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Exploring the over-diagnosis of bipolar disorder in mental health care. Bipolar disorder is significantly over-diagnosed in current mental health practice for several specific reasons. Understanding true bipolar disorder is essential for clinicians and patients. The consequences of incorrect diagnosis are usually over-medication and inadequate treatment for the actual problem One of the diagnostic fads in mental health, the over-diagnosis of bipolar disorder , is ongoing and problematic. This review aims to shed light on what makes this problem so tenacious. It is also a tool for people who may need to question their diagnosis. The diagnosis of bipolar disorder is applied these days with alarming regularity. We’ve all become used to “that’s my OCD ” when someone is double-checking; “she’s schizo” when a person is ambivalent; and “he’s so ADD” as a facetious diagnosis of anyone showing lack of attention. Now we hear “she’s bipolar,” meaning an individual’s moods change rapidly or are extreme. Each of these incorrect usages grossly minimizes the struggles of actual sufferers while mischaracterizing the diagnoses. The misuse of bipolar disorder has surpassed these casual statements and is now commonly misapplied by actual mental health professionals. Patients assume that this diagnosis explains their troubles when the truth may be more complex or much simpler. Throughout my career as a psychiatrist, aside from seeing patients, I have supervised many clinicians and reviewed many patient charts. Over the past 20 years or so, I have seen the diagnosis of bipolar disorder appear in charts and patient histories with implausible frequency. As a rule, I no longer accept these diagnoses until there is further proof. Unfortunately, my skepticism is usually borne out. From the 1950s to the 1980s, American psychiatrists tended to underdiagnose bipolar disorder compared to our European colleagues. If someone was very sick and had a chronic course, we usually labeled them as having schizophrenia. Eventually, we understood that severe mood illness was common and corrected our ways. However, from the 1990s into this century, things have changed. From 1996 to 2004, psychiatric hospitals showed a four-fold increase in the diagnosis of bipolar disorder for children and about 50 percent for adult in-patients. For out-patients during the same time period, we saw a previously unheard-of change. There had been up to a 40-fold increase in the diagnosis of bipolar disorder in children and a doubling in adults. Although there has been some correction for children , in adults, the trend continues. A recent large study of adult patients found that since the year 2000, psychiatrists have tripled their billed visits for diagnosed bipolar patients, while their visits for schizophrenia patients remained the same. Just a few years earlier, these visits were roughly equal, which makes sense as the prevalence of the two disorders is also roughly equal. The chief area of confusion in bipolar disorder is seeing moodiness or rapid mood changes (negative moods, anger outbursts, mood lability) along with impulsivity (e.g., spending a lot of money without forethought) as indicative of a bipolar disorder. While these might be important clues, they do not constitute the actual illness. In reality, they are common aspects of many problems, including depression , substance abuse, personality disorders , and even reactions to stress. By themselves, they serve only to invite more specific questions. Normal depressions often produce labile moods, anger , tantrums, and a range of emotional responses. As a matter of frequency, these changes from regular depression are much more common than from bipolar disorder. Bipolar disorder is a severe psychiatric disorder. It consists of alternating depression and manias, which often lead to hospitalizations and a chronic course of illness. Patients’ lives can be chaotic with loss of jobs and relationships and associated problems like drug and alcohol abuse and cognitive impairment. There are exceptions, but many people who function well in their homes and careers do not have bipolar disorder. The defining part of the illness is the existence of manias. These are episodes of several days to weeks (not minutes or hours) in which the person has very high energy, so high that they can go with little or no sleep for days without being tired (the patient will only stay in bed 1-4 hours, not all night tossing and turning). The high energy is reflected in behaviors such as rapid speech, excessive goal-directed activities (e.g., cleaning, doing repairs), and uncharacteristic conduct (spending, sexual, or grandiose in nature), as well as having a clearly high mood. High moods may be bright, expansive, grandiose, or very irritable. In cases that go untreated, the person may become fully psychotic with delusions and hallucinations. In true mania, all these things appear together for a significant time period: several days to weeks, as mentioned. Parts of these symptoms for shorter periods are not mania. Examination usually finds another explanation, such as alcohol intoxication, drug use, or, commonly, depression manifesting as anger. There is something called “hypomania,” in which a person shows all the symptoms for the same periods, but not such that safety is a concern. This is still a type of bipolar disorder. The manias alternate with depressions, which are just like other depressions. There is usually an interlude of normalcy between periods of manias and depressions. As the person has more and more episodes of illness, the time between them becomes shorter until there is no normal mood at all. Despite these clear diagnostic criteria, patients who do not fit them are frequently diagnosed. It is true that some people have mood shifts and behaviors that are difficult to diagnose. Bipolar disorder may be an important consideration here, as the symptoms may be concealed by other issues. A thorough evaluation with a co-reporter (an important element that is often overlooked in serious and complex cases) usually reveals