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Psychiatrist vs Psychologist: Whom Should I Seek?

Psychiatrist vs Psychologist: Whom Should I Seek?

There is often much confusion between the terms psychiatrist and psychologist. People may use these terms interchangeably, but this is not to be the case. While both psychiatrists and psychologists treat people suffering from mental health issues and behaviour disorders, they are not the same. When should I see a psychiatrist? Is psychiatry and psychology even the same thing? Who should I see first? Such thoughts may run through your mind when mental health treatment is brought up. In this article, we hope to clear the doubts and achieve greater clarity on who they really are and how they differ. 

 

Before we begin, if you’re reading this article to find important insights on seeking help from a mental health professional, we would like to commend you for taking the necessary steps to help yourself or your loved one. Making such a decision can be very daunting, and your mind might be in a disarray with constant worries of familial, societal and cultural stigma. However, it is ever so important to remember that there is no shame or embarrassment in wanting to help yourself or your loved one get better. Mental health is equally as important as physical health and seeking help is a sign of strength rather than weakness. 

 

What’s the Difference Between a Psychiatrist and a Psychologist?

Fundamentally, the biggest difference between the two is in the approach they take towards treating mental disorders, and the capacity to prescribe medications. Unlike psychologists, psychiatrists are trained medical doctors at their core. Amongst the network of mental healthcare professionals, psychiatrists are certified to provide neuropharmacological support that is deemed essential in stabilising certain mental conditions, such as where chemical imbalances in the brain are involved. 

 

As medical doctors, psychiatrists play a crucial role in the diagnostic process, as well as the prevention and treatment of emotional, mental, behavioral, and developmental issues. While conducting assessments, they may also involve relevant physical examinations, blood tests, or pharmacogenomic testing to narrow down the scope of diagnosis. While psychiatrists specialise in the mental phenomena, such physical examinations cannot be omitted entirely especially if they provide important clues to help them rule out other possible physical conditions. 

 

Psychiatrists also have the capacity to assess your medical history. Physical and mental wellness go hand-in-hand – psychiatrists will need to grasp the full picture before finalising on a diagnosis. On the Huffington Post, Carol W. Berman, M.D., a clinical assistant professor of psychiatry at NYU Medical Center in New York City, writes, “Because we learned how the body interacts with the mind, we can rule out physical disorders as a cause of mental illness. This is important, since a person may have a hyperactive thyroid, for example, which can trigger panic attacks, anxiety, insomnia, or anorexia. We can look at thyroid blood tests or have a patient consult an endocrinologist if we suspect the problem stems from thyroid disease.”

 

In contrast, psychologists are not trained medical doctors, and thus cannot conduct any physical examinations nor prescribe medications. Clinical psychologists however, possess an accredited Master’s in Applied Psychology at the very minimum, and can make a diagnosis for the patient if he thinks he has a mental health condition. 

 

Psychologists typically make use of various methods of psychometric testing, personality tests, observations and interviews to come to a conclusion. But that’s not all – psychologists also engage in psychotherapy treatment, with common forms including cognitive behavioural therapy (CBT). Psychotherapy aims to help clients identify their key issues and concerns, before moving on to create a treatment plan to achieve the desired outcomes. Often conducted over several sessions, psychotherapy equips the individual with problem-solving and emotion-coping strategies to overcome the problem. For example, if a client comes in hopes of seeking help for social anxiety, psychotherapy (such as CBT) would be greatly beneficial in tackling maladaptive, limiting thoughts and behaviours that fuel negative emotions. 

 

While there are differences in qualifications and the methods of treatments applied by psychiatrists and psychologists, it is key to note that they still work closely together. For the optimal treatment of certain mental health conditions, psychiatrists may refer you to psychologists for concurrent psychotherapy. Likewise, if a clinical psychologist determines your condition to be better managed with medications, a referral to a psychiatrist can be expected. Often once a proper diagnosis is done, the psychiatrist and psychologist may work together to build a treatment plan for the patient, focusing on managing symptoms through the use of medications and psychotherapy. 

 

Who Should I See First?

Where physical symptoms may be severe, or where it may be hard to take basic care of yourself, turning to a psychiatrist would be a good option. After all, psychiatrists are trained medical doctors who can also work with your primary care doctor (if any) to provide optimal treatment. It is also suitable for individuals who are unsure as to whether their physical symptoms are linked to other underlying medical conditions. In such cases, psychiatrists will be able to detect a medical mimic. To put it simply, take for example a presenting complaint linked to the shortness of breath. While it may seem like a panic attack, it is crucial to eliminate any other clinical suspicions of lung diseases such as pulmonary embolism. 

