A Primer on Depression and Bipolar Disorder

II. MOOD DISORDERS AS PHYSICAL ILLNESSES

C. Treatment of Depression and Bipolar Disorder

As has been mentioned several times above, the most effective tools available for the treatment of depression and bipolar disorder are medications (i.e. drugs). Nevertheless, many victims of these illnesses are often concerned and confused about taking medication, and therefore resist treatment.

From my experience with hundreds of people who have CMI, I have concluded this resistance originates from two erroneous ideas. First, there is a confusion of therapeutic psychiatric medication with illegal psychoactive "street drugs''. Anyone beginning treatment with psychiatric medication needs to understand clearly that there is no more connection between the former and the latter than there is between a Greyhound bus and a miller moth.

The street drugs are chosen because they interfere with normal operation of the brain and produce abnormal and often bizarre mental responses. They actually destroy normal brain function, and if abused in sufficient quantity for sufficient time, can lead to injury or even death. In contrast, psychiatric medication has been very carefully chosen, perhaps even "designed'', to restore normal brain function to the greatest extent possible.

They are very carefully tested for efficacy and safety. Only after passing a rigorous review procedure are they released for public use. Subsequent to release, their performance is continuously monitored as they are used in thousands to millions of doses each year. In short, one need not have any fear whatsoever that psychiatric medication will have the same harmful effects as illegal street drugs.

Second, many potential users are fearful that psychiatric medication will degrade or interfere with their mental abilities. These fears are rarely a problem for people with deep depression (who basically will do anything reasonable to gain release from the depression), but often are quite strong for people who are mildly to moderately manic because those people feel ``good'', and believe that they have superior mental (and sometimes physical) abilities and performance.

These people don't want anyone tinkering with their ``mind''. They need to be convinced and reassured that controlling their mania will not degrade their intelligence, insight, cognitive and learning abilities; I can vouch first-hand for this statement. What they will lose is speed: the same tasks take a little longer. But those tasks will typically be done more carefully. It's a tradeoff: one loses the manic sense of speed and power, but one also is no longer driven obsessively, scattered by dozens of intrusive ideas and thoughts. And one loses the sense of isolation that characterizes mania because one is unable to make meaningful person-to-person contact with those around oneself.

For me, the manic state always produced the sensation of my seeming to be living in someone else's mind, or someone else living in mine. That is an unpleasant experience. I am more than happy to sacrifice manic "facility" in order to get rid of the other unpleasant, threatening, and destructive aspects of mania.

I will not go through the catalog of medications here because it has grown quite large, and excellent and authoritative discussions are easily available in the books cited in the Bibliography. In broadest terms, there are three groups of medications used to treat depression: (1) the tricyclics, (2) the MAO inhibitors, and (3) SSRIs (Selective Serotonin-Reuptake Inhibitors). The tricyclics were discovered first, and sometimes remain useful treatment strategies to this day. The MAOIs have restrictive dietary constraints for their use, and can have troublesome side effects; but for some people they provide effective relief. The breakthrough came with the development of the SSRIs. They work by inhibiting the reuptake of the essential neurotransmitter serotonin from a synapse between two nerve cells that have just fired, thus leaving it in place for the next time it is needed. These drugs (e.g. Prozac, Zoloft, Wellbutrin, Effexor) have proven to be extraordinarily effective in treating depression, while having only minor side effects. They have the advantage of not introducing something new to the "ecology" of the brain, but merely inducing the brain to leave one of its own natural "ingredients" in place so that it can be used when next needed.

It must be emphasized that specific person may respond to several of these drugs, just a few or even just one, or none. The challenge to the therapist is to discover, as quickly as possible, the drug that works best for each individual treated. If he/she is skilled (and lucky!), the first choice may work effectively and quickly. But if it doesn't, it is imperative to continue to try other possibilities until one is found that works!

This requires strong commitment on the part of both the victim and the physician. For example, in 1985, I started off with Desyrel, chosen by my doctor because it was the current ``wonder drug'' and putatively had few side effects. For me Desyrel was a disaster: it gave me no relief from depression after months of treatment (typically an antidepressant begins to work within 3 weeks of when it was started), it confused me, it made me uncontrollably sleepy during the day, and interfered with thinking and cognition.

Only after months of being so ``treated'' did I get effective help from Drs. Grace and Dubovsky, who switched me to a tricyclic, desipramine. As described above, within three weeks this different medication broke the depression. If you are not getting relief after a reasonable time, don't be shy about talking to your doctor about trying a different medication. The change might save your life. In 1997, when Desipramine had failed for me, it was clear what to do: Dr. Johnson immediately phased it out, and moved me to the SSRI Effexor without a hitch. That has made a world of difference!

Until recently, the first line of defense against mania was lithium (carbonate). It was discovered by John Cade in Australia in 1949, but was not used therapeutically in the U.S. for almost another 20 years. Sometimes in emergency cases the victim is started off on an antipsychotic drug such as Thorazine, Mellaril, or Trilafon; these are designed to help the victim calm down and make closer contact with reality. In cases of extreme mania -- someone totally out of control, needing to be restrained -- the effects of these antipsychotic drugs are often downright amazing. In the space of a very few days the victim becomes calm, and fairly normal in terms of overall behavior.

In 1997 this approach, including restraint, was necessary for me. If lithium fails to control the mania sufficiently, or has undesirable side effects, the therapist will then try other anti-manic agents such as Valproic Acid (Depakote), Tegretol, or Klonopin. These days Valproic Acid has generally become the preferred treatment for mania.

It is also worth mentioning that the effects of anti-manic treatment generally improve with time. In my own case, for example, I have noticed a definite, continuous "ramping up" in my general sense of well being, and my objective job performance. At the same time, it has been possible to reduce by almost half the amount of the medication I originally took. On the other hand, when lithium failed me, it failed suddenly, and I would have needed intensive medical supervision to have detected the transition.

After I was moved to Depakote, I felt much better than before; a persistent hand tremor that I had while taking lithium vanished, and I feel generally "calm" all the time. It is a blessing. All of these experiences point to the fact that it is essential to stay in close contact with your doctor while being treated for these illnesses; the disease is chronic, and your fight against it is likely to last a lifetime!

There are a number of practical issues to be faced when taking psychiatric medications. Like all medications, psychiatric drugs have side effects. Many of them are inconsequential, some are more serious. For example, with the antidepressants, it is common to experience a dry mouth. Sometimes this is so serious as to prevent one from speaking, and a drink of water doesn't solve the problem because what is needed is saliva produced by the body.

This one has been a problem for me because when I was a professor, I gave lectures. I solved the problem by chewing sugarless chewing gum when I felt the dryness start. It's a bit vulgar in appearance, but I simply explained to my students why I did it, and they accepted it.

Lithium can have two troublesome side effects. One mentioned above is that it often causes small-muscle tremor. I remember a period of time when I could not drink tea because I couldn't lift the cup from the table to my mouth without spilling it all over the table. Tremor was especially troublesome for me because it got so bad that I simply could not write; this seriously interfered with my daily professional activities. My doctor told me there was another drug to control the tremor, but I decided not to take any drugs that I didn't have to; eventually the tremor went away, seen only under extreme stress, and even then only a little.

A more serious side effect of lithium is that if its concentration in your bloodstream gets too large it can damage your kidneys. This problem can be avoided by having blood tests to measure the lithium level in your blood. Typically this will be done fairly frequently (monthly or maybe even weekly) when you first start lithium, but later, if your level is pretty constant, your doctor will check it maybe every 3 months. Similar remarks apply to Depakote.

Finally there is the very serious problem lithium caused me during rehabilitation from my auto accident: the margin between the therapeutic and toxic levels of lithium in the bloodstream is small. And because I became dehydrated while in the hospital, my lithium blood-level soared way above the toxic level, and induced the terrible coma I have described above. With Depakote, the known therapeutic range is about a factor of four, and the highest dose is still much below toxic. Thus compared to lithium, there is an enormous safety factor. In my case, I take almost the minimum dose, so I never expect to have any trouble with it.