the bipolar diagnosis. To make a point: spending too much money, having an affair, gambling, losing your temper, changing moods quickly, not sleeping well, feeling energetic, being grandiose, talking too fast, and having rapid thoughts are not, by themselves, bipolar disorder. All of these happen more frequently due to depression, substance abuse, personality disorders, and just being human than to bipolar disorder. Any of them may be a clue about a bipolar diagnosis. But bipolar disorder includes the full syndrome, as I described above. There have been several converging pathways that have led to the current situation. Over-generalization of research and over-reliance on questionnaires play large roles here. In the case of research, studies about bipolar disorder done on patients in psychiatric hospitals do not tell us what happens with the much larger group of people in clinics and offices. The results of these studies are commonly applied to office patients and give a misleading picture of the risk for bipolar disorder. As for questionnaires, I commented on them in a previous post. Briefly, they work best for screening, not for diagnosis. Another factor is newer medications. These medicines, called atypical antipsychotics (Risperdal™, Abilify™, and Seroquel ™ are common brand names), are effective in both bipolar disorder and common depression. Consequently, a clinician may not know which condition has improved when a patient feels better. If they assume the patient has bipolar disorder when she has only depression, over-medication with multiple medications will likely result. Bipolar disorder is both common and serious. We should not make the diagnosis without evidence that conforms to diagnostic criteria, nor should we accept diagnoses that raise questions (such as the common case of a person labeled “bipolar” who has never taken mood stabilizers and has been without symptoms for years). This problem with diagnosis has gone on far too long. Clinicians of all stripes should review this important illness. As for patients, they should also read the criteria and discuss how they fit, or not, with their own clinician. Mark Rego, M.D., - Website -

Many patients don’t want to take mood-stabilizing medications. What can be done? People with bipolar disorder often refuse medications even when they recognize the need for them. Family conflicts over autonomy and stigma can affect the person's willingness to engage in treatment. Clinicians can facilitate communication between patients and caregivers in coping with bipolar disorder. In young patients, non-adherence may reflect disagreement between parents in split households. As many as half of people with chronic psychiatric disorders such as bipolar disorder (BD) doesn’t consistently take their prescribed medications. The consequences—an increased risk of suicide, hospitalizations, social and work impairment, and medical problems —can be quite damaging, not only for the patient but for their families. What can be done? The psychosocial treatment that my colleagues and I developed for bipolar illness, family-focused therapy (FFT), engages the patient and family members in an ongoing process of psychoeducation about BD and training in communication and problem-solving skills (Miklowitz, 2010, 2019). One of its subsidiary goals is to enhance the patients’ acceptance of mood-stabilizing medications. In this article, I offer suggestions as to how psychologists, in conjunction with the treating physician, can work with the family to enhance the goals of pharmacological treatments. Causes of nonadherence Why would a person stop taking medications that would almost certainly reduce their risk of illness recurrences? The research literature emphasizes intolerable side effects (e.g., weight gain, hand tremors), financial burden, lack of insight into the condition, questions about the effectiveness of medications, or reactions to the physician or treatment environment. In our view, the patient’s relationships with family members (and their different views about the illness and its treatments) are potent factors in determining why some individuals accept medications and others reject them entirely. When a clinician encounters a person with BD who has refused medications, it is useful to start with a chain analysis: What sequence of thoughts, feelings, and events prompted the decision to stop medications (or to refuse them when first recommended)? What were the contributions of side effects, disbelief in the diagnosis, or societal stigma? Are there family dynamics contributing to this decision? Usually, family caregivers are supportive and recognize the need for the patient to be on board with their treatments. However, in their attempts to assure the patient’s commitment to medications, some caregivers unwittingly contribute to nonadherence. Engaging the family as an ally in treatment The first module of FFT consists of four or more sessions of psychoeducation, where clinicians explore the meaning of the bipolar diagnosis to the patient and family members: how are episodes of mania and depression experienced by the patient, and how is that different from what parents or spouses see? What are the early warning signs of recurrences, and what can the patient, the family, and the treatment team do when these early signs appear? In the context of this discussion, the patient’s feelings about medications like lithium, valproate, lamotrigine, or antipsychotics (e.g., risperidone) often come to the fore. Consider the following clinical scenario: Liam, an 18-year-old former patient with bipolar I disorder (name and identifying details changed), was hospitalized for two weeks with a manic episode. He was discharged from the hospital to live with his mother and sisters. He was ambivalent about taking his daily regimen of four 300 mg lithium tablets and depended on his mother to fill his prescriptions and arrange psychiatry appointments. He was still symptomatic when he came home, and his mother reacted by asking him, almost compulsively, whether he had taken his lithium that day. In what he described as “a blow for freedom,” he