Categories
Uncategorized

STYLIST Magazine Contribution – When does ‘normal’ anxiety become an anxiety disorder?

Categories
Uncategorized

A Critical Assessment of NICE Guidelines for Treatment of Depression-

World Psychiatry. 2023 Feb; 22(1): 43–45.
Published online 2023 Jan 14. doi: 10.1002/wps.21039
PMCID: PMC9840485
PMID: 36640399

A critical assessment of NICE guidelines for treatment of depression

Falk Leichsenring, 1 , 2 Christiane Steinert, 3 Felicitas Rost, 4 Allan Abbass, 5 Nikolas Heim, 3 and John P.A. Ioannidis 6 , 7 , 8 , 9 , 10

The UK National Institute for Health and Care Excellence (NICE) recently updated its recommendations for the treatment of depression 1 . This effort has many strengths, including the meticulous documentation of the process; systematic reviews, meta‐analyses and cost‐effectiveness analyses; and inclusion of stakeholder comments that feed into the guidelines. Here we attempt a constructive critical appraisal of areas where future improvements for this but also for other similar initiatives are feasible, with a special focus on psychotherapies for depression.

We first notice that the methods and analyses of the NICE guidelines were not subjected to formal external peer review for any of the addressed questions. Asking stakeholders for comments is welcome, but it is unlikely to be equally rigorous, leaving it to the guideline committee how these comments are considered. External peer review is recommended as a default quality stan­dard for treatment guidelines 2 .

Furthermore, study protocols were pre‐registered only for some conditions (e.g., for new episodes of depression and treatment‐resistant depression), but not for others (including chronic depression, depression with personality disorder, and psychotic depression). Pre‐registering should be established as a default stan­dard in guidelines for all reviewed conditions.

For the primary analysis concerning new episodes of depression, network meta‐analysis (NMA) was chosen 1 . NMA has the advantage of incorporating both direct and indirect evidence, but complex assumptions need to be fulfilled, and the level of evidence provided is still debated 3 . For these reasons, NMA results and the derived inferences require extra caution.

For treatment ranking, the guideline committee primarily focused on effect sizes from NMA treatment comparisons with placebo or treatment‐as‐usual, and compared these effect sizes between treatments. From these comparisons, the committee concluded that some treatments appeared to be “more effective” than others 1 . For most treatments, however, the differences between treatment and control effect sizes were below the minimal clinically significant difference defined by the committee (standardized mean difference, SMD >0.5 or <–0.5) 1 . This applies to comparisons between individual cognitive or cognitive‐behavioral therapy (CT/CBT), individual interpersonal therapy (IPT), individual problem solving, individual short‐term psychodynamic psychotherapy (STPP), and group behavior activation. Thus, with only subtle effect size differences, treatment ranking carries large uncertainty. Furthermore, assuming differences between two treatments if one of them shows descriptively a larger effect size than the other compared to a control condition, without comparing them directly, should be avoided 4 .

The guideline committee reported head‐to‐head comparisons of active treatments only in a supplement. These comparisons show that, in more severe depression, the differences between individual behavioral therapy, individual CBT, individual IPT and individual STPP are neither statistically nor clinically significant (SMDs <0.50) 1 . In less severe depression, only a few clinically significant differences were found: for example, in a pairwise comparison, STPP was statistically and clinically significantly superior to counselling (SMD=–0.61, 95% CI: –1.05 to –0.17), but was ranked below counselling.

Thus, the committee’s conclusions about differences in efficacy between active treatments are not consistent with its own head‐to‐head comparisons. They are also not compatible with independent peer‐reviewed evidence of no substantial differences in efficacy between psychotherapies 5 . The committee, however, erroneously interpreted this independent evidence 5 as confirming its treatment ranking1,B, p.165. In summary, procedures for treatment ranking need to be pre‐defined, and subtle differences below the threshold of clinically meaningful values should not be overstated.

In principle, possible allegiance and conflicts of interests need to be controlled for 2 , for example by including methodologists, patients, and different‐field experts, and by limiting the involvement of field specialists to a consultation role 6 . Avoidance of stacking is also essential, ensuring that guideline developers do not have an over‐representation of believers in one or another treatment modality 6 .

The guideline committee based the hierarchy of treatment recommendations on both efficacy and cost‐effectiveness, which is useful in trying to optimize the use of treatments for conditions with high prevalence 1 . For cost‐effectiveness, however, peer reviews and pre‐registration are missing. Moreover, the cost‐effectiveness literature is notoriously replete with biases. This further complicates matters in a field such as depression where the primary studies are often also biased (e.g., sponsor bias in pharmacotherapy trials and allegiance bias in psychotherapy trials). Furthermore, the studies used by the committee for cost‐effectiveness analysis did not cover all relevant treatment types. For those not covered, it is not clear whether cost‐effectiveness estimates are valid. Additional cost‐effectiveness analyses commissioned by the committee were based on the NMA treatment‐control effect sizes shown above to be questionable, which further limits the derived treatment ranking.