It is crucial to take your medications exactly as your doctor prescribes. Do not "experiment'' with changing the dose on your own. Sometimes it is hard for people to remember whether or not they have already taken a pill that day, but it is vital not to take too many or too few. I beat the problem of an aging memory by using the small compartmented pill dispensers available in drug stores. They usually have seven compartments labeled with the days of the week, so one can tell immediately whether the correct number of pills have been taken.

It should also be stressed that you should never stop taking your pills all at once (``cold turkey''); to do so shocks the nervous system, and could precipitate a very severe psychiatric episode. If your doctor agrees that you should give up on a medication, always ramp the dosage down slowly over several days. For someone like me this is probably useless advice because it seems plain that I will be on my medications for the remainder of my life.

next: Suicide and Bipolar Disorder - Part II
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Tips on the school management of the child with ADD. The following suggestions are intended for teachers in the classroom, teachers of children of all ages.

Teachers know what many professionals do not: that there is no one syndrome of ADD but many; that ADD rarely occurs in "pure" form by itself, but rather it usually shows up entangled with several other problems such as learning disabilities or mood problems; that the face of ADD changes with the weather, inconstant and unpredictable; and that the treatment for ADD, despite what may be serenely elucidated in various texts, remains a task of hard work and devotion.

If anyone ever tells you dealing with a child with special needs is easy, then take little notice of anything they tell you. Dealing with children who present complex learning patterns or challenging behaviour will stretch you to your very limits personally and professionally. When working with a child with ADHD/ADD in the classroom, it is persistence that will prove to be your greatest asset.

The ideas and strategies suggested below are for all age groups and specific age groups. Use your own judgment to decide on the suitability of an intervention technique for the child and age group you are working with.

1. Be sure you are dealing with ADHD/ADD. It is definitely not the role of a teacher or parent to diagnose, but it is your role to pick up on a likelihood/possibility that this condition may be causal in the child's difficulties and refer on to medical personnel who are in a position to diagnose and medicate if appropriate.
2. Have you had the child's hearing and vision checked out?
3. Access to support systems is crucial. Do you know a colleague who has successfully dealt with an ADD/ADHD child? Do you have someone who you can talk to about your frustrations and celebrate your successes with? You will also need access to knowledge. This can come in the form of a person or an information source such as the INTERNET. You could also check on this site at www.adders.org for contacts of a local Support Group in your area as they would be able to give you local information. Also on adders.org you will find many resources which may help. You can also use any of the information on here to give to parents who may want to find out a lot more for their child.
4. Accept the child for who they are, recognise their qualities and their good points as well as those which are disruptive behaviours and irritating points. Trust is a 2 way thing - the child needs to learn to trust the teacher and when they do they will give so much back to that teacher it is quite amazing. Remember these child get used to being told they are wrong or that they are being naughty, this has a major effect on their sense of self worth and well being. A lot of these children end up expecting to be told off or criticised and often will not want to tell the truth as they know from past experience that they will not be believed - other children are also very quick to point the finger of blame as they know that the child is normally held responsible for things which go wrong so try to build up trust between yourself and the child and let them know that you do believe what they are saying and you are going to be fair in any sanctions which may have to be given out. They often have a great sense of injustice when they are the ones to have sanctions imposed on them and they see other children doing things at the same time or at other times who are not even spoken to about these. The ADHD Child will then learn that no matter what they say they will get the blame for things so they may as well do these things anyway!
5. You will need the parents to be on side with you. Encourage them to be open with you and to exchange information with you, sometimes parents have strategies which often work at home which can be applied to the classroom situation. This is also a 2 way thing and be open with the parents and work to build up trust between yourself and the parents to be able to work together for the good of the child.
6. Don't be afraid to ask for help. Teachers are too often willing to soldier on without asking for help. This does not do you any good in the long term. Sick and worn out teachers are a loss to children. So speak up. Say when you need help and advice.
7. Use the child as a resource. Ask what lesson do they recall as being the best they have ever been in. What was there worst ever lesson. How were the two lessons different? Try and unpack the child's learning style with their help.
8. Does the child know what ADD/ADHD is? Can they explain it to you? Can the child suggest ways that their difficulty might be made more manageable within the school setting?
9. ADD/ADHD kids need structure. Lists help. Such as lists of the process they are involved in such as writing an essay. Lists like how to behave when being told off can be of great help.
10. It is crucial that the child is caught being good. Many of the reactions to situations will be impulsive. We tend to notice the impulsive reactions that are overt and noticeable because they break a rule or code of behaviour. However, if you observe the child you will notice a vast array of reactions not all of which are outside accepted behavioural conventions. When an acceptable behaviour is presented. Praise and reward.
11. Having clear behavioural expectations in places the child can see them can help. For instance a sign saying please sit still and listen could be posted behind the place where the teacher often talks. The teacher may then point to the poster as a first reminder to come back on task.
12. ADD/ADHD means that the child has a problem with concentration. Therefore when you have an expectation that a series of instructions will be followed they will need to be presented more than once and in more than one way. They will also need to be presented so that the child can refer back to them as need be.

13. If the child is off task it is often a good idea to get them to move around for a couple of minutes, when they then go back to the task they are more likely to settle back to the actual task then if they are just told to get on with their work. It is often difficult to allow individual children to get up and walk around when the others are all working - it is therefore a good idea to have something set up with another teacher where you can get the child to take a note to the other teacher and bring a message back - this does not have to be very much in fact the note could even just say what are you having for dinner tonight - as long as you and the other member of staff have sorted this out in advance they will be able to realise that this is helping the child to be less disruptive in your class. Another idea is to ask them to come and wipe the board for you. Once they have been able to move around for a couple of minutes they will be able to go back and focus on the work in hand and will probably get much more accomplished than normal.
14. Eye contact is a good way of bringing a child back to task.
15. Seat the ADD child near to your desk and make sure that the child is within your line of sight most of the time. This will help the child stay on task.
16. Don't fall into the trap of getting into discussions where the child is acting as a barrack room lawyer. These are not meaningful to the child and they only serve to wear you out. If the child needs stimulation then the child needs to be encouraged to say so in an assertive way. They need to then engage in an activity that they have found settling in the past. For a short period and with permission.
17. Make the day's schedule predictable and visible. Post the schedule where the child will be able to see it and will see it. For instance on their desk or on the board. Tell the child if any changes to the regular schedule are going to happen. Tell the child well ahead of time about a change of activity and keep on warning them until the transition has taken place.
18. Work toward the child drawing up the schedule for their out of school time.
19. Timed tests are not good measures of knowledge for a child with ADHD/ADD. Therefore they have little if any educational value for these children. It would be best to eliminate them and choose an alternative method of testing for knowledge retention and application.
20. Use alternative methods of recording if the child finds them useful. Remember what matters is that the child processes the information you wish to impart. The method of processing can make a difference to the child. Pen and paper is very simple and convenient for the teacher but if it doesn't work for the child then an alternative needs to be found.
21. Frequent feedback helps keep the ADD/ADHD child on task; it is also very useful in letting them know what is expected of them and if they are achieving expectations. Naturally the resultant praise will be very encouraging.
22. One of the most crucial teaching techniques for children with ADD is to break down large tasks into small tasks. This ensures that the child does not feel overwhelmed. As the child learns they can bite of more and more they will need the chunks to be larger. Increasing and managing the way information and task are presented does take time and is a highly skilled business. However, this will be extremely helpful in avoiding tantrums born of frustration with small children and with older children it can help them avoid the defeatist attitude that so often gets in their way.
23. Novelty and fun are good ways to gain attention. ADD/ADHD children will respond to it with enthusiasm.
24. Try your very best to catch the child being good. Many of their responses are impulsive. We tend to notice the socially inappropriate responses and miss the many acts of generosity and apparent maturity that may also be the impulsive response. Of the real problem with ADD/ADHD children is not the condition but the hostility that has arisen due to the persistent imposition of punishment.
25. Teach the child how to draw up mind maps. Encourage the use of this technique in lessons, it will give the child a greater sense of being in control of what is going on.
26. Many ADD/ADHD children have a tendency toward being visual learners. Therefore some form of visual cue allied with your verbal explanation will probably aid comprehension of the task being set and the expectations you have for the piece of work being set. They also very often have things which they are very interested in - if a child has a passion for cars then most subjects can incorporate cars - English - write about a car, Maths - count cars - Art - draw, paint, model a car, History - of the motor car, Geography - travel / journeys by car. Most things can be incorporated with a little imagination.
27. Keep every thing as simple as possible. Make things fun so that they will attract the child's attention thus increasing the chances that the message will be absorbed.
28. Use difficult situations and moments in the Child's day as opportunities to teach the child and give feedback. Averagely children with ADD/ADHD are quite poor at comprehending how they come over to others. Therefore a piece of silly behaviour can be dealt with by asking the child how it affected others. How it affected the way others will see the child etc.
29. Make your and the schools expectations very clear.
30. Give some thought to the use of a points based reward system as part of a behavioural modification program younger children. Children with ADD respond well to rewards and incentives.

