deserve special treatments.
  4. Obsessive focus on the external
    This applies to how they dress and carry themselves. Typically they are attractive, have material possessions and are of certain social status. They appear to be an excellent “catch”. They will go all out to inflate their status and standing. Another client told me that her husband, a covert narcissist, was charming and social. His real self only surfaced when they were on their own and when he felt threatened by her. This creates problems as people may not believe her when she tells her challenges.
  5. They are master manipulators and schemers.
    The key emotions that you feel when you’re with a narcissist are guilt, shame and confusion. The hallmark of a person with NPD is the inability and unwillingness to take responsibility for any action and word. Consequently, they project their emotions onto the survivors and make them feel guilty and responsible. They can also be verbally abusive and are good liars. They scheme and twist the words of the survivors to their advantage. They have no issue in making their partners the bad guy and spread rumours that paint themselves as the victim. The bottom line is this: they need to make themselves feel good at the expense of everything and everyone. When they don’t get what they want, they will withdraw either physically and /or emotionally from the partner. They may give the silent treatment, be passive-aggressive, stonewall and/or ignore the partner. At the end of it, the partner will accept the blame and promise to not upset them next time.
  6. They are hot, then cold.
    When they want something, they will go all out to get it. As such, in the early stages of the relationship or when they are on a mission to keep you under their control. They will pull out all the stops to make you feel wanted, admired and loved. One moment, you could be the most important person in their lives and in the next, when you don’t agree with them on something, it could be a trivial matter, you would become a worthless person that is undeserving of his/her respect and love. The switch from hot to cold is unnerving and they will make the survivors think that the problem lies with them.

 

In spite of the detrimental impacts of being in a relationship with a narcissist, the good news is that it is possible to heal from it. I have supported and seen my clients live a meaningful and flourishing life following the breakup with a narcissist. Though the journey may not be easy, if one is willing to work with a professional to go deeper and understand the pattern of relationships in their lives, they can find healing and freedom. 

What are the steps to heal? 

  1. Educate yourself on NPD and accept that it is a disorder. Know that you are not alone and you are not the problem. Raise awareness for it. The World Narcissistic Abuse Awareness Day is on 1 June. Get involved and when you are ready, share your story. You can empower and help others by sharing your experience courageously.
  2. Get professional help as dealing with trauma can be complicated. Learn to connect the past to the present; typically, the dynamics between the person with NPD and the survivor is one that the latter is familiar with. It is not uncommon that upon the realization that the partner has NPD, the survivor can see that a family member could be one as well. Those who persist in such toxic relationships are usually accustomed to such dynamics from childhood.
  3. Practice boundaries – physical and emotional. Have zero contact or keep it to a minimum should you share the care of the children. The survivors are usually empathic and attuned to the feelings of others. Be mindful not to take on feelings that are not yours. Have clarity on what is your responsibility and discard those that are not yours.
  4. Build a strong foundation – focus on one’s strengths and resilience, in ending the relationship and working through the issues. Find meaning in it by rewriting the narrative.
  5. Forgive and work on self-love. Self-compassion is a critical component in recovering. Learn to take good care of yourself – physical, emotional, psychological, spiritual, social.
  6. Pay attention to your body as trauma is stored in your body. Practice mindfulness to bring yourself to the present moment when you’re triggered by difficult memories. The triggers will still be there, and the healing process will be imperfect and a work-in-progress.

  7. Focus on the good – that is in you; the work that you have put in to heal and maintain your well-being by learning new skills and maintaining good habits. Celebrate quick wins when you are able to enforce boundaries or not take on responsibility for how others are feeling.
  8. Embrace a healthy relationship. After being in a toxic relationship for a long time, being in a healthy relationship can feel weird and scary. You aren’t sure what to make of it. The lure to get back to what is familiar albeit negative for you is high. Be aware of it and put measures in place so that you can recalibrate when you feel threatened.

 

Let’s remember that significant relationships in our lives will impact our mental well-being. Even as we focus on the benefits of positive relationships and promote it, we also need to provide support for those who have been through traumatic and toxic relationships. The key is to remember that relationships should enhance your lives and motivate you to be a better version of yourself. When there are disempowerment and manipulation in the relationship, it is not healthy, and you can make the decision to get out of it. 

Healing comes with returning your focus to yourself, acknowledging your feelings and emotional experience and taking responsibility for yourself. Through the right help and therapy, you can learn new skills, to regulate your emotions, have better communication and understanding, and help yourself break the cycle of unhealthy patterns. Your resilience can be enhanced, and a flourishing life is once again within your reach. 


DSM-IV and DSM-5 Criteria for the Personality Disorders