Another challenge is whether extrapolations from new episodes of depression to other conditions are valid, when there is no solid evidence for these other categories of depression. For example, in depression with personality disorder, the committee recommends combining antidepressants and psychotherapy. For the choice between psychotherapies, readers are referred to the treatments for new episodes of depression. Then, for patients not sufficiently responding to pharmacotherapy alone, switching to psychotherapies listed for new episodes of more severe depression is recommended as one option. In reviewing new episodes of depression, however, the committee excluded depression with personality disorder and treatment‐resistant depression. Thus, the committee’s ranking of psychotherapies for new episodes of depression may not be valid for these other conditions. Finally, for the cost‐effectiveness of chronic depression and depression with personality disorder, the committee also used the economic data for new episodes of depression.

As another problem, the guideline committee found the quality of studies to be quite low. The committee tried to adjust results for bias, but a pre‐registered threshold analysis for assessing confidence in recommendations was not carried out. Quality of evidence was evaluated narratively using the GRADE system, but without assessing confidence. Assessing confidence in evidence is essential for guidelines 6 .

The committee also draws an arbitrary distinction between the more complex forms of depression, which not only reduces gener­alizability to clinical practice but appears to have led to the ex­clusion of relevant studies. Available randomized controlled tri­als have not clearly distinguished between chronic depression and treat­ment‐resistant depression. For chronic depression, the committee recommends CBT, antidepressants or their combination 1 . However, these recommendations do not take into account the evidence for STPP and long‐term psychodynamic therapy in treat­ment‐resistant depression and in depression with personality disorder78, conditions highly associated with chronic depression. Guidelines need to avoid arbitrary distinctions of disorders.

Moreover, the committee did not sufficiently consider the limitations of the available evidence 2 , especially the limited remission rates (about 30%) of short‐term psychotherapies (4‐20 sessions), with SMDs of 0.30 9 . Aggravating this problem, most effect sizes of short‐term treatments are not stable at follow‐up1. Especially for chronic depression, success rates may be improved with longer‐term treatments 9 . The committee, however, considered long‐term treatments only as an option for depression with personality disorder.

Finally, an explicit link between evidence and recommendations is missing 2 . We acknowledge that the evidence in this field is uncertain, and this may be the reason why the committee found it “difficult… to link the recommendations directly to the NMA results”1,B, pp.48,66, and based its recommendations ultimately on “clinical experience”1,B, p.66. However, it is unclear whether clinical experience can offer any solid guidance when treatment differences are modest, uncertainty is high and bias is substantial. Guidelines should fully admit this uncertainty and avoid over‐simplified, over‐confident recommendations 6 .

REFERENCES

1. National Institute for Health and Care Excellence . Depression in adults: treat­ment and management. www.nice.org.uk/Guidance/ng222.
2. Brouwers MC, Kho ME, Browman GP et al. CMAJ 2010;182:E839‐42. [PMC free article] [PubMed[Google Scholar]
3. Faltinsen EG, Storebo OJ, Jakobsen JC et al. BMJ Evid Based Med 2018;23:56‐9. [PubMed[Google Scholar]
4. Makin TR, Orban de Xivry JJ. Elife 2019;8:e48175. [PMC free article] [PubMed[Google Scholar]
5. Cuijpers P, Quero S, Noma H et al. World Psychiatry 2021;20:283‐93. [PMC free article] [PubMed[Google Scholar]
6. Lenzer J, Hoffman JR, Furberg CD et al. BMJ 2013;347:f5535. [PubMed[Google Scholar]
7. Fonagy P, Rost F, Carlyle JA et al. World Psychiatry 2015;14:312‐21. [PMC free article] [PubMed[Google Scholar]
8. Abbass A, Town J, Driessen E. Psychiatry 2011;74:58‐71. [PubMed[Google Scholar]
9. Leichsenring F, Steinert C, Rabung S et al. World Psychiatry 2022;21:133‐45. [PMC free article] [PubMed[Google Scholar]

Articles from World Psychiatry are provided here courtesy of The World Psychiatric Association
Categories
Uncategorized

Vacillators and Romantic Relationships

COPYRIGHT CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated or reproduced in any manner without the author’s permission.

Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

 

Vacillators and Romantic Relationships

We all know that person who lives in La La land, who wants a fairy tale love story where they live “happily ever after”!  We all know that couple that is either madly in love, or fighting like cat and dog, blaming each other for anything and everything. Their relationship is either on the high or low. This way of relating and functioning describes vacillators- where either one partner or both are vacillators.  Vacillators are people who approach relationships in an idealistic, and romanticised fashion –“everything has to be perfect”. They deeply crave emotional connection & will do all they can to get it. This can be at the expense of them undermining their own needs, or emotionally manipulating their partners. Vacillators are emotionally demanding; they want to receive consistent love & undivided attention.

 

Vacillators set high standards for their partners, and the relationship. When they don’t get what they want -which is often the case due to unrealistically high expectations- it crashes them, provoking a huge sense of disappointment, and anger. These feelings are always targeted at their partner who is seen as having failed them. Vacillators sway between idealisation of their partner and the relationship, & denigration of the same – “I’m so in love with you and you are amazing” and “you are useless, l don’t need you” dynamic . There are intense highs are lows, and inherently viewing the world in black and white terms, with no in between. This leads to cycles of pushing their partners to love & connect with them, & angrily pushing them away. The lows can manifest in actual physical and/or verbal fights, while the highs are both exaggerated and superficial. This couple is typically in a trauma bond, where the early unresolved relational trauma is unconsciously played out, in a victim and abuser dynamic.

 

Underneath this behaviour is as huge sense of insecurity, and a deep seated fear of abandonment. This gets acted out in the relationship by creating the fairy tale relationship in the mind, which is difficult to sustain in real life. Consequently, being in a relationship with a vacillator can be both exhausting and confusing. The behaviour itself is indeed a trauma response, rooted in the past relationships with their care givers. Their partners are simply paying the price for their early life care givers’ failures. These behaviours are indeed transference manifestations (Freud, 1915).

 

Vacillators often find flaws in their partners, & want them to change in order to suit their phantasy of an ideal person and relationship. The more the partner gives in, the more they are likely to keep pushing for change. The changes are never enough, as they are based on an ideal and a phantasy, not on reality. If the partners  conform, they simply reinforce the power in the vacillator. If the vacillators partner changes accordingly, they are left feeling very small, fragile, insecure, and powerless.

 

Predisposition

Vacillators are people who are likely to have  disorganised attachment styles. They are likely to have grown up with parents who were inconsistent & unpredictable in emotionally connecting with them as children. Therefore, their attachment style is far from secure, but a disorganised one- as the word says “dis- organised”. Their parents would have made them feel insignificant, and that their feelings didn’t matter to them. They grew up with a constant fear of being abandoned and let down, yet they also experience intense love from then same parents.

 

We don’t talk much about vaccillators, or vaccillating in  relationship discourses, yet this phenomenon is very common. Being in a relationship with a vacillator can be damaging and being a vacillator can also lead to an inability to sustain long term, fulfilling  relationships. Partners can support each other to work through this dynamic, once the vacillator is able to acknowledge that they are indeed vacillating, and causing damage to their loved ones. Vacillators can also go into individual therapy to work on this early life trauma, secondary to adverse childhood experiences. Creating security in the relationship and boundaries is likely to help the couple, as the vacillating behaviour itself is stimulated by a fear of abandonment. Cycles of anger, and idealisation can cause huge damage to the relationship and to individuals in the relationship. The denigration erodes other positive qualities of the relationship.

 

 

Disorganised Attachment Style and Attachment Styles

The psychological health of an adult individual and relationship patterns  is directly linked re postulated to the quality of the relationship between the baby and their primary care giver, which shapes the attachment styles they built in infancy. These attachments styles are internalised ways or relating laid out in our formative years, which get reactivated in our adult relationships (Ainsworth et al, 1978; Bowlby, 1969).

Bowlby (1969) postulated that there are different types of attachment patterns which are:

1) Secure attachment is developed when they baby is able to develop a healthy attachment style with their care giver. The baby is able to play independently away from the mother, and run back to the mother, a secure base, when it needs to, and know that mother will be waiting in reverence. These parents would have had consistent boundaries and responded consistently. The parent was able to honour and respect the child’s boundaries and made them feel emotionally safe. The child was allowed to express themselves, and the parent remained emotionally connected to the child. In adulthood, these people are likely to have a secure sense of self, they can self validate and not seek validation from their partners and they can approach relationships from a mature place.  They are able to emotionally sooth themselves- conflict in the relationship,  partner’s temporary absence, or   a break down of  a relationship is not so emotionally crashing for them.

2) Anxious-Preoccupied   attachment is an attachment style developed when  the baby is unsure whether they are emotionally secure or not, mainly because they get ‘mixed messages’ from their care giver. The parents would have lacked boundaries, and struggled with emotionally regulating themselves. The parent would have not responded to the child’s needs and didn’t help the child with emotional regulation.  They may have dismissed, minimised, denied, or ignored the child’s emotional needs. In adult life, and in relationships, there is constant fear of abandonment, and hypervigilance to emotional sates. They may pick fights to stay close and the individual struggles with boundaries. The anxiously attached individual tends to be emotionally reactive, and to neglect themselves in relationships, to maintain proximity with their partner. They find it hard to deal with conflict as feelings becomes overwhelming and the threats of abandonment is costly to them.