31. If the child appears to have difficulty with social skills and appropriate behaviours. It would be very useful to analyze just what skills are lacking and then teach or coach the child in these skills. There are some very good resources about specific ADHD coaching on adders.org
32. Make a game out of things. Motivation improves ADD.
33. Pay particular attention to who sits next to who.
34. Your life will be much easier if you can keep the child engaged and motivated. Time spent planning activities to make them as engaging as possible will be repaid many times over.
35. Give as much responsibility as possible to the child.
36. Try a home-to-school-to-home positive contact book.
37. The development of self-assessment and self-reporting is crucial to the development of internal limit setting. For instance the use of daily reporting sheets can be very effective. More effective still if the child sets the behaviours to be monitored. The child decides if they have achieved the set behaves. Usually I ask the child to get the teacher to initial if they agree or disagree with the child's perception of their own behaviour. This should be done in a clinical fashion if the teacher disagrees but with lots of praise if the child has achieved targets and is correct in their perceptions.
38. Suddenly given these children unstructured time can be a recipe for disharmony. Let them know well in advance when unstructured time will be so they can plan out what to do and how to fill the time.
39. Give as much praise as you are humanly able.
40. Develop active listening skills by encouraging children to take notes of not only what they hear but the ideas they have and their thinking around an issue.
41. Give serious consideration to the use of alternative methods of recording.
42. Get the full attention of the class before starting to teach.
43. Try and arrange for students to have a study partner or be part of a study group. Get the children in the group to exchange telephone numbers and other contact information. This will enable the child to clarify points that they may have missed quickly and easily. It will also allow other members of the group to benefit from their energy and enthusiasm.
44. Explain and normalize the treatment the child receives to avoid stigma. Be prepared to sit down with the whole class and explain in language they understand about how people are all different and that a lot of children have problems of one sort or another and then explain about how ADHD symptoms can show in a child and how the rest of the class can help that child to fully integrate with their peers. Peer relationships are often very difficult so it is essential for the child's self esteem and general well being to help them to fit in with their peers and for them to be accepted by their class mates.
45. Review with parents often. Avoid the pattern of just meeting around problems or crises, celebrate success. It is very nice on occasions for parent to receive a phone call from school to let them know when their child has had a good day. They often sit at home or work dreading that phone call to say that their child is in trouble again at school. This is also very good for the child and their self esteem as when they get home the parents can give spontaneous praise and tell them how wonderful it was that their teacher had phoned them today to tell them how well the child has done.
46. Read aloud at home and in class as much as possible. Use story telling. To help the child build up a sense of sequence. Help the child build the skill of staying on one task.
47. Repeat, repeat, repeat.
48. Vigorous exercise helps work off excess energy, it helps focus attention, it stimulates certain hormones and neurochemicals that are beneficial, and it is fun. Make sure the exercise is fun, so the child will continue to do it for the rest of his or her life.
49. With older children, their learning will be enhanced considerably if they have a good idea of what will be learnt that day.
50. Be on the lookout for things to enjoy about the child. The energy and dynamism they have can be very beneficial to their group/class. Try and pick up on their talents and nurture these. As they have taken many of life's knocks they tend to be resilient, always bouncing back because of this they can be generous of spirit, and glad to help out.

About the authors: Drs. Hallowell and Ratey are experts in ADHD in children and have written many books on the subject including "Driven To Distraction."

• I am a capable person.

• I am a competent person.

• I am an intelligent person.

• I am a worthwhile person.

• I can dare to take a risk.

• I am entitled to good.

• I choose to be happy.

• I can ask for what I want.

• I can say what I feel.

• I am a radiant expression of God.

• I trust and follow my inner guidance.

• I am an unlimited being.

• I can create anything I want.

• I picture abundance for myself and others.

• I have a right to exist.

• I can dare to see what I see.

• I can dare to think what I think.

• I can dare to question anything.

• I can dare to feel what I feel.

• I have a right to come to my own conclusions.

• I am Happy Joyous and Free.

• I have a right to make mistakes.

• I have a right to be wrong.

• I have within myself the answers to all my needs.

• I am a beautiful person.

• I am free to be me.

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continue story below


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• I do not need to prove myself.

• My mind and body are now in balance and harmony and manifest divine perfection.

• I accept responsibilities in my life happily and enthusiastically.

• I am the master of my being and an active co-creator of my life.

• The entire Universe Loves me, serves me, nurtures me and wants me to win.

• I am a success to the degree that I feel warm and loving to myself.

• My debts represent my & others beliefs in my future earning ability.

• The most important thing to my loved one's happiness is that I be happy first.

• My value and worth are increased by every thing I do.

• All my experiences are opportunities to gain more power, clarity and vision.

• I can fill all my needs if I am willing to pay the price.

• I have a right to ask for and expect something in life.

• Comparison of myself with another is meaningless.

• I am the center of my universe; my world revolves around me.

• The Christ/Goddess/Spirit within me is creating miracles in my life here and now.

We can tell ourselves good things!

I AM a magnificent Spiritual being having a Joyous and exciting human adventure!

If we Truly believed the positive affirmations we would not have to say them. When we most need to say them is when we least believe them when we are feeling the worst. The source of all of our wounds ultimately is feeling abandoned by God, feeling unlovable to our Creator.

"Integrating the Spiritual Truth (the vertical) of an unconditionally Loving God-Force into our process is vital in order to take the crippling toxic shame about being imperfect humans out of the equation. That toxic shame is what makes it so hard for us to own our right to make choices instead of just reacting to someone else set of rules."

Column "Empowerment" By Robert Burney

We need to own that we have the power to choose where to focus our mind. We can consciously start viewing ourselves from the witness perspective. It is time to fire the judge - our critical parent - and choose to replace that judge with our Higher Self - who is a loving parent. We can then intervene in our own process to protect ourselves from the perpetrator within - the critical parent/disease voice.

Article "Learning to Love your self" by Robert Burney

We need to stop giving power to the monster within.

"The "critical parent" voice in my head has always berated me for not being perfect, for being human. My expectations, the "shoulds," my disease piled on me were a way in which I victimized myself. I was always judging, shaming and beating myself up because as a little child I got the message that something was wrong with me.

There is nothing wrong with me - or you. It is our relationship with ourselves and life that is dysfunctional. We are Spiritual beings who came into body in an emotionally dishonest, Spiritually hostile environment where everyone was trying to do human according to false belief systems. We were taught to expect life to be something that it isn't. It isn't our fault that things are so screwed up - it is however our responsibility to change the things we can within ourselves."

"I needed to learn how to set boundaries within, both emotionally and mentally by integrating Spiritual Truth into my process. Because "I feel like a failure" does not mean that is the Truth. The Spiritual Truth is that "failure" is an opportunity for growth."

"The part of you that tells you that you are not lovable, that you are not worthy, that you are not deserving, is the disease. It is trying to maintain control because that is all that it knows how to do. We are not "better than." We are also not "less than." The messages that we are "better than" come from the same place that the messages of "less than" come from: the disease. We are all children of God who deserve to be happy. And if you are right now judging yourself for not being happy enough or healed enough - that is your disease talking.

next: Romantic Relationships and How We Set Ourselves Up For Failure

For me, unhealthy boundaries are overt or covert attempts to control another person's behavior according to what I want and desire, rather than as a path to my own self-growth and serenity.

