Archive for February 2016

Dave wasn’t quite ready to get married, but his girlfriend, Lizzie, had made it clear that the time had arrived. She brought it up almost daily. “We’ve been together for four years,” she said. “I know you love me. We’re really happy together. So why you don’t want to marry me?”

Dave knew she was right. He loved Lizzie and wanted to be with her forever. But some part of him still wanted to say “no” to marriage, at least for the moment. He just couldn’t explain it to her.

Janie had recently broken up with her boyfriend, and her friends were pressuring her to sign up to an Internet dating site. But Janie was reluctant. “My biggest problem is not whether or not any guys will be interested in me,” she said a little shyly. “I’m sure someone out there will be. But what if I’m not interested in them? How do I politely reject someone? I just hate the idea of hurting someone’s feelings. And what if someone doesn’t take ‘no’ for an answer? It’s hard for me to be really firm.”

Larry’s buddies were going to an expensive club. Larry didn’t have that kind of money to blow on a night of drinking, and he also didn’t really want to get wasted, which he knew was going to be the end result of the evening. But he could not figure out how to get out of it without pissing off all of his friends.

Susie had landed a paying internship at the company of her dreams. She knew that she was starting at the bottom, but she had hopes that her new employers would be impressed by her abilities and that she would quickly move up in the business. At her interview she had said that she would be willing to do anything they wanted, but really, she had no idea that they were going to expect her to keep the kitchen clean and pick up coffee and doughnuts for the morning meeting.

Do any of these situations sound familiar?

In a recent Forbes Business article Jonathan Becher(link is external) offers several quotes from powerful men who consider “no” to be an important part of a successful life strategy: Here are just three of his examples:

Steve Jobs: “Focusing is about saying ‘no.’”

Warren Buffett: “We need to learn the slow ‘yes’ and the quick ‘no.’”

Tony Blair: “The art of leadership is saying no, not saying yes. It is very easy to say yes.”

But for many of us, it’s not so easy to develop this art.

Why is this?

Fear of conflict

Many of us are afraid of conflict. We don’t like others to be angry with us or critical of us. We therefore avoid saying “no” when we are afraid that it will put us into conflict with someone else, whether that someone is an intimate partner, a colleague or friend, or a supervisor or boss. Many of us also try to avoid battles with our children, because we feel that if we say “no” to them, they will stop loving us.

As children we are taught not to go against authority. We are supposed to do what parents, teachers, and others in power tell us to do. We obey because of fears of being punished, but also because of a desire to please and be loved by these people who are very important to us. We carry this worry with us into adulthood.

But we are also pulled by a desire to fit in with and be liked by our peers. Research has shown that men and women have a tremendous need to belong to a peer group. Whether boy or girl, man or woman, we desire acceptance by our friends, or the people we want to be friends with, as a way of establishing and maintaining a sense of identity, of “selfness.”

Don’t want to disappoint or hurt someone

So, you don’t want to tell your mom you won’t be home for the holidays because she’ll be so disappointed. Okay, makes sense, right? Sometimes we do things that make others feel better, even if it’s not quite what we want to do. But what if she’s going to be disappointed that you are making a job or a career choice that she doesn’t like, but that is your total dream? Or what about something small, like disappointing a friend by not going out to dinner with her when you’ve got a huge work project due the next day? Or even smaller, what if you and your boyfriend or girlfriend can’t agree on a restaurant or a movie? Do you give in so that they won’t be disappointed?

Desire to be unique

Yet we are also encouraged to think “outside the box,” to focus on our unique talents and our personal truths. Most of us want to be viewed as special in some way, as different from the very group that we belong to. It is sometimes this need to be seen as a separate person that drives those of us who defy authority, often to our own detriment. “You’re not the boss of me,” shouted at some time or another by many young children, is a driving life force for all of us. But of course defiance and purposefully unacceptable behavior can backfire. It can make you stand out, but it can also separate you from the very group that you want to belong to.