3) Dismissive-Avoidant  attachment style is developed when the baby had parents who regularly shuts down, emotionally withdraw, or dissociates, leaving the child emotionally unattended to. These parents may also shame the child for who they are and tend to be authoritarian and perfectionistic.  As adults, the avoidant attached genuinely seeks connection but struggles with intimacy. They are likely to ghost, or abruptly end relationships. They also tend to be lone wolfs and cynical and critical of relationships. They may also lack empathy and struggle to understand other peopled viewpoints and needs that are separate to theirs. They are likely to remain single or push their partners away for self-preservation.

4) Fearful-Avoidant  attachment style is developed when in childhood, the baby was completely unable to relate, as they were unable to experience a secure base where they could run back to.  These children may have experienced abuse, neglect and violence from parents or witnessed it between parents. They are likely to have grown up in environments where there was poverty, and considerable lack of safety, shaming and the chid unable to be themselves. In these dynamics, the vital role of the parent as a reliable, trustworthy, consistent and solid care giver is lacking. In adulthood, these people are likely to cerate push-pull dynamics in relationships where they seek closeness and rejects. Romantic relationships can be highly triggering and overwhelming for them, leading to cynicism, and criticism of their partners. They may also re-enact their childhood trauma by setting their partners up into dramatic scenarios. They have unrealistic expectations of their partners and what a real relationship is.

 

The disorganised attachments are likely to be vacillators in relationships. All they are doing is re-anacting the early relationship template of having parents who are unreliable and untrustworthy. They do the same by creating idealised views of the world and relationships, and seeking others to meet their high standards.  Unconsciously, they tend to pick  partners who like being worshipped, and enjoy going through the emotional highs and the lows. The push- pull, and rejecting mimics what they felt in the care of their primary care givers.

As an individual and couples therapist, l have seen many people work through these unhealthy ways of relating, and develop healthier ways of relating.  I have helped both subjects and partners of vacillators and helped them repair these attachment styles and develop healthier and secure attachment styles. Attachment  styles are not fixed for a lifetime. They can be mended and repaired through good enough psychological work (therapy), and secure relationships with a partner who is securely attached themselves.

 

How to Heal

 Subject

-Knowing that this behaviour is a trauma response is important.

-Self-reflection is critical as it enables you to stop and think before reacting or doing things that are harmful to your partner

-Working on communication and boundaries is important. You may want to invite your partner to support you with working on this.

-Having therapy to work on the trauma is also important as it enables you to learn healthy ways of relating & work through the trauma.

 

Victim

-Learn to create boundaries and to understand that the behaviour is not to do with you specifically but your partners past trauma. This will enable the victim to separate what’s happening to them as something that’s not directly towards them.

-Communication and setting boundaries is important and being consistent in doing so.

-Be mindful of love bombing and suffocating affection that comes with vacillators, as it soon becomes rejection. Being aware of it makes it less painful.

-Seek therapy if you are struggling with a relationship with a vacillator.

 

References

 

Ainsworth, M.D.S., Blehar, M.C., Waters, E, and Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Oxford, UK

 

Bowlby, J. (1969). Attachment and Loss, Vol. 1: Attachment. Attachment and Loss. New York: Basic Books.

Image Credit- Moosa Maseneke- Unsplash

Categories
Uncategorized

Guardian Contribution-I long to move to the seaside, but will it unsettle my children?

22/01/2022

I long to move to the seaside, but will it unsettle my children?

You’re unhappy where you are. How can you be sure you won’t be just as unhappy in a different town, asks Annalisa Barbieri

 

Four years ago, we relocated at a time we thought least harmful to our children: the youngest was starting primary school, the eldest junior school. They are now nine and 13. They are of mixed ethnicity and we wanted to live somewhere more multicultural, in a larger house in a less urban area. Our close family live outside England, so we thought moving nearer to extended family might provide some roots. The children settled well but contact with the extended family didn’t really happen.

Last year, going through the menopause, I became depressed and sought counselling. I recognised I’d been so focused on what might be best for the children that I’d disregarded what was right for me. I’ve always wanted to live by the sea and have become increasingly despondent about having missed an opportunity to move there four years ago. During lockdown my husband and I had time to reflect; he thinks our family unit will be stronger if we move again, before the children are any older. We both want our eldest settled before GCSEs. She is very empathic, knows I am unhappy and constantly asks why.