As a recovering co-dependent, I have the right to define my personal boundaries. I set my own boundaries in order to enhance my relationships, to promote my own serenity, and to ensure that my process of self-growth continues. My right to set healthy boundaries carries with it the responsibility for me to clearly communicate my boundaries to those persons closest to me who may be affected by my boundaries. I never use my boundaries as bludgeons for punishing another person or as a tool to control others.

Also, I don't assume or expect others to intuitively know and respect my boundaries. That is a fantasy. In regard to boundary setting, my boundary is "no surprises." If you are in a relationship with me, you are entitled to know my boundaries and the price for violating them before you violate them. Also, you are entitled to discuss the boundary openly and honestly with me. If warranted, I'll negotiate and adjust the boundary to help minimize any resulting conflict.

For me, there is a distinct difference between "boundary setting" and the process of disciplining my children. Child rearing, training, and discipline is my responsibility to my children. One of the many areas where I am striving to teach my children is how to set boundaries for themselves. For example, "don't start smoking just because someone you look up to is smoking or so that someone else will accept you." I'm trying to get my children to set a "no smoking" boundary for themselves, based on my educating them and giving them knowledge that smoking is harmful to their health. That way, it's not just a "rule" of mine they must obey (and probably violate behind my back). It becomes their decision. It becomes a boundary they own.

If someone is violating my boundaries, and it is truly harming me or hurting me, I am responsible for doing something about the situation. I can express my boundary, but if they don't respect it, I can't make them respect it or own it, even if I take them to court. All I can do is protect myself from that person.

Here then, are the guidelines for boundary setting that are currently working for me:

• I will keep my boundaries as simple and as few as possible.
• I reserve the right to change my boundaries as I grow and change.
• I will communicate my boundaries lovingly and clearly, before they are violated, when possible.
• I will not become a boundary ogre. I will be mindful that my perspective of reality is unique, and will not use boundaries as a means of forcing my perspective upon others.
• I will endeavor to treat all people as my guests, especially those closest to me.
• I will be kind, yet firm with those people who choose to violate my boundaries. If they continue to do so, I will take the steps necessary to protect myself, with care and mindfulness, seeking the path of minimum psychological harm to myself, the other person, and any one else who may be affected.
• I will not use boundaries to intentionally create conflict in any relationship.
• I will re-examine and question my boundaries if unhealthy results occur because of the boundary (for example, a situation gets worse because of the boundary, rather than better).
• I will respect the boundaries that other people set and communicate to me.
• I will honor and accept that all people need room and space to grow; I will not expect the world to conform 100% to my expectations.

Questions I ask myself about my boundaries:

• Is this a healthy boundary? Am I setting this boundary for myself? to enhance my serenity?
• Am I setting this boundary as an attempt to control someone else's behavior?
• Am I setting this boundary merely to antagonize someone else?
• Will this boundary honestly help me be a better person?

• Is this boundary still necessary? Do I need to let go of it

next: One Day at a Time

A short essay on overcoming fear, the meaning of our dreams, and dealing with nightmares.

Life Letters

To a frightened friend,

You fear your dreams, dread your inevitable surrender to them. How true the old cliché, that we most fear what we don't understand. I look into your eyes and recognize the pleading in them. They beg me to make your fear go away. I wish I could. I can't.

What I can do is attempt to assist you in coming to some understanding of your dreams. You see, our wholeness brings us many gifts. And dreams, my friend, are one of them. They tell us in yet another way about our deepest selves, about our inner conflicts and how we characteristically deal with them. They show us our fears, our secrets, our uncertainties - and they serve as signposts that can guide us toward answers. They are messengers, which travel to us, again and again, until they are received. They may frighten us with their dramatic stories, and yet we can come to appreciate that in delivering up to us in symbolic forms, our worries and our obstacles, they often present us with solutions. Dreams reflect elements of their extraordinary creators and contain both darkness and light, as does the very essence of life.

Your nightmares are not demons, nor foreign and dangerous invaders sent to conquer and destroy. Instead, they are your offspring. And much like your children, while they can be troublesome, they, too, are gifts, and require your attention.

When I envision you at night, I see you trembling in terror, hopelessly seeking to push back and away from the images of sleep. I want to provide you with comfort and lullabies, soothe you as you gently drift into the darkness. We both know that this is not possible.

And so, instead, I ask you to peer back with me- way back - to the time of ancient man and woman. Imagine that thousands of years have just slipped away, and that together we are watching a prehistoric scene. Our ancestors have just come upon a fire, and we watch them cringe in terror. How evil and alive it must seem. The smoke threatens to swallow them up and steal their very breath away. The heat reaches out towards them, much like the flames of hell that so many children of the future will someday envision. The fire before them is a deadly creature and they flee from it.

Move forward in time just a bit with me now. Some brave soul has begun to study fire, to explore its possibilities and to perceive it multidimensionally. This courageous one eventually discovered that fire, while still threatening and powerful, can also be used to serve. He or she now attempts to call it forth, determined to make use of its force. Soon fire, which for so long was a horrifying mystery, becomes to humankind a source of light, warmth, protection, energy, and even an instrument of healing!

So very much that has been learned by those who came before us now remains within our keeping. The very same magnificent spirit who came to understand the value of fire exists within you, my friend. Carry it with you into the dark and cold places of your fear. Call upon that spirit tonight. Call it forth in prayer, or meditation, or in song. Allow it to gently guide you into sleep. Permit it to silently issue you strength and courage as you face your own fire. You will come to understand that your nightmares, however violent, are like ancient woman's flames - they illuminate the shadows. Let your fire bring you light!

Love, A Fellow Traveler...

next: Life Letters: Appreciating the Gift

Raising a child with a disability can be very stressful. Find out about stress, how to prevent a build up of stress and relaxation techniques.

All of us experience stress and the experience can be painful, distressing and sometimes overwhelming. Parents of children with disability often have good reasons to feel stressed. When we are able to recognize the feeling of being stressed, we then become able to make choices that will ease the stress. This page describes stress, how it affects us and provides some suggestions for how to be in control of our stress.

Contents

• What is stress?
• Steps to prevent a build up of stress
• How we react to stress
• Long-term effects of stress
• Relaxation - how it helps
• Ways to relax
• For further information

What is stress?

In our increasingly busy world, more and more people are becoming aware of feeling stress and the way that it affects their lives.

Stress:

• Is the body's way of dealing with situations that are dangerous or threatening;

• Prepares us to either stand up and fight the threat or run away and escape it;

• Is found in many daily situations;

• Can range from being a mild worry to extreme panic;

• Is caused by events called 'stressors' (some are good stressors and some are bad stressors), and

• Is not always caused by 'bad' events. Even happy events, such as getting married or having a baby can be quite stressful.

One of the keys to being able to get control of stress is to become more aware of our feelings when we are stressed. Ask yourself the following questions:

• What happens when I am stressed?
• How do I feel?
• In what ways does my body react to stress?

Using normal activities to relax can be quite useful. Ask yourself:

• How do I like to relax?
• What happens to my body when I relax?

For people who may be under more extreme stress, normal activities may not be enough to help them relax. It may be necessary to use relaxation exercises to consciously relax the muscles of the body and focus thoughts positively to really reduce stress levels.

Disclaimer: General information only - you should consult with the relevant professional before applying it to a particular situation.

Steps to prevent a build up of stress

Some of these include:

• Being realistic about what you expect of yourself;

• Get enough rest;

• Make sure you have a good diet;

• Get a reasonable amount of exercise;

• Try to take some time out just for yourself;

• Develop a method that helps you deal with stress, especially unexpected stress - this might include things such as progressive muscle relaxation, visualization or imagery and self-talk;

• Talk to someone who you feel understands you about what stresses you;

• Try to take active steps to resolve conflict in your life;

• Try to avoid taking on things that provide extra pressures, and

• Be positive!