Here’s a funny thing about the quality of specialness and difference. It seems that for many of us, feeling different feels best within the context of an accepting, affirming peer group!

Harder for women?

My PT colleague Kathryn Lively writes that women often have difficulty saying “no” to men, because we want to get along, want to be nice and don’t want to hurt another person’s feelings. In my work as a therapist over the years, I have certainly seen plenty of examples of this phenomenon; but I have also worked with many men who don’t say “no” because they don’t want to “rock the boat.”

What can you do about it?

Techniques

There are many techniques for getting better at saying “no,” once you’ve located some of the psychological reasons that make it difficult.

Marcia Linehan, creator of Dialectical Behavioral Therapy (DBT), suggests practicing saying “no” in small, unimportant situations, like not buying something at a drugstore.
Eating disorder specialist and my PT colleague Susan Albers suggests that you stop and breathe before saying “yes,” in order to give yourself a little space and an opportunity to assess and respond to your own needs.
Seek advice. We’ll talk more about this in a moment, but in essence the point is to get backup for your own position.
Don’t be fooled by the word “everyone else…” It is almost universally untrue that everyone else is doing the same thing or wants you to do whatever is being asked of you.
Take a minute to ask yourself how bad the guilt, anxiety, disappointment or other emotions you might feel if you don’t do whatever’s being asked of you will be. Can you tolerate them? Is it worth it to do that thing in order not to feel those feelings?
Assess the fallout. How bad will it be? Again, is it worth it to give in? Or not to?Consider that there is no perfect answer. If you say “yes” this time, you can try “no” sometime later. And maybe, just maybe, “yes” this time will make it easier to say “no” the next time.
Remember that you can change your mind in most cases. Don’t get trapped by the belief that you only have one opportunity. There will be many more (see above).
And finally, remember that sometimes “yes” is actually a better answer. We’ll talk more about this in a minute.

Getting backup

So how does this fit with saying “no”? It seems that most of us feel much better about saying “no” to someone if we have the backup of some buddies or folks that we trust.

Dave, for example, talked to his brothers and sister about his quandary with Lizzie. They helped him to put into words what he was feeling, and also to think about what was going on for Lizzie. After several conversations, he was able to explain to Lizzie that he loved her very much but wanted to ask her to marry him on his own time. Every time she brought it up, he felt like she was telling him what to do – “like my Mom, not my future wife.” They agreed that this theme of Lizzie acting like his Mom and Dave acting like a kid was something they needed to work on in their relationship in general. But now that they had a way of talking and thinking about why he was dragging his heels, Lizzie actually didn’t feel the need to keep pressuring him anymore!

Janie’s friends offered her a variety of techniques for saying “no” to guys, from “ghosting” or simply not answering their calls, which she said she could never do, to saying nicely but firmly that she simply didn’t think it was going to work. “It’s just part of the process,” she realized. “It’s not me being a mean or bad person.”

Larry also talked to a couple of friends who were not part of the drinking group. They told him that they just saw it as a waste of their time. “You spend a ton of money on something that leaves you feeling miserable and that affects your performance the next day,” they told him. “And the truth is, those guys won’t even notice if you don’t go. They’re just pushing you because they want the company.” To Larry’s amazement, they were right. He simply said that he couldn’t do it the next time, and after a couple of tries to change his mind, the other guys left him alone. And there was no change in the way they treated him at work. “I don’t even know that they realized I wasn’t there in the end,” he said.

Sometimes, “no” is the wrong word

Susie’s situation was a little different. In her case, after talking to several friends who supported her indignation – “you weren’t hired as a gofer or a maid!” said one, and “they wouldn’t do that to a guy,” said another – Susie talked to an older mentor, who said that in fact they would and had done exactly the same with male interns, that she was at the very bottom of the ladder, and that if she hung in there and made herself as useful as possible, not just in menial tasks but also doing research for projects and even, when appropriate, offering thoughts or ideas about current and future projects, she would soon find herself moving up the ladder. Her mentor said that she was not encouraging her to make herself into a doormat or that she accept inappropriate demands, but that in this particular case saying “no” would be counterproductive. And she then pointed to two senior members of the staff and said that they had each been interns at one time – and had each cleaned the fridge and brought coffee to the other staff.