My mother died when I was a young woman and I’ve had little family support (no siblings, an emotionally unavailable father). I feel desperate to put roots down somewhere and create a supportive network of friends. My dilemma is whether to force another move on my children when they are settled here. This place has positive features for them; the place we’ve thought of moving to is less multicultural. Maybe I should just suck it up until they leave home. Mothers are supposed to put their children’s interests first, after all.

The core to resolving your dilemma lies in working out what’s within you and what are external factors. Too many people seek to change their surroundings (work, or partner, or home), while the issue within them remains unchallenged. They then wonder why the new place (or partner, or job) hasn’t made them happier.

I talked to psychotherapist Dr Joyline Gozho, who immediately noted your upbringing: “You probably had a lot of unresolved and unmet needs in childhood, and now that you’re a mother, they’re coming to the fore.” When you add in the menopause, which can be a time of great reflection (“What happened to me? What about my needs?” are questions often asked), and Covid, which is making so many people reprioritise, it’s not surprising you are in a dilemma. But you don’t need to do anything just yet.

The first thing both Gozho and I felt you needed was time to explore your own feelings, without thinking about family and future. “You need to have considered therapy that looks at your individual needs,” Gozho said. You mention seeking counselling but not whether you addressed these issues in it. “Your mother dying and your emotionally unavailable father – those are huge losses that may have left you feeling emotionally deprived.”

You rhetorically ask if a mother is supposed to put her children’s interests first. Not always, and certainly not if it makes the mother unhappy to the point of the children knowing about it, because they will then blame themselves. Gozho and I were concerned that your eldest knows how unhappy you are and wonder what internal narrative she may be establishing for herself. She shouldn’t be worrying about you when she is about to enter the turbulent waters of adolescence.

Woman's head and Great Britain map
I want to move back to the UK. How can I convince my husband to give it a try?
Read more

You talk about being “desperate” to put down roots, while also talking about pulling them up. This contradiction makes me wonder how much of this need is within you, yet you constantly search for it externally. You need to home in on what it is you feel you are missing, and whether living by the sea will give it to you. The seaside is lovely, but when people talk about moving there in a certain utopian way, it strikes me as running away. That’s never a good basis for stability and growth.

Have you spent any time in the place you’d like to move to, winter and summer? Talked to people who live there? I would do this as soon as possible.

Making a flow chart and asking, “What if we do this, and what then?” can give great clarity. If you find the only good reason for moving to the seaside is that you want to, I wonder about putting yourself under that sort of pressure to make it a success.

 Every week Annalisa Barbieri addresses a family-related problem sent in by a reader. If you would like advice from Annalisa on a family matter, please send your problem to ask.annalisa@theguardian.com. Annalisa regrets she cannot enter into personal correspondence. Submissions are subject to our terms and conditions: see gu.com/letters-terms.

 

Image Credit- Elias Vicarios- Unsplash

Categories
Uncategorized

Controllers and Romantic Relationships

COPYRIGHT CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated or reproduced in any manner without the author’s permission.

Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

 

Control is a form of abuse, so is other forms of coercive behaviours. Being in a relationship with a controller is unhealthy; it can be very damaging. Controllers dominate the relationship, leaving no space for their partners. The relationship itself is shaped by dominance & submission. Controllers do not only seek to control all aspects of the relationship, but  their partner as an individual, stripping them off their individuality. This can be depersonalising, and easily erodes one’s sense of self.

 

Control in Relationships

Many people in controlling relationships do not even recognise that their partners are controlling them. This is so because the controlling, and patronising behaviour is often coveted, and subtle.  It is often done in the name of love, which can be confusion to the victim, and difficult to pick up for anyone who has a poor sense of self.  It may take others to identify it, and highlight it for them. In some instances, controllers are aware of their behaviours, while others may not be cognisant of their behaviour as being controlling. Resultantly, they don’t realise how much harm they cause their partners.  The behaviour becomes normalised, yet incredibly harmful. This is why therapy is incredibly helpful for both the subject, and the victim. Nevertheless, it is the victim who suffers the most, where there is a controlling partner. This dynamic is typically a result of a trauma bond which is very difficult to disentangle, as the underlying trauma needs to be addressed.

As a therapist, l have worked with many people who experience control issues in their relationships-both controllers and victims. I am aware of how prevalent control  issues in relationships are, yet many people only become aware of them once they start therapy. This highlights how much damage control silently cause in relationships. Healthy relationships are created, they are not magical. It is therefore crucial that the discourse around romantic relationship dynamics  continues & the nuances of it unpacked.

 

Healthy relationships are nourishing, while controlling relationships are depleting, and damaging. Women and men are both prone to becoming controllers, or to be controlled in relationships, and it’s not exclusive to a particular coupledom. People in in same-sex relationships, polyamory, or heterosexual relationships all experience these issues. Controlling behaviour in relationships often coexist with verbal and or emotional abuse.