 

On the other hand, you may choose to make a trip to see a psychologist if you think you have a less severe mental condition. For individuals seeking to overcome phobias or resolve difficult issues in life, it may be more effective to undertake psychotherapy. A Psychologist can help you work through your problems, deal with emotional challenges or cope with particularly traumatic life events so as to make positive changes in your life.

 

We can all play a part in alleviating our own or our loved one’s suffering by increasing our understanding of mental health disorders. If you’re still struggling with making a decision after much thought, making the first step to contact a professional would help. You can be assured that the team at Promises will serve with your best interests at heart, and will work closely with you to provide optimal treatment. 

 


References:

  1. https://www.huffpost.com/entry/ten-tips-to-consider-befo_b_10264590 (Accessed 03/04/2021)
  2. https://www.reliasmedia.com/articles/109640-medical-conditions-that-mimic-psychiatric-disease-a-systematic-approach-for-evaluation-of-patients-who-present-with-psychiatric-symptomatology  (Accessed 04/04/2021)
Suicide Risks for Persons with Addictions

Suicide Risks for Persons with Addictions

Written by: Juliana Pang, Therapist

Caregivers with a family member affected by addiction problems are often exhausted, drained dry of their empathy and compassionate capacities.

They recount countless cycles of suspended hope followed by just as many broken promises as they watch the affected person return time and again to their compulsive addiction despite a seemingly obvious trail of destruction behind them.

Caregivers learn to cope with the endless demands on their energies by blending the words uttered by the affected persons as a cocktail of lies, manipulation and attention-seeking antics to get what they want.  In time, the cries for help from the affected person turn into cries for help by the boy who cried wolf and eventually fading into indistinguishable white noise.

Professor Lisa Firestone of the Glendon Association observes that there is a natural tendency for caregivers to minimise any suicide expressions in general.  Responses such as, “Well, his past attempts weren’t serious.” or “He is just manipulating to get something.” are commonly observed.  There is also a general tendency to not want the expressions to be true.  In the case of addicts, words such as “I want to die” or “I am going to end my life” no longer convey the same meaning or gravity of their sense of desperation.

Why should we want to pay attention to an addict’s cry for help?

In Singapore, we lose 1.1 lives every day to suicide.  It is still the leading cause of death for youths aged 10 to 29.  While direct correlation evidence is still being researched on, studies in America have shown that more than 90% of people who kill themselves suffer from depression have a substance abuse disorder or both. Suicidality and addiction share a high concordance relationship.

When we overlay the statistics with a physiological lens, we note that both groups of persons have been observed in studies to have a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis which essentially controls our body’s response to stress.

In a person with a normal functioning HPA axis, on the reception of a stressor, the hypothalamus in our brain instructs the secretion of the corticotropin-releasing factor (CRF) and vasopressin to stimulate our pituitary glands to produce the adrenocorticotropic hormone (ACTH).  The ACTH, in turn, stimulates glucocorticoid synthesis and release (commonly referred to as cortisol) from the adrenal glands.  This chain reaction provides a person the increased energy to handle the stress event and to do so without suffering from the pain and fatigue.  When the stress event is gone, the body produces a negative feedback loop which then brings the body system back to homeostasis.

In a person exposed to a persistent or extreme level of stress, or in a person who frequently activates the HPA axis through substance use, the body starts to blunt the sensitivity of the HPA axis and blunt cell receptivity to cortisol in its efforts to return to and maintain homeostasis.  This alteration to the sensitivity of the HPA axis affects our ability to tolerate physical and mental stresses and creates a need for a much bigger stimulus to activate the HPA axis (which may mean higher dosage of substance use); and when the HPA axis does react, produces a much bigger and exaggerated response (which may translate to more aggressive behaviours).

What Does This Mean In Practical Terms?

Many suicidal persons described having a voice in their head which is constantly there; telling them how much they need to seek fulfilment and comfort by reaching for the desired stimulus, whether it be a substance or a behaviour, of which one is killing themselves.  Their mind starts to command them to constantly plan, to seek out and to take actions to soothe the unbearable lack that they are feeling.  Eventually, the voice in the head goes from coaxing and persuading to being more intensive and aggressive towards the self to take immediate drastic actions.