How we react to stress

Some of the common ways we react include:

• Becoming forgetful or having difficulty concentrating - our brains may feel as though they are overloaded;

• Becoming anxious and worried;

• Crying or feeling like crying;

• Having difficulty concentrating, due to the brain seeming to be overloaded;

• Eating, drinking or smoking too much;

• Experiencing headaches, indigestion, nausea or diarrhea;

• Feeling our muscles tensing;

• Experiencing dizziness;

• Having a lowered resistance to infections;

• Experiencing trembling or shaking in hands, legs or other parts of the body;

• Finding yourself holding something tight (like a steering wheel or the arm of a chair);

• Frequent nail biting or teeth grinding; and

• Having trouble speaking.

The list could go on! Needless to say, there are many different ways that people react to stress.

Long term effects of stress

If the stress is not reduced it can have long-term affects on our health, causing:

• Allergies;
• Ulcers;
• High blood pressure;
• Strokes, and
• Heart attacks.

Relaxation - how it helps

The opposite to stress is relaxation. Relaxation helps by:

• Lowering blood pressure;
• Relieving muscle tension;
• Increasing our stamina or endurance;
• Improving our mood;
• Helping us feel less angry, agitated or anxious.

Disclaimer: General information only - you should consult with the relevant professional before applying it to a particular situation. See disclaimer details.

Ways to relax

Some things that people find useful for relaxation include:

Massage and yoga
There are many courses, books and videos available that teach people how to use these methods. Each method teaches how to consciously relax the body and make the brain clear and able to function well during stressful situations. Consciously relaxing the body and the mind can result in a feeling of peace and quiet seldom experienced in other ways.

Massage
Massages can be great for relaxing muscles and relieving tension. It is not necessary to follow any set type of massage to get a good result and there are many types of massages available.

Progressive muscle relaxation
Progressive muscle relaxation is a way to learn about how your muscles feel when they are tight and relaxed. It includes a series of exercises where you tighten and release different muscles in your body. This type of relaxation can be done at any time during the day - while standing, walking, or driving the car.

Visualization or imagery
Visualization or imagery is a way to control your thoughts so that you can replace stressful thoughts with relaxing ones, and in this way, give yourself new energy. This involves finding a quiet place to sit for a few moments, and picturing in your mind something that you find relaxing - this may be something like walking on the beach or laying in a field on a warm, sunny day. If stressful thoughts come back into your mind, don't worry as this is normal. Just go back to thinking about your chosen image. With practice, you should find it easier to stick with this thought and you will end up feeling much more relaxed.

Self-talk
When people are feeling stressed they may find their stress is made worse by negative thoughts running through their minds. Quite often these messages are not accurate and come about because of fear or because we don't believe in ourselves. 'Self-talk' is where you consciously decide that you are going to replace these messages with different messages.

Exercise
Exercise is one of the best forms of relaxation. Going for a brisk walk is easy and inexpensive, and releases chemicals in your brain that help you to relax. It is also a great way to stay fit, and a fit body can handle stress better!

Aromatherapy
Aromatherapy is the use of oils and herbs that help reduce stress. Some people burn fragrant oils or incense. Others use pillows that contain the particular herbs or plants that aid them to relax. Something as simple as a few drops of your favorite oil in a warm bath can be wonderfully relaxing. Many health stores sell aromatherapy products and will be able to assist you in choosing oils that are right for your needs.

Disclaimer: General information only - you should consult with the relevant professional before applying it to a particular situation. See disclaimer details.

Laughter - the best Medicine
Laughter can be a very quick and helpful way to relax. It helps to deal with emotionally tense situations, face challenges and responsibilities and relieves anxiety by expressing what might otherwise be negative and stressful thoughts through jokes and humor.

If it's been a while since you had a good laugh, think about some things you could do that would increase your chances of having a good laugh. Hire a video or DVD of a movie that made you laugh in the past or take up a fun activity such as belly dancing with a group of friends. You will be sure to laugh!

For further information

Books

• Atkinson, J M (1988). Coping with stress at work. Thorsons Pub. Group - Distributed by Sterling Pub Wellingborough, Northamptonshire, England & New York.
• Bell, S (1996). Stress control: how you can find relief from life's daily stress. SkillPath Publications, Mission, KS.
• Blake, R (1987). Mind over medicine: can the mind kill or cure? Pan, London.
• Garfield, C (1979). Stress and survival. Mosby, St. Louis.
• Grace, C & Goffe, T (1993). Relax. Child's Play International Ltd., Swindon, England & New York.
• Hayward, S (1998). Relax now: removing stress from your life. Sterling, New York.
• Henderson, L (1996). Slow down, take a deep breath and relax. Gore & Osment Publications. Kelly, John M (1991). The executive time & stress management program. Alexander Hamilton Institute ,Maywood, NJ.
• Kidman, A (1986). Tactics for change: a self-help manual. Biochemical & General Consulting Service, St. Leonards, N.S.W.
• Lake, D (1994). Strategies for stress. Gore & Osment, Rushcutters Bay, N.S.W.
• Montgomery, B (1984). You and stress: a guide to successful living. Nelson, Melbourne. Montgomery, B (1982). Coping with stress. Pitman, Carlton, Victoria.
• Roe, D (1996). Young children and stress: how can we help? Australian Early Childhood Association, Watson, A.C.T.
• Saunders, C & Newton, N ( 1990). Women and stress. Angus & Robertson, North Ryde, N.S.W.
• Schultz, C & Schultz, N (1997). Care for caring parents. Australian Council for Educational Research, Camberwell, Victoria.
• Schultz, N (1990). The key to caring. Longman, Cheshire, Melbourne.
• Sutherland, V J (1990). Understanding stress: a psychological perspective for health professionals. Chapman and Hall London & New York.
• Tickell, J (1992). A passion for living kit. Formbuilt, Coolum Beach, Queensland.

More Alternative and Complementary Medicine Books

Videos & Cassettes

• Australian Broadcasting Commission (1992). PGR - Stress and tension ABC Television. Adelaide, South Australia (video recording).
• (1995). The coral reef. Flinders Media, Bedford Park, South Australia (VHS videotape - 16 min. 40 sec).
• Davies, M (1988). Sitting by the creek. Training, Health and Educational Videos, Heathcote, Victoria (video recording).
• Mellott, Roger (1989). Stress management for professionals: staying balanced under pressure. CareerTrack, Boulder, CO Publications (sound recording). Miller, E E & Halpern, S (1980). Letting go of stress. Stanford, California. (sound recording).
• Rainbow, M (1993). Jonathan's magical journey. Inner dimensions, Kew, Victoria (sound recording).
• Sanders, Matt (2000). Triple P Positive Parenting Program: Coping with stress. Families International, Milton, Queensland. (video recording).
• (1986) Stress and health: Kit. Flinders Medical Centre, South Australia (1 audio tape, 2 brochures).
• Todd, J (1989). Springtime Sunset. Flinders Media, Bedford Park, South Australia (video recording).

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

THERE AIN'T MUCH to it: Just give up desires. Of course, you can't possibly do that permanently, but you can do it right now. Ask yourself What do I want right now? You almost always want something. And the state of wanting is a state of discontent. Whatever you want right now, just give it up. Say to yourself I don't want that. Decide you don't want it.

Don't worry, it'll come back. But for right now, you'll gain yourself a peace-of-mind break. This is not difficult, and you can do it.

Notice what you want right now, and let it go. Give it up. Then notice what else you want and let that one go too. You'll notice a relaxing feeling of contentment come over you.

If you don't notice that contentment, and you want to feel it, give up that desire too.

To learn more about how to accomplish this feat, read The How of Tao.

Here's a conversational chapter on optimism from a future book:
Conversation on Optimism

If worry is a problem for you, or even if you would like to simply worry less even though you don't worry that much, you might like to read this:
The Ocelot Blues

Learn how to prevent yourself from falling into the common traps we are all prone to because of the structure of the human brain:
Thoughtical Illusions

next: The Root of All Happiness And Contentment

The antidote to stress is relaxation. To relax is to rest deeply and that's where restorative yoga comes in.