 

How to recognise control in a relationship?

 

Controllers are partners who:

 

  • Monitor and/or dictate how you spend your time, and make you feel guilty about leaving them out.
  • Monitor and/or dictate who you spend your time with make you feel guilty about it.
  • Monitor and/or dictate how you spend your finances and make you feel guilty about it.
  • Monitor or dictate what you wear & make you feel guilty about it.
  • Morbid jealousy and accusations of cheating or betrayal.
  • Intrude into your personal material such as going through your phone, bank statements etc.
  • Blame you when things go wrong & being repeatedly made to compromise & give up what’s important to you.
  • Make you feel your opinion is secondary & your reality is warped.
  • Control how you should behave around others-edit your self.
  • Gaslight and make you question your truth.
  • Use their emotions to set the tone and control situations.
  • Prone to use anger as a weapon to silence or frighten their partner.
  • Undermine your needs, prioritising theirs.

 

Predisposition

Controllers are people who are likely to have grown up in environments where they had to emotionally take care of themselves from a young age, and become tough because they felt emotionally neglected, and vulnerable. A parent or any care giver needs to be emotionally available to a developing child in the formative years,  offering what Bion (1962) termed containment, where the emotionally attuned and receptive adult take on (introject) the child’s distressing emotional states and feelings, metabolises it, and hands it back in a detoxified manner. If there is emotional neglect, the baby never gets to learn to develop the capacity to process and regulate their own emotions. If this form of neglect happens throughout childhood, the child develops a defensive way of coping which protects that vulnerability. Becoming tough, in order to protect oneself is indeed a part of that protective mechanism. Emotional neglect is a form of abuse and if it happens consistently throughout the child’s life, it leaves long lasting scars.  Research (Bellis, et al, 2014) suggests that people who suffered emotional abuse (Adverse Childhood Experiences) are likely to grow up to become adults who have anger issues, other difficulties regulating emotions, have difficulties with interpersonal relationships, as well as develop frank mental health challenges.  Anger is a core feeling in controller’s lives, as it makes them feel powerful, yet they do not associate it with vulnerability. Deep down, controllers feel incredibly weak and powerless; controlling the other person makes them feel powerful. People who were bullied in their childhood are likely to become controllers to their partners, so is people who grew up witnessing their parents’s dysfunctional relationships.

 

The controlling behaviour itself is a trauma reaction, as one felt exposed and vulnerable as a child. We fight, flight or freeze as survival, instinctual reactions. One would consider controlling behaviour as part of the “fight” way of functioning. From a very young age, controllers’ only way of survival has been to be tough, and this becomes integrated as part of one’s personality, albeit pathological. Controllers often finds it difficult to relinquish power, and give up their position which is all they have known. Giving up the power also means exposing their vulnerability, and there is a threat of psychic collapse. This is why most controllers present to therapy with anger related issues, either in individual or couple’s therapy. They do not often view their behaviour as problematic, until the therapist points it out to them. Anger is what you see on the tip of the iceberg, while underneath it there is fear, anxiety, shame, worry, insecurity, guilt, and a lot of fragility.

 

Victims of controlling partners are likely to be people who have a very impoverished sense of self and lack a definition of themselves. They are therefore unable to fully articulate their needs since they do not know what they value, or not and the limits of how they should be treated. They often lack the ability to advocate for themselves, and depend on their partner, deferring to them to make decisions. People who are in this type of relationship are likely to be co-dependent on each other, one playing the role of the controller and the other the victim. Victims of controlling behaviours are likely to be people who grew up being made to feel like their neds were insignificant and secondary. They had to rely on others-parents, or older siblings, to make decisions for them. Being in the dynamic with a controller is a familiar place for them. Freud (1912) described this as a transference, where one relates to figures in their current life as if they are figures from their past. While this phenomenon is unconscious, there is repetition of the dynamics in these early relationships “there and then”, projected in the present “now” and there are similar feelings evoked. This is why people who are victims do not often realise it, as it is a repetition of something repressed, however familiar at an emotional level.  Freud (1912) argued that in repeating, remembering, and working through these early experiences, we are able to use the transference to unravel the past, and work through the early trauma that was repressed in the present. This is why therapy is significant in helping both victims and perpetrators of controlling behaviours in relationships. It is true that a big part of how we relate to our partners in romantic relationships is transferential. Some partners will unconsciously create  parent – child dynamics, while others will have sibling dynamics etc. These transferences are not always fixed &  get illuminated at different times- for example a partner can  easily become the critical mother, annoying sibling etc, or a simple argument can provoke a powerful response, as a transference response. The reaction is due to the familiarity of the experience & the feelings it evokes.