F. Diane Barth L.C.S.W.Off the Couch

At Rosewood, our specialty is the treatment of eating disorders(link is external). However, very rarely does someone present with just an eating disorder. It is common that comorbid issues are also present. Dr. Nicole Garber, Rosewood’s Chief of Pediatric and AdolescentEating Disorders, shares her expertise on teens and self-injurious behavior – a common co-occurring issue with teens and eating disorders.

Typical Scenario

Maria comes into the office with her mother. Maria looks tired and will not make eye contact as she sits down. Before the door is even closed, her mother says in almost hysteric tones, “Show her, show her what you have been doing!” Hesitantly Maria pushes up the sleeve of her shirt to reveal several linear, superficial cuts that were self-inflicted. Her mother sits down looking frustrated and says “I just don’t understand, how she can be hurting herself”.

The above is a scene that clinicians deal with on a daily basis. Self-injury, or more formally Non-suicidal Self-injury (NSSI), is common in teenagers with anywhere from 8-61% of the population engaging in self-injurious behaviors. The 8% estimate is from community estimates, and the higher end of the spectrum is from patients seeking mental health services. The average age of onset for self-injury is between 14 and 15 years old and earlier in adolescents. Girls self-injure more than boys, but the rates become more equal through the later adolescence period.

What is NSSI?

NSSI is defined as “Direct and deliberate destruction of body tissue in the absence of any observable intent to die”. (Nock) One must ask about the intent of the injury and not assume on way or the other.

Why do young people self-injure?

Often in the popular press, self-injury will be presented as a means that a young person gains attention. At times, self-injury may be used as a cry for help, but more commonly it is used to regulate emotions. A young person may self-injure when they are experiencing very intense emotions and they do not know how to self soothe in a more adaptive manner. It is known when someone self-injures there are endogenous opiates that are released that can cause the person to feel better which is part of the reason that a young person continues the behavior despite other negative consequences. Often time young people with trauma will feel numb or dissociated and will self-injure in order to ground themselves and feel something.

What are some warning signs that my teenager may be self-injuring?

One may notice blood stains on clothes, towels, or tissues. Often there will be frequent unexplained wounds or an increase in “accidents”. One may also notice always wearing long sleeves or pants, even if not appropriate for situations or weather. Most young people self-injure in private, so there may be more time spent alone and irritability prior to them being able to go someplace private if they are having the urge to self-harm.

What to do if my teenager is self–injuring?

If you discover your child is self-injuring, take a deep breath and take a few moments (or hours) to collect yourself. Ask your child about what you are noticing and try to take a curious and non-judgmental stance. Let them know that you realize that they must be experiencing significant pain if they are self-injuring, and that you are there for them and want to get them help. Then book an appointment with a mental health practitioner, therapist or psychiatrist, for an evaluation. Over 90% of teenagers that self-injure meet criteria for one or more psychiatric diagnosis such as depression, anxiety disorder, or conduct disorders. It is also known that self-injury in adolescents increases the risk of a suicide attempt and completing suicide.

Treatment of Self-injury:

The mental health practitioner will work with the teenager and family members to develop a treatment plan that will address the self-injury and any co-occurring disorders. Specific therapies have been developed to treat NSSI in teenagers including dialectical behavioral therapy (DBT) and mentalization based treatment (MBT). Both DBT and MBT have a coherent model to understand self-injurious behaviors, employ an active therapist, balance validation with change, make a connection between thoughts, feelings, and behaviors, and encourage agency amongst the adolescents.

In summary, self-injury is common in adolescents and is most often used to as a means to regulate their emotions. If you suspect your child is self-injuring, please seek an evaluation with a qualified mental health practitioner as there are effective treatments that exist.