Picture this scenario: You feel sick. You go to the doctor and he tells you to go home and relax, so you go straight to the couch and turn on the television. You may think you've ratcheted down, but, explains Judith Lasater, PhD, author of Relax and Renew: Restful Yoga for Stressful Times, relaxing is a dynamic state that requires separation from external stimuli like TV. Unfortunately, most people don't know how to accomplish that and need to be taught. "Doing nothing is the healthiest thing you can do for yourself," says Lasater, "because when the body's in a state of relaxation, all measurable indices of stress are reduced—you can't be anxious and relaxed at the same time."

Once you know how to achieve a state of dynamic relaxation, you can then learn to dis-identify. Meaning? You separate yourself from your thoughts: you have them, but they aren't who you are. You can observe them arising but can detach from them. "If we're at the mercy of our thoughts, which can change 60,000 times a day," explains Lasater, "we'll always feel stress and suffer because what we think is never going to fully satisfy us." Learning to relax, therefore, is learning to let go of what you think and who you think you are. You aren't your body or your thoughts.

The purpose of props

Research shows you need four things in order to relax: a feeling of safety, darkness, warm hands and feet, and a cool core body temperature. Props, such as blankets, bolsters, blocks, straps, eye pillows, and sandbags, help create this environment by manipulating the nervous system so the only possible response is relaxation. "Really, we manipulate our nervous system all the time with cigarettes, coffee, anti-depressants, and other drugs to create a certain inner state," says Lasater. "Restorative yoga is doing the same thing except it's using only your body and breath."

If you don't have formal yoga props, improvise. Use a chair or a couch; a small, firm pillow; a few blankets; and something to cover your eyes. Then test out the environment with something simple: Lie on the floor with your legs raised up on the chair, your head and neck supported by a pillow, your body under a blanket if you're cold, and your eyes covered. Now breathe comfortably for 15 to 20 minutes. According to Lasater, it takes the average person 15 minutes in a basic restorative pose to relax deeply, so set your timer and enjoy.

Ease on down the road

Restorative yoga works wonders when you're stressed or over-tired, but it also has therapeutic value when you're injured or not feeling well enough to do your regular practice. Whether your lower back is bothering you, your head hurts, or hot flashes have zapped your strength and energy, doing supported poses allows your body to reap the benefits of traditional poses without taxing your muscles or re-injuring yourself. We've asked a few of our favorite therapeutic yoga teachers to suggest poses that might feel good and help ease particular conditions. Feel free to experiment, see which pose feels best, and mix up the order of the sequences. Keep in mind: If something doesn't feel good, don't do it.

Source: Alternative Medicine

next: Coping With Trauma When Living With A Mental Illness

Excerpts from the Archives of the Narcissism List Part 10

1. The Exposure of the Narcissist
2. Could Negative Input be Narcissistic Supply?
3. Narcissists, Disagreements and Criticism
4. Unresolved Conflicts
5. The Narcissist Wants to be Liked?
6. Old Sources of Narcissistic Supply (NS)
7. Hurting Others
8. Narcissists and Intimacy
9. Personality Disorders are Culture-Dependent?
10. Fortress Narcissism
11. Inverted Narcissists

1. The Exposure of the Narcissist

The exposure of the False Self for what it is - False - is a major narcissistic injury. The narcissist is likely to react with severe self-deprecation and self-flagellation even to the point of suicidal ideation. This - on the inside. On the outside, he is likely to react aggressively. This is his way of channeling life-threatening aggression.

Rather than endure its assault and its frightening outcomes - he redirects the aggression, transforms it and hurls it at others.

What form his aggression assumes is nigh impossible to predict without knowing the narcissist in question intimately. It could be anything from cynical humour, through cruel honesty, verbal abuse, passive aggressive behaviours (frustrating others), and to actual physical violence. I would consider it unwise to leave a child alone with him in such a condition.

2. Could Negative Input be Narcissistic Supply?

Yes, it could. I make clear that NS includes attention, fame, notoriety, adulation, fear, applause, approval - a mixed bag. If the narcissist gets attention - positive or negative - it constitutes NS. If he succeeds to manipulate people or influence them - positively or negatively - it qualifies as NS.

The ability to influence other people, to induce feelings in them, to manipulate them emotionally, to make them do something or refrain from doing it is what counts.

The receipt of NS releases libido (=increases the sexual drive).

3. Narcissists, Disagreements and Criticism

The narcissist perceives every disagreement - let alone criticism - as nothing short of a THREAT. He reacts defensively. He becomes indignant, aggressive and cold. He detaches emotionally for fear of yet another (narcissistic) injury. He devalues the person who made the disparaging remark. By holding the critic in contempt, by diminishing the stature of the discordant conversant - he minimizes the impact on himself of the disagreement or criticism. Like a trapped animal, the narcissist is forever on the lookout: was this remark meant to demean him? was this sentence a deliberate attack? Gradually, his mind turns into a chaotic battlefield of paranoia and ideas of reference until he loses touch with reality as we know it and retreats to his own world of fantasized grandiosity.

The cerebral narcissist is competitive and intolerant of criticism or disagreement. To him, subjugation and subordination establish his undisputed intellectual superiority or professional authority over others. Lowen has an excellent exposition of this "hidden or tacit competition" in his books. The cerebral narcissist aspires to perfection. Thus, even the slightest and most inconsequential challenge to his authority is inflated by him to cosmic proportion. Hence, the disproprtion of his reactions.

4. Unresolved Conflicts

The narcissist is forever entrapped in the unresolved conflicts of his childhood (including the famous Oedipus Complex). This compels him to seek resolution by re-enacting these conflicts with significant others in his life. But he is likely to return to the Primary Objects in his life (=his parents, other caregivers in the absence of parents, peers) to do either of two:

1. "Re-charge" the conflict "battery", or

2. When unable to do (a) - enact the old conflict with another person

The narcissist relates to his human environment through his unresolved conflicts. It is the energy of the tension thus created that sustains him.

He is a person driven by the imminent danger of eruption, by the unsettling prospect of losing his precarious balance. It is a tightrope act. The narcissist must remain alert and on-edge. Only if the conflict is fresh in his mind can he attain such levels of mental arousal.

Periodically interacting with the objects of his conflicts, sustains the inner turmoil, keeps the narcissist on his toes, endows him with the feeling that he is alive.

5. The Narcissist Wants to be Liked?

Would you wish to be liked by your television set? To the narcissist, people are instruments, sources of supply. If he has to be liked by them in order to secure this supply - he will strive to ensure their liking. If he has to be feared - he will make sure they fear him. He does not really care either way as long as he is being attended to. Attention - whether in the form of fame or infamy - is what it's all about. His world revolves around his constant mirroring. I am seen therefore I exist, sayeth the narcissist.

But the classic narcissist is also looking to get punished. His actions are aimed to elicit social or other sanctions from his environment. His life is a Kafkaesque ongoing trial and the open-endedness of the trial is itself the punishment. A punishment (a reprimand, an imprisonment, an abandonment) serves to vindicate and validate the internal damning voices of his sadistic, ideal and immature superego (really, the voices of his parents or other caregivers). They confirm his worthlessness. They relieve him from the burden of the inner conflict he endures when successful: the conflict between the gnawing sense of guilt and shame for having invalidated his parents' judgement - and the need to secure narcissistic supply.

Thus, free of his past "chains" - his world in ruins - the narcissist embarks on a new voyage, to conquer a new land, to keep new promises, riding into the horizon of a continent of boundless new narcissistic supply, unadulterated by the quotidian and the routine and by his past.

6. Old Sources of Narcissistic Supply (NS)

One should not romanticize the narcissist. His regrets are forever linked to his fears of losing his sources. His loneliness vanishes when he is awash with narcissistic supply.

Narcissists have no enemies. They have only sources of narcissistic supply. An enemy means attention means supply. One holds sway over one's enemy. If the narcissist has the power to provoke emotions in you - you are still a source of supply, regardless of WHICH emotions these are.

He seeks you out probably because he has absolutely no other NS sources at this stage. Narcissists frantically try to recycle their old and wasted sources in such a situation. But he would NOT have done even this had he not felt that he could still successfully extract a modicum of NS from you (even to attack someone is to recognize his existence and to attend to him!!!).