At unconscious level, what attracts us to our partners is the very thing that either we may have sought in our own parents, or see in our partners & want to regain & preserve it.

 

Couples can work through and heal from this form of abuse, if they put in the work through therapy. Individual therapy is also helpful in addressing control issues in relationships, for both victim and the controller. A big part of this behaviour is related to past trauma. Recognising that there is an issue is the first step into the healing journey, and developing empathy towards each other. It is true that some cultures normalise controlling behaviours in relationships, and women are often viewed as subservient to men. This is very harmful, as it often leads to other forms of abuse such as physical, verbal, and emotional abuse.

 

How to heal from controlling behaviour in relationships

 

Victim

  • Recognising and accepting that you are being controlled is the beginning of the healing journey. When we acknowledge something in our lives, there is a huge transformation that already takes place.
  • Learn to advocate for yourself and be firm & consistent.
  • Make your partner aware of how their behaviour makes you feel and remind them that you are an adult, and you have the right to make decisions for yourself.
  • Have meaningful relationships with your family and friends. Controllers like any abusers often alienate their victims.
  • Seek professional help as some of these behaviours are deep rooted.

 

The Controller

  • Learn to let go of the need to control your partner and the relationship.
  • Understanding the source of the need to control and being able to reflect on it is helpful in managing this behaviour. Think about your past and when you were made to feel weak and vulnerable. Have compassion over your younger self and understand that is the past.
  • Find ways of managing your anger, which is often at the root of controlling behaviours.
  • Seek professional help individually and work through some of this childhood trauma that gets acted out in the relationship.
  • Seek couples therapy & learn healthier ways of relating with your partner with their assistance.

References

 

Bellis, M.A., Hughes, K., Leckenby, N. et al. National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England. BMC Med 12, 72 (2014). https://doi.org/10.1186/1741-7015-12-72

 

Bion, W. R. (1962). Learning from experience. London: Karnac

 

Freud, S. (1912). The Dynamics of Transference. – Strachey, J. (1958). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works. [Electronic version]. Retrieved from PEP Archive database. http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib,cookie,url&db=pph&AN=SE.012.0097A&site=ehost-live

 

Freud, S. (1914). Remembering, Repeating and Working-Through (Further Recommendations on the Technique of Psycho-Analysis II). – Strachey, J. (1958). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913)

 

Image Credit- Jonas Svidras- Unsplash

Categories
Uncategorized

Victim Mentality and Romantic Relationships

COPYRIGHT CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated, or reproduced in any manner without the author’s permission.

Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

 

Do you know someone who “wallows in self-pity”, or complains about their life/situation without doing anything about it?   They blame everyone else around them, but themselves. They lack any sense of responsibility or accountability over their own actions and overlook how they contribute to situations that they repeatedly complain about. People around them are quick to label them “energy vampires”, and you can only take them in small doses, because being around them is emotionally depleting. They bring you down, no matter how much you love them. The description l gave matches people who have victim mentality.

 

Victim Mentality

Victim mentality is one of the phrases/concepts that has emerged in this current psychobabble era;  its also a period where people are more open to talking about abuse in relationships. Victim mentality is harmful in any type of relationship-friendship, sibling, collegial, and other interpersonal relationships. It is even more harmful in romantic relationships where the power disparities are likely to get bigger, as a result of this way of functioning. If there is one partner who views themselves as a “victim” in every situation, it subconsciously puts the other partner in the perpetrator role. It then becomes very easy for the victim & their partner to inhabit these roles, and unconsciously enact them. Ironically, people who have victim mentality tend to pair up with “controllers”-people who like to control and dominate others. This means each partner adopt a fixed role & play it well.

 

Victims in Relationships

Victims are people who tend to be passive in relationships & simply let things happen around them. They allow their partners to get away with abusive behaviours, and let their boundaries pushed, without enforcing them. Victims feel that they can neither  speak up, nor advocate for themselves. So they simply complain, and complain, and complain , about the same situation. Since they view themselves as the victim, it’s safer for them to complain without doing anything about the issue they complain about.  At an unconscious level, this behaviour is a result of fear of abandonment, and lack of trust in themselves as lovable and deserving. Safety is an innate need. Our ancestors lived in batches for safety reasons. Abandonment meant being mauled by wild animals. We all have that inbuilt  and hard wired need for safety, and security, which is part of our evolutionary make up. Victims also lack a definition of themselves; any threat of loosing partners (by speaking up) will trigger extreme anxiety of loss of self and/or psychic disintergration. Therefore, the   dynamic where there is victimhood leaves the victim in this fixed position without making any effort to change things, due to the fear of abandonment. Things going well for long periods of time can also make the victim fearful and insecure. They may unconsciously trigger bad behaviours from their partners, in order to reinforce that victim role, as it gives them a sense of validation. These destructive cycles reinforce that victim role and perpetuates the destructive cycle.