The relief of death, a final refuge, becomes alluring and pleasurable and the fear of dying eventually transforms into the fear of not dying and becoming the loser, disappointment, and burden that they already believe themselves to be to their caregivers.  This dual push towards drastic action and the need for an ever-increasing amount of substance in addicts leads to an increase in the risk level of suicidality.

What Can We Look Out For?

How then does the caregiver separate the wheat from the chaff amid the chaos that addiction has already wrought onto the family system to detect the risks of suicidality?

Below are some, though not exclusive, common markers to look out for. It is particularly useful to note changes in the content of the affected person’s expressions and any escalation or sudden extinction of intensity.

  • Mood
    • Intense Emotional Outbursts
    • Extreme Isolation or Withdrawal
    • The feeling of Being a Misfit in Every Way
  • Speech
    • Hopelessness
    • Helplessness
    • Worthlessness
  • Behaviour
    • Researching or Procuring Means of Suicide.
    • Self-Harm, Including Risky Substance Use or Behaviours.
    • Planning of Affairs.
  • Presence of Trigger Events
    • Loss of Primary Relationship.
    • Physical or Mental Health Conditions That Debilitate.
    • Abuse or Trauma Events.
What Can Caregivers Do On Observing The Signs?

Ask the Suicide Questions:

  • In the past few weeks, have you ever wished that you were dead?
  • In the past few weeks, have you felt that you or your family would be better off if you were dead?
  • In the past week, have you made plans about killing yourself?
  • Have you tried to kill yourself?

If the answers are yes to any or to all the questions, caregivers are encouraged to take the following first steps:

  • Be empathetic towards the suicidal wish.
    • The objective is not to agree with the act of suicide but to understand what has happened to lead the affected person to the conclusion that suicide is the only solution.
  • Find a genuine connection with the affected person.
    • However difficult that person might have been in your life, express what this person means to you personally and how the loss of this person would affect you.
  • Make a safety plan.
    • Ask the affected person to agree to not take or delay any action to harm themselves until they get to or you get them to professional help.

In these situations, working with professional therapists can help the affected person build up their sense of self, adjust unhelpful beliefs towards the whole life experience, reignite their sense of being a valued part of humanity and community, develop skills to cope with life’s stresses and build a treatment and recovery plan for any inter-connected problems such as their addiction problems.

Professor Lisa Firestone observes that suicidal persons are generally ambivalent: a part of them wants to die but a part of them wants to live as well.  There is often a process of the dividing up of the self within the person, between an aspect which is life affirming and engaging with the outer world; and the anti-self, which is self-critical, self-hating and ultimately suicidal.  The key to recovery is to connect with and help strengthen that part of them that wants to keep on living.


1 Glendon.org. 2021. Understanding & Preventing Suicide – DVD « The Glendon Association. [online] Available at: https://www.glendon.org/product-post/understanding-preventing-suicide-dvd0/

2 Sos.org.sg. 2021. Suicide Facts and Figures | Samaritans of Singapore (SOS). [online] Available at: https://www.sos.org.sg/learn-about-suicide/quick-facts

3 Addiction Center. 2021. Addiction and Suicide – Addiction Center. [online] Available at: https://www.addictioncenter.com/addiction/addiction-and-suicide/

4 Goeders, N., 2003. The impact of stress on addiction. European Neuropsychopharmacology, 13.

5 Glendon.org. 2021. Understanding & Preventing Suicide – DVD « The Glendon Association. [online] Available at: https://www.glendon.org/product-post/understanding-preventing-suicide-dvd0/

6 Dazzi, T., Gribble, R., Wessely, S., & Fear, N. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299

7 Glendon.org. 2021. Dynamics of Suicide: An Interview with Dr. Israel Orbach « The Glendon Association. [online] Available at: https://www.glendon.org/product-post/dynamics-of-suicide-an-interview-with-israel-orbach/

8 Glendon.org. 2021. Understanding & Preventing Suicide – DVD « The Glendon Association. [online] Available at: https://www.glendon.org/product-post/understanding-preventing-suicide-dvd0/

9 Glendon.org. 2021. Firestone, R.W. – The “inner voice” and suicide « The Glendon Association. [online] Available at: https://www.glendon.org/resource/firestone-r-w-the-inner-voice-and-suicide/

Photo by Francisco Moreno on Unsplash

Stress – What It Really Is & How To Manage It.