So, what should you do?

First, get over the excitement of seeing him again. To be courted is flattering, perhaps sexually arousing. Try to overcome these feelings.

Then, simply ignore him. Don't bother to respond in any way to his offer to get together. If he talks to you - keep quiet, don't answer. If he calls you - listen politely and then say goodbye and hang up. Indifference is what the narcissist cannot stand. It indicates a lack of attention and interest that constitutes the kernel of negative NS.

7. Hurting Others

Narcissists do feel bad about hurting others and about the unsavoury course their lives tend to assume. Their ego-dystony (=feeling bad about themselves) was only recently discovered and described. But my suspicion is that a narcissist feels bad only when his supply sources are threatened because of his behaviour, or following a narcissistic injury (such as a major life crisis: divorce, bankruptcy, etc.)

The Narcissist equate emotions with weakness. He regards the sentimental and the emotional with contempt. He looks down on the sensitive and the vulnerable. He derides and despises the dependent and the loving. He mocks expressions of compassion and passion. He is devoid of empathy. He is so afraid of his True Self that he would rather demean it all than admit to his own faults and "soft spots". He likes to talk about himself in mechanical terms ("machine", "efficient", "punctual", "output", "computer").

He slaughters his human side diligently and with a dedication derived from his drive to survive. To him, to be human and to survive are mutually exclusive. He must choose and his choice is clear. The narcissist never looks back, unless and until forced to by life itself.

8. Narcissists and Intimacy

ALL narcissists fear intimacy. But the cerebral narcissist deploys excellent defences: "scientific detachment" (the narcissist as the eternal observer), intellectualizing and rationalizing his emotions away, intellectual cruelty (see my FAQ 41 regarding inappropriate affect), intellectual "annexation" (regarding the other person as his extension, or territory), objectifying the other and so on. Even emotions which are expressed (pathological envy, neurotic or other rage, etc.) have the not totally unintended effect of alienating.

9. Personality Disorders are Culture-Dependent?

There is a debate in psychology ever since Freud whether mental disorders are culture dependent. Could some "personality disorders" be the norm in a different, non-Western, culture?

Could some behaviours be mandatory in one culture while derided in another? I was born in a culture which regarded the ABSENCE of physical abuse as parental neglect and indifference, for instance. Michele Foucault and Louis Althusser (the Marxist philosophers) said that mental health is used as a tool by the prevailing power structures in an effort to perpetuate their power and to propagate it. Lasch claimed that Western society in general is narcissistic. Peck suggested that modern day narcissists are "possessed" by inner demons. Many theoreticians dispute the very theoretical construct known as "personality". They say that there is no such thing.

10. Fortress Narcissism

It is not the maintenance of a double life that is at stake. It is the maintenance of LIFE itself. The personality of the narcissist is a precariously balanced house of cards, symbiotically attached to its sources of narcissistic supply. Any negative input (indifference, disagreement, criticism) - however minute - shatters it, shakes it to its lacking foundations and casts an ominous pall over the narcissist's very existence. This is enormously energy consuming, so the narcissist has no energy left for others.

When it all comes crushing down (a life crisis which results in a major narcissistic injury) - a tiny and passing window of opportunity opens. The narcissist - no longer defended by his crumbling defences, finally experiences the seething abyss of his negative emotions. Many narcissists then entertain suicidal ideas. Some resort to therapy. But the window closes and the opportunity passes and the narcissist reverts to his old, time proven methods. A precious few benefit from the upheaval in their lives.

Others just keep plodding on in the grey world that is fortress narcissism.

11. Inverted Narcissists

The inverted narcissist is not "milder" than the other forms of narcissism.

Like them, it has degrees and shades. But I would agree that it is much more rare and that the DSM IV variety is the more prevalent.

The Inverted narcissist is liable to react with rage whenever threatened (as all of us do)....

• When envious of other people's achievements, ability to feel, wholeness, happiness, rewards and successes.

• When his sense of self-worthlessness is enhanced by a behaviour, a comment, an event.

• When his lack of self-worth and void of self-esteem is THREATENED (so this narcissist might surprisingly react violently or with rage to GOOD things: a kind remark, a mission accomplished, a reward, a compliment, a proposition, a sexual advance).

• When thinking about the past, when emotions and memories are evoked (usually negative ones) by certain music, a given smell, a sight.

• When his pathological envy leads to an all-pervasive sense of injustice and being discriminate against by a spiteful world.

• When he encounters stupidity, avarice, dishonesty, bigotry - it is these qualities in him that the narcissist really fears and rejects so vehemently in others.

• When he believes that he failed (and he always entertains this belief), that he is imperfect and useless and worthless, a good for nothing half-baked creature.

• When he realizes to what extent his inner demons possess him, constrain his life, torment him, deform him and the hopelessness of it all.

Then even the inverted narcissist rebels. He becomes verbally and emotionally abusive. He raises unfairly things told to him in confidence. He uncannily pierces the soft spots of his target, and mercilessly drives home the poisoned dagger of despair and self loathing until it infects his adversary.

The calm after such a storm is even eerier, a thundering silence, indeed.

The narcissist regrets his behaviour but would rarely admit his feelings. He simply nurtures them in him as yet another weapon of self destruction and self defeat. It is from this very suppressed self contempt, from the very repressed and introverted judgement, from this missing atonement, that the narcissistic rage springs forth. Thus the vicious cycle is established.

next: Excerpts from the Archives of the Narcissism List Part 11

Excerpts from the Archives of the Narcissism List Part 9

1. Love and Sex
2. Schizotypal Personality Disorder
3. Inverted Narcissism
4. Narcissists and Women
5. Narcissists and their Ex's
6. Narcissists Victimize

1. Love and Sex

There is nothing wrong in showing love with our bodies. Love can and should be expressed in many ways, the physical one never to be excluded.

Love can and should be poured into many vessels: in words, in tender gestures, in empathy and consideration, suffused with the right kind of silence or bursting with the joy of momentary unity. Love is the art of merging the distinct and still maintaining the distinction. What better way of applying this principle than sex? What is the orgasm of a loving couple if not a moment of fusion, individually experienced?

So, love and sex do go together.

It is when sex is mistaken for love that pathology sets in. Sex can be had without love. Loveless sex is the emotional equivalent of eating. It can be a gratifying experience. But sex without love is NOT love. To provoke our physiological reactions in isolation is NOT to know and to be known, to love and to be loved. To acquire a sense of self worth and a modicum of self esteem by penetrating or being penetrated, by seducing or by letting go is a poor, illusory substitute for the Real Thing. It is also demeaning. The Other is objectified. It is to USE men (or women) to obtain a supply of sorts: narcissistic or hedonistic. When we become the slaves of sex, its minions, pawns on the gaming board of our compulsion, our ego an extension of our genitals - then love becomes impossible. For one cannot really love an object and one cannot respect that upon which one is dependent and one cannot cherish one's self because of such dependency. How can we love others if we despise our subjugated, compulsion-torn, selves? How can we act compassionately, as love demands, if constantly enraged in our diminishment?

Loveless sex is not love. Is sexless love - love?

No, it isn't. A love devoid of sex to me is lacking. The love of God, the love of a mother, the supposedly platonic - all are painted with the thick brush of sex. Not to crave for someone's body, to single out his soul - and only his soul - for intercourse is not to love. Thus incomplete, it is deformed attachment, enmeshment, dependence - but not love. We love with all our senses, with all our being, with body and with soul. When we love - we ARE. If lacking one dimension - the whole edifice crumbles. A love without sex withers, shrivels in the glaring sun of discord and ruptured intimacy. It is not in vain that the Bible says "to know" when it really means to merge in the ultimate, most sublime, most profound act of loving - in sex.

I am not sure we will all find true love. I am not sure we are not conditioned to confuse love with sex. But I am sure of one thing: the way is as important as the destination. Searching for true love is an act of love in itself. As long as we pursue the path to self betterment, to healing through the power of love - we are in love: with life, with our emerging selves and, gradually and hesitantly with others. This is the triumph of the human personality, however disordered.