 

Internal Experience

It’s easy to ignore the distress behind people who have the victim mentality, and simply view them as annoying, weak, irritating, or spineless people.

 

People who adopt the victim role often have:

 

  • Low self esteem
  • Depression
  • Low confidence
  • Impoverished sense of self
  • Anxiety
  • Insecurity
  • Worriers
  • Emotionally fragile

 

Predisposition

People who adopt the victim mentality are likely to have grown up in environments where they felt vulnerable and unprotected by their care givers. They were made to feel bad for  being themselves, or speaking up for themselves, & often had to tune into their parents’ feelings and emotions. They  were neither nurtured emotionally, nor allowed to develop what Winnicott (1960; 1965) called the True Self.  According to Winnicott (1960; 1965) the mother must be receptive to the baby’s emotions, and respond to them in a way that the baby can be more trusting of their own abilities and develop their True Self. In order for the True Self to develop, the mother has to be able to receive what Winnicott termed the baby’s “gesture”, which gives gives expression to a “spontaneous impulse”. The source of this gesture is the True Self.  When the mother is unable to meet these spontaneous gestures, by receiving the baby’s omnipotence, the baby complies with the mother’s defensiveness, which forms the origins of the False Self.  In order for the True Self to develop, the mother has to be able to  makes sense of the baby’s needs by being attune to the baby’s emotional needs, and respond with empathy. There has to be repeated experience of this nature, which the baby has to internalise.  Failure to do that, the baby creates a defensive- False Self – out of compliance, which hides the True Self. When the False Self becomes organised, it acts as a protector of the True Self,  albeit inauthentic, weak and fragile. In contrast, the True Self is playful, creative, and robust.  If the  True Self, was never cultivated, the False Self becomes dominant over the True Self.  In adult life, the False Self means an impoverished  internal world and weak ego.  Since the  False self is inauthentic, one will seek validation in others- victim mentality. The lack of development of the True Self is what is behind feeling “fake”, “wearing a mask”, “an imposter” or feeling detached from oneself, and the world. People who adopt the victim mentality role are likely to have never developed their True self and therefore have an organised False Self, which lacks confidence & agency.

 

From an attachment perspective, victims are people who are insecurely attached, therefore fearful of abandonment. Most people who have victim mentality have anxious avoidant styles. Following Bowlby (1969) formulation of anxious avoidant attachment style, anxiously attached adults are people who are likely to have had mixed messages from their care givers. They could not depend on them, they had to care for themselves by keeping a distance, in order to feel safe. Anxious avoidant people tend to repeat the same pattern in romantic relationships-they tend to be very clingy and submissive to their partners, which is what lends them into victimhood. Although they may play the victim role, they are sensitive  to rejection. They crave to feel wanted, and needed by their partners, hence the submissiveness & placating themselves- the “martyr”.

 

People who had a secure attachment with their care givers/ parents, in childhood, are likely to approach adult romantic relationship from a place of confidence, autonomy, and maturity and see themselves as an adult who has agency, not a victim. If one has an insecure avoidant attachment style, they are likely to play out the internalised way of relating by drawing their partners close by being needy, and seeing themselves as victims who need protection. They do so instead of them doing something about the situation.  The clinginess itself & passivity is what perpetuates the cycle. From an attachment perspective, care givers of the anxious avoidant child would have not provided them enough safety and security and they could not rely on the parent to meet their basic needs. The partner of the victim is dealing with unmet needs from the parents.

 

 

How to Heal from Victim Mentality

  • Remind yourself that you are special & you deserve to speak up for yourself.
  • Learn to put your needs first or at least consider your needs in any situation.
  • Take risks and change the familiar patterns that you are stuck in for example apologising for things you haven’t done, taking the blame.
  • Remember you are not to blame for who you are, however you have the responsibility to change the dynamic
  • Seek individual therapy of you think you have victim mentality. Many a time we do not recognise how much of our behaviour is simply a manifestation of our way of relating, from the internal working models laid out in childhood. Not all these patterns are healthy & we have a duty to change them.

 

References

Bowlby, J. (1969). Attachment and Loss, Vol. 1: Attachment. Attachment and Loss. New York: Basic Books.

Winnicott; D.W. (1960). Ego Distortions in Terms of True Self and False Self. The Maturational Process and the Facilitating Environment: Studies in the Theory of Emotional Development. NY

Winnicott, D. W. (1965). “Ego Distortion in Terms of True and False-Self” in The Maturational Process and the Facilitating Environment: Studies in the Theory of Emotional Development 140. New York: International Universities Press

Image Credit- Anthony Tran- Unsplash