Stress – What It Really Is & How To Manage It.

Stress is something we can never escape from, be it good (eustress) or bad (distress). From the small, tedious daily hassles to long-term occurrences that weigh on your mind, stress can impact us in different ways, and the experience varies for everyone. Just as how different individuals have differing levels of pain tolerance, the same applies for stress.

Stress comes in many forms, but they can be largely categorised under ‘environmental’ (e.g noise), ‘social’ (e.g family demands, friendship conflicts), ‘physiological’ (e.g sleep disturbance) and ‘cognitive’ stressors (e.g low self-esteem, high expectations of oneself). While a certain level of stress may be necessary to provide motivation and encourage positive growth, excessive and unhealthy levels of stress especially in the long-term may cause undesirable mental and physical health consequences:

Psychological Impacts Physical Impacts
Mood swings Disrupted sleep patterns / insomnia
Undue anxiety or fear Hyperventilating
Difficulty concentrating / forgetfulness High blood pressure
Disorientation Nervous behaviours such as teeth grinding or nail biting
Increased frustration and irritability Nausea
A racing mind / constant worrying Poor eating / digestive upsets
Poor decision-making processes Increased heart rate / rapid breathing
Low self-esteem Sweating / sweaty palms
Sense of helplessness Muscle tension
Apathy Restlessness / fatigue

 

When stress becomes chronic, physical health consequences can definitely worsen, and an individual may also develop depression or anxiety disorders. As such, while there is no one-size-fits-all, this article aims to provide useful tips and suggestions on how you can better manage your stress levels, and to avoid being overwhelmed and giving in to chronic stress.

To guide us along, there are two main types of stress-coping mechanisms – ‘Problem-focused’ and ‘Emotion-focused’ coping. These are possibly the most basic approaches to healthy stress-coping, and aim to reduce or eliminate the causes of stress, apart from merely alleviating its symptoms. 

Problem-focused Coping

Problem-focused coping is where action is taken to clarify and resolve the stressor directly, and hence addresses the demands of a given situation. An example of this method of coping is when a student who is worried over an upcoming examination copes by attending more review sessions and reading up on her course materials diligently. This serves to reduce her anxiety and increase her confidence to excel in her examination. A problem-focused mechanism is primarily used when one appraises a stressor to be within his capacity to change, and hence makes the appropriate adjustments and alterations to cope with the impending demands. As such, it is also important to learn how to identify the root cause of the direct stressor before responding to it accordingly. 

Emotion-focused Coping

Emotion-focused coping may be a concept that you find familiar. Unlike problem-focused coping, emotion-focused coping involves making efforts to regulate your emotional response to a stressor. This means identifying your feelings, focusing and working through them. According to Folkman and Lazarus (1980), such a mechanism can be extremely helpful especially when you need to work through your emotions before you can think clearly enough to act rationally. Emotion-focused coping can be done in various forms such as:

  • Venting or talking to a friend / close oneWhenever you feel stressed or overwhelmed, bottling up may not be the best way around. Talking to others about what’s bothering you could bring great relief, and perhaps they could also provide you with the constructive feedback or encouragement that you need.  Physical affection, such as hand-holding and hugs can help combat stress too. Just as how others may come to you whenever they need support, don’t be afraid to lean into your social circle and find comfort in your friends. Of course, do also remember to be mindful of your friends’ emotions and needs while you’re busy venting!

 

  • Journaling
    In this digital age, perhaps Journaling may come across as a rather old-fashioned way of coping with your emotions. Many a time, people would rather distract themselves and destress by playing mobile games or browsing through social media as and when they are feeling stressed. Although those can be a possible methods of destressing, the beauty of journaling shines through when you give yourself some time to reflect and balance yourself by creating your very own safe space. Writing in a journal can help you clear your mind by releasing any pent-up feelings, to let go of negative thoughts, as well as to enhance your self-awareness as you write about your progress.

 

  • Meditation
    Practising mindful meditation is an effective strategy to combat stress, for it can help you eliminate the stream of jumbled thoughts that are contributing to your heightened stress levels. Studies have shown that training in mindfulness can potentially increase your awareness of your thoughts, emotions, and maladaptive ways of responding to stress, therefore allowing one to cope with stress in a healthier and more effective way (Bishop et al, 2004, in Shapiro et al, 2005). With guided meditations that can easily be found online, all you need to do is to set aside some time for some mental self-care.