I think that the narcissist unconsciously selects a mate that can help him recreate old conflicts with his Primary Objects / caregivers (parents, in humanspeak). This repetition complex stems from the unconscious belief that repeating is resolving or that resolution will emerge somehow in one of the repetition cycles.

There is much more about this in my book and in my FAQs.

Don't be so eager, so competitive, so transparent, so matter-of-fact, so dependent. It scares men away. Men are looking for pure sex or pure romance. Pure sex should be something casual, light-hearted, no strings attached, no egos intertwined, no identities involved, no baggage brought, no competitions won or lost. It is a tension free thing, devoid of anxiety and compulsion. Pure romance is like snowflakes: tender, beautiful, soft spoken, misty, engulfing, soothing.

Romance is also hard to reconcile with the tintinnabulation of the bells of competition or with the high strung eagerness of narcissistic supply. As you are, you don't stand a chance with either type: the purely sexual or the purely romantic. Take it easy, cool off, relax, pursue no goals, enter no contests, keep no notes, spread your sheets and spare your spreadsheets.

2. Schizotypal Personality Disorder

A-propos culture and society determined mental health disorders - did you know that a belief in telepathy (which I do NOT confess to, personally) constitutes one of the criteria in the Schizotypal PD?

Schizotypal Personality Disorder is to my humble mind, perhaps THE most culture-dependent PD of all.

I will start by saying that it is NOT clearly demarcated from BPD. In most cases there is co-morbidity with another disorder. STs suffer from anxiety, depression and other dysphoric mood states. A very typical feature is strange convictions and sometimes reactive psychoses. Most STs believe in the supernatural, confess to magical thinking and are very superstitious (in the sense that superstition dictates their behaviors to the point of making it "dysfunctional"). STs construct their sentences idiosyncratically and communication with them might be stilted and difficult.

STPD seems to have some genetic component. There are many first and second degree schizophrenic relatives in the families of STPDs.

The treatment includes both antipsychotic medicines when required plus VERY tactful exploration of the eccentric belief systems of the STPD in talk therapy.

Of course the determination of eccentricity and idiosyncrasy is rather dependent on the predominant cultural and societal values, lore, and narratives of the time.

The DSM IV has this to say:

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior beginning by early adulthood and present in a variety of contexts as indicated by five (or more) of the following:

• Ideas of reference (excluding delusions of reference)
• Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations)
• Unusual perceptual experiences, including bodily illusions
• Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over-elaborate, or stereotyped)
• Suspiciousness or paranoid ideation
• Inappropriate and constricted affect
• Behaviour, or appearance that is odd, eccentric, or peculiar
• Lack of close friends or confidants other than first degree relatives
• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self.

Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder.

3. Inverted Narcissism

The DSM IV defines the NPD using nine criteria. It is sufficient to possess five of them to "qualify". Thus, theoretically, it is possible to be NPD WITHOUT having grandiosity. Many researchers (Alexander Lowen, Jeffrey Satinover, Theodore Millon) suggested a "taxonomy" of pathological narcissism. They divided narcissists to sub-groups (very much as I did with my somatic versus cerebral narcissist dichotomy). Lowen, for instance, talks about the "phallic" narcissist versus others. Satinover makes a very important distinction between narcissists who were raised by abusive parents - and those who were raised by doting mothers or domineering mothers. I expanded upon the Satinover classification in FAQ 64.

I wrote "Malignant Self Love" exactly five years ago (1996). I corresponded with thousands (including dozens of mental health professionals) since then. It is clear to me from this correspondence that there is, indeed, a type of narcissist, hitherto rather neglected and obscure. It is the "self-effacing" or "introverted" narcissist. I call it the "Inverted Narcissist" and others on this list preferred to use "Mirror Narcissist", "NMagnet", or "NCodependent (NCo for short)". Alice Ratzlaff compiled an excellent "DSM" type "list of criteria".

Methodologically she erroneously insisted upon calling it a narcissist in the classical sense but finally we compromised on "Inverted Narcissist".

This is a narcissist who, in many respects, is the mirror image of the "classical" narcissist. The psychodynamics of such a narcissist are not clear, nor are his developmental roots. Perhaps he is the product of a doting or domineering primary object/caregiver. Perhaps excessive abuse leads to the repression of the narcissistic and other defence mechanisms themselves. I mean to say that perhaps the parents suppressed every manifestation of grandiosity (very common in early childhood) and of narcissism - so that the defence mechanism that narcissism is was "inverted" and internalized in this unusual form.

These narcissists are self-effacing, sensitive, emotionally fragile, sometimes socially phobic. They import all their self-esteem and sense of self-worth from the outside (others), are pathologically envious (a transformation of aggression), are likely to intermittently engage in aggressive/violent behaviours, are more emotionally labile that the classic narcissist, etc.

We can, therefore talk about three "basic" types of narcissists:

1. The offspring of neglecting parents
   They resort to narcissism as the predominant object relation (with themselves as the exclusive object).

1. The offspring of doting or domineering parents (often narcissists themselves)
   They internalized these voices in the form of a sadistic, ideal, immature superego, and spend their lives trying to be perfect, omnipotent, omniscient, and to be judged "a worthy success" by these parent-images.

1. The offspring of abusive parents
   They internalize the abusing, demeaning and contemptuous voices and spend their lives in an effort to elicit "counter-voices" from their human environment and thus to extract a modicum of self esteem and to regulate their sense of self worth.

All three types are doomed to eternal, recursive, Sisyphean failure.

Shielded by their protective shells (defence mechanisms) they constantly gauge reality wrongly, their actions and reactions become more and more rigid and ossified and the damage inflicted by them on themselves and on others ever greater. This damage is what my book is all about.

4. Narcissists and Women

The narcissist does regard the "subjugation" of an attractive woman to be a source of narcissistic supply.

It is a status symbol, proof of virility and masculinity and it allows him to engage in "vicarious" narcissistic behaviours (=being a narcissist through others, transforming others into tools at the service of his narcissism, into his extensions). This is done by employing defence mechanisms such as projective identification. Many of my FAQs and the essay are dedicated to these issues.

Primary NS is ANY kind of NS provided by others who are not "meaningful" or "significant" others. Adulation, attention, affirmation, fame, notoriety, sexual conquests - are all forms of NS.

Secondary NS is afforded by people who are in CONSTANT, repetitive or continuous touch with the narcissist. It includes the important roles of narcissistic accumulation and narcissistic regulation, among others.

The narcissist believes that being in love IS going through the motions and pretending to some degree. To him, emotions are mimicry and pretence.

5. Narcissists and their Ex's

There are two possible reactions:

The Ex "belongs" to the narcissist. She is an inseparable part of his Pathological Narcissistic Space. This possessive streak is not terminated with the official, physical, separation. Thus, the narcissist is likely to respond with rage, seething envy, a sense of humiliation and invasion and violent-aggressive urges to separation, especially since it implies a "failure" on his part and, thus negates his grandiosity.

But there is a second possibility:

If the narcissist were to firmly believe (which is very rare) that the ex does not and will never represent any amount, however marginal and residual, of any kind (primary or secondary) of narcissistic supply - he will remain utterly unmoved by anything she does and anyone she may choose to be with.

If you don't supply - you don't exist.

There is a lot more on these issues here.

6. Narcissists Victimize

"Classical, full fledged" narcissists victimize. Nothing evil here, nothing premeditated, no sinister grins. Simply an absentminded, offhanded, kind of indifference and lack of empathy. And a lot of hurt people.

On balance I (a narcissist) prefer to help the victims. They are far numerous and far more hurting. And I have done far too much to add to their numbers. This is my way of trying to make amends, I guess.

To me, women are either holy or whole. If holy, how could I dare contaminate them with sex, impinge upon their purity and saintliness with my bestial passions and infringe upon their perceived "aloofness" and "above the (sexual) fray status" with my demands.

If whore, sex with them must be impersonal, mildly sado-maso, somewhat autoerotic and devoid of every emotion.

next: Excerpts from the Archives of the Narcissism List Part 10