 

  • Reframing the situation and finding meaning in it
    When we are stressed, we often only focus on the bad and how much we dread a particular situation. However, it can be helpful to look on the bright side and to find the benefit and meaning in a stressful event. By doing so, we can make these experiences a little more tolerable, as well as to grow and build resilience as we go along.

 

Other Means of Coping with Stress

Last but not least, pay more attention to your diet and nutrition intake. For some of you, caffeine is a must-have on a daily basis, with some people having four to five cups of coffee per day. However, when you combine stress with the artificial boost in stress hormones from caffeine, this creates a significantly compounded effect. While caffeine can be particularly effective in providing you with the short-term energy boost and increased alertness, it can potentially heighten stress levels in the long-term. As such, it is always good to consume it in moderation and to be mindful of your caffeine intake. In addition, you may want to consume foods rich in vitamin B, which can help to reduce stress responses in your body.  

As previously mentioned, everyone experiences life events in their own unique way, and a strategy that works for you may not for others. With that said, we hope this article has helped you to understand the various ways to combat stress better, and that you find the strategy best suited for you. However, if you ever find yourself struggling to cope with stressful life events, do reach out to one of our psychotherapists or counsellors for help.


References:

  1. Zimbardo, P. G., Johnson, R. L., & McCann, V. (2017). Psychology: Core Concepts (8th ed.). Pearson. (Accessed 25/11/2020)
  2. Shapiro, S.L., Astin, J.A., Bishop, S.R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: results from a randomised trial. International Journal of Stress Management, 12 (2), 164-176. (Accessed 25/11/2020)
  3. https://dictionary.apa.org/problem-focused-coping (Accessed 25/11/2020)
  4. Photo by Tim Gouw on Unsplash
What Are Anxiety Disorders and How Do They Affect Us?

What Are Anxiety Disorders and How Do They Affect Us?

We are no strangers to feelings of anxiety – at certain stages of our lives or in particular situations, we would have experienced anxiousness and worry with relation to our careers, studies, relationships and even our environment. However, anxiety levels may go beyond the healthy norm for some people, and may instead develop into anxiety disorders that may have a debilitating effect on their lives. According to the American Psychology Association (APA), an individual who suffers from an anxiety disorder is described to have “recurring intrusive thoughts or concerns”, where the duration and severity in which the individual experiences anxiety could be blown out of proportion to the original stressor, resulting in undesirable tension and other physical alterations. In this article, we will be exploring a few types of anxiety disorders as well as how they can manifest within us.

 

Generalised Anxiety Disorder (GAD)

Generalised Anxiety Disorder is a psychological issue characterised by persistent and pervasive feelings of anxiety without any known external cause. People who are diagnosed with GAD tend to feel anxious on most days for at least six months, and could be plagued by worry over several factors such as social interactions, personal health and wellbeing, and their everyday routine tasks. For example, an individual with GAD may find himself experiencing headaches, cold sweats, increased irritability and frequent feelings of “free-floating” anxiety. Others may also experience muscle tension, sleep disruptions or having difficulty concentrating. Often, the sense of anxiety may seemingly come from nowhere and last for long periods of time, therefore interfering with daily activities and various life circumstances.  

 

Panic Disorder

In contrast, Panic Disorders are characterised by the random occurrence of panic attacks that have no obvious connection with events that are co-occurring in the person’s present experience. This means that panic attacks could occur at any time, even when someone is casually enjoying a meal. Of course, panic attacks could also be brought on by a particular trigger in the environment, such as a much-feared object or situation. Some individuals have reported that panic attacks feel frighteningly similar to a heart attack, especially with the rapid increase in heart palpitations, and the accompanying shortness of breath. Other symptoms also include trembling, sweating, and feelings of being out of control. With these panic attacks bringing on sudden periods of intense fear and anxiety, it can be exceptionally terrifying when these attacks reach their peak within mere minutes. However, a notable difference between a panic disorder and GAD is that an individual diagnosed with panic disorder is usually free of anxiety in between panic attacks.  

 

Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder is a disorder marked by patterns of persistent and unwanted thoughts and behaviours. Obsessions are recurrent thoughts, urges or mental images that cause anxiety. On the other hand, compulsions are the repetitive behaviours that a person feels the urge to do in response to an obsessive thought or image. One common example often exhibited in films is where an individual has an obsessive fear of germs. This person may avoid shaking hands with strangers, avoid using public restrooms or feel the urge to wash their hands way too frequently. However, OCD isn’t purely limited to feelings of anxiety due to germs. OCD can manifest in other ways as well, such as wanting things to be symmetrical or in perfect order, repeatedly checking on things (“Did I leave my stove on?”), or the compulsive counting of objects or possessions. While everyone double-checks their things and has their own habits, people with OCD generally cannot control their thoughts and behaviours, even if they are recognised to be rather excessive. They can spend at least 1 hour a day on these thoughts and behaviours, and will only feel the much-needed brief sense of relief from their anxiety when they perform their rituals. As such, OCD can be exceptionally debilitating to one’s mental health.

 

Social Anxiety Disorder

Persons with Social Anxiety Disorder, or SAD, experience high levels of anxiety and fear under particular or all social situations, depending on the severity of their condition. They are often afraid of being subjected to judgement, humiliation or rejection in public, causing them to feel embarrassed. As such, individuals with SAD may feel extra self-conscious and stressed out, and try to avoid social situations where they might be placed at the centre of attention.

 

Phobic Disorders

A phobia involves a pathological fear of a specific object or a situation. This means that one may experience intense anxiety upon encountering their fears and will take active steps to avoid the feared object. Phobias may centre on heights(acrophobia), birds (ornithophobia), crowds and open spaces(agoraphobia), and many others. People with agoraphobia, in particular, may struggle to be themselves in public spaces, for they think that it would be difficult to leave in the event they have panic-like reactions or other embarrassing symptoms. In severe cases, agoraphobia can cause one to be housebound. 

 

Options for the treatment of anxiety disorders include medication from a psychiatrist and therapy with a psychologist, psychotherapist or counsellor, and anxiety disorders can be treated with either one or both methods. While medication does not cure anxiety completely, it helps to relieve its symptoms, allowing the individual to cope better. Psychotherapy methods such as Cognitive Behavioural Therapy can be particularly effective as well, for it aims to help victims of anxiety disorders change their way of thinking, behaving, and their way of reacting to certain anxiety-causing stimuli. 

 

It is important for us to recognise that seeking treatment for anxiety disorders is crucial, especially if it hinders or interferes with our daily life. While one may choose to adopt the “I can handle it myself” attitude – perhaps due to any pre-existing stigma or societal expectations –  we need to acknowledge that we will ultimately be worse off if we do not seek help early. Don’t struggle alone, talk to us about ways to manage your anxiety and find the support you need.

 


References:

  1. https://www.apa.org/topics/anxiety (Accessed 03/12/2020)
  2. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml (Accessed 03/12/2020)
  3. https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml (Accessed 03/12/2020)
Photo by engin akyurt on Unsplash
Five Unhelpful Things You Should Avoid Doing When You Meet Someone That Self-Harms

Five Unhelpful Things You Should Avoid Doing When You Meet Someone That Self-Harms

The anonymous author of this article is a person in the recovery of Major Depressive Disorder and Borderline Personality Disorder. The views of the author are not those of Promises. 

I have struggled with Self-Harm since I was a kid. Most of us are aware of the tantrum’s kids put up when they are upset. They hit others, drop to the floor, scream, and cry. When I felt overwhelmed by certain emotions, in particular anger or sadness, I would use my hands to hit my head. I had trouble identifying and regulating my emotions. My primary school counsellor told me that I have anger management challenges when I shared with her how I find myself unable to control my anger and would hit myself or the well. Little did I know that these behaviours were early signs and symptoms to what would become a diagnosis of Major Depressive Disorder and Borderline Personality Disorder given to me in my 20s.

When the word ‘Self-Harm’ is mentioned, most people think about ‘cutting’. A very common and increasingly concerning the mode of coping for persons in distress, more so for young people, even children. Fortunately, I never turned to ‘cutting’ until I was 23. I was actively suicidal from the stress of battling my illness while also trying to excel in my degree. I began with a penknife and one cut. Soon, that one cut led to many and I found myself with a new problem.

I struggle with Self-Harm till this very day; however, I have come a long way with the help of medications and therapy to reduce the frequency of Self-Harm. I have been trying to replace Self-Harm with healthier coping methods such as exercise. 

When I do not wear long sleeves, I end up exposing the scars on my wrists to the world. Generally, I tend to feel ashamed of my scars and it took me some time to embrace them. However, responses from others who have noticed my scars have caused discouragement to me and led me to feel ashamed once again. Ironically, this does not deter me from ‘cutting’; instead, it increases the urge because I develop self-hatred and feel like I deserve to be punished and scarred for my behaviour.

Through this sharing of my experience, I hope to send a message of love to peers who are challenged with Self-Harm, whatever form it might take on. I also want to raise awareness among members of the public on what were some unhelpful words and behaviours people have made towards me, more so out of a lack of awareness rather than a lack of concern. I have learnt to forgive them, and at times have also made the effort to voice my discomfort over their words and actions. Here are five things people have said or done to me that were completely unhelpful, and very likely also to be unhelpful to anyone else challenged with Self-Harm.

1. Touching me without permission
I get it, you notice the scars and you get worried. Without thinking, you grab my arm and go “what is this? Did you cut yourself?”. Leaving the question for later, the very act of grabbing my arm to look at my scars without permission is a big ‘NO’. I am hypersensitive to my scars and it takes much courage for me, even till today, to deliberately lift my arm to show my scars. What may surprise you is that, often, this act comes largely from my own parents and also the professionals I see for help. It is good practice to always ask someone for permission if you wish to touch them, even if it means to give a hug. Because some of us who have challenges with trauma and dissociation are hypersensitive to touch. Hence, do be mindful of those around you and remember: If you do not like people grabbing you to see something (on you), it’s the same and perhaps even more, for those of us learning to accept our scars.

 

2. “Doesn’t it hurt?”
No, it doesn’t. This answer may come as a surprise to many, but when I am under extreme stress and emotional distress, the act of physically inflicting hurt on myself gives me relief. The greater the physical “pain” the greater the relief. For me, this goes for any act of self-harm be it ‘cutting’, punching the wall, or knocking my head against the wall until it starts bleeding. I can only compare this to someone who meets with an accident. The body goes into shock to the point the person may have a broken leg; however, he or she is not feeling any pain. I do not have a formal education in psychology or biology, but I believe my brain “shuts down” the part that feels pain which aids me to self-harm without feeling the actual pain.

 

3. “The scars are so ugly! Why do you enjoy this? Can’t you stop?”
This is a three-part question, but it often comes to me in one line of questioning. First, I want to say that I do not enjoy this. Not at all. I would love to have clear and beautiful skin too. Every time I look down at my arm to see the scars, I feel hatred towards myself. “How could I do this to myself? I am a horrible person”. And yet, I find that I cannot stop. A coping method I have turned to, since childhood, to cope with the traumatic experiences and intense emotions is self-harm. It has become the default and almost automatic ‘subconscious’ act whenever I am in distress.

 

4. “It doesn’t look too bad”
I know that this statement is in direct contrast to the one above. But I have had this said to me by peers and sadly, professionals. There is not much need for me to elaborate on this statement as it is obvious that it is unhelpful. This statement makes me feel like a failure and makes me want to hurt myself even more. The ‘Depression voice’ is always on standby, ready to jump in with a “See, you are useless at even trying to hurt yourself? You call that a cut?! You are a coward. Go and do it again”.

 

5. Taking away or hide the sharp items that I could use to hurt myself
This is probably most relatable to parents and caregivers supporting someone who is challenged with self-harm. It is very natural to become protective and do what it takes to stop your loved one from hurting themselves. “If I take away their means to hurt themselves, then they have no choice but to stop, right?” Unless you tag along with your loved one 24/7, it is very easy to drop by the nearest bookstore to buy a new penknife. More importantly, in doing so, you are taking away the one thing that I have which keeps me from jumping out of my window or overdosing on my pills. Until I learn to safely stop self-harming in therapy, to take it away from me by force, will throw me into an emotional turmoil that will only make me feel worse.

So please, next time you notice someone with scars that look like they might be from the act of cutting one-self, please be gentle and kind to the person. Be extremely mindful of what you say. Perhaps, a guiding thought could be: If you cannot entertain the idea of causing pain to yourself, imagine how much pain the person must be in to be able to cause harm to themselves. When I self-harm, it is a desperate means for me to stay alive. It is a cry for help: for attention, for love, care and non-judgemental support.

If you know a loved one who self harms please do gently prod him/her towards seeking help from a trained professional.


Photo by Chaozzy Lin on Unsplash
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