began leaving lithium tablets around the house for her to find: on the counters, behind the toilets, even underneath her pillow. When they began attending FFT, she was threatening to kick him out of the house. Liam acknowledged that he needed lithium but was only willing to take it if he could decide for himself. His mother wondered aloud how she would know if he was being adherent. Through a structured problem-solving exercise in FFT, they agreed that: (1) taking lithium was fully his decision; (2) she was only to ask him about the tablets if she found any around the house, and then at most once a day; (3) he agreed to let her know when he was running out; and (4) he allowed her to communicate with his physician to exchange information about his compliance and lithium levels. Although Liam never fully warmed to taking lithium, his mother’s willingness to back off from over-monitoring helped him remain adherent after his hospital discharge. In this example, lithium nonadherence became a proxy battle for Liam’s quest for independence and autonomy. Ironically, his unwillingness to be adherent increased the chances that he would have another illness recurrence and be even more under his mother’s thumb. But he knew of no other way to express his resentment. What if caregivers don’t agree on the need for medications? Sometimes, a patient’s unwillingness to take medications reflects an alliance with one of two parents against the other. Greta, a 13-year-old patient (name and identifying details changed), had “unspecified BD,” a common diagnosis in adolescent patients. She had a history of recurrent hypomanic episodes lasting one or two days each, during which she became irritable, spoke and ate rapidly, slept little, became highly distractible, and seemed full of energy. Her “crashes” involved full withdrawal into her bedroom, often missing school for weeks at a time. Greta’s parents were separated and on their way to a divorce . She lived with her mother for one week and then with her father for the next in a 50/50 custody arrangement. FFT sessions were arranged separately for the two dyads. Conflict and tension between the parents, and between Greta and each parent, were salient. About four weeks into FFT, during a session with her mother, Greta announced that she was no longer taking lamotrigine, which had been prescribed at a low dose of 50 mg. With gradual inquiry, she revealed that her father did not believe she had BD and had told her that she didn’t have to take lamotrigine or any other medication at his house. In a follow-up phone call between the FFT clinician and the father, he said, “I don’t think she gets along with her mother. That’s why she has mood swings. She doesn’t need pills.” A conjoint session was arranged for the two parents without Greta present. The clinician made clear why they needed a collaborative plan for her psychiatric treatments (both the FFT and the medication sessions) in the same way that they seemed able to coordinate her diet, schoolwork, and social activities. The clinician did not challenge the father’s beliefs directly but provided him with a recap of Greta’s diagnostic evaluation and explained why lamotrigine had been recommended for her mood stability. The clinician also encouraged the father to discuss the matter with the physician and then with Greta. After two parent-only sessions, the father agreed that he would encourage Greta to take lamotrigine when she was at his house, provided that the couple could reevaluate the issue in three months. This case illustrates how nonadherence in a younger patient can reflect a larger battle between parents, seemingly over health care but also over unresolved marital issues. Observations like these have led us to wonder how often young patients who are medically nonadherent have parents who inadvertently aid and abet their decisions. The importance of psychoeducation Committing to medications is difficult for people with BD due to side effects, costs, disbelief in the diagnosis, and the stigma of taking psychiatric drugs. It is much harder when families unwittingly contribute to the patient’s nonadherence due to misunderstandings about mood-stabilizing medications, excessive monitoring, or critical and blaming attitudes. Encouraging caregivers and patients to develop a cohesive approach to pharmacological treatment is critical to the patient’s mood stability and quality of life David J. Miklowitz, Ph.D., - Website - References Miklowitz, D. J. (2010). Bipolar disorder: a family-focused treatment approach (2nd ed.) New York: Guilford Press. Miklowitz, D. J. (2019). The bipolar disorder survival guide: what you and your family need to know (3rd ed.). New York: Guilford Press.

A Personal Perspective: Stereotypes about mentally ill people still prevail. Many of us have expectations about how a mentally ill person looks. People with mental health diagnoses—one in five of us—usually look like the rest of the population. Mental health stigma, like racial bias, can be subtle but damaging, and needs to be addressed when it happens. The other night I told a woman I’d just met at a party that I’ve written three memoirs about being bipolar . “I’d never have guessed,” the woman said. “You certainly don’t look like you’re bipolar.” At the time, I thanked her, because I couldn’t think of what else to say. But later in the evening, I started to wonder what the hell she’d meant. It’s true, some mental illnesses come with preconceived notions of how an afflicted person might look. Take depression , for example—we may expect it to be accompanied by a gloomy expression, slumped posture, and cast-down eyes. People with untreated schizophrenia occasionally exhibit a lack of grooming—unwashed hair or unkempt clothing. But bipolar disorder? What does bipolar typically look like? I suppose it depends on where you’re at on the spectrum. When I’m manic, for example, I dress and look very differently than when I’m depressed. I’ll wear upbeat colors like gold and coral, or a medley of stripes and bright prints. I’m usually feeling sexy then, and my clothing reflects it: it says, “Hey, look at me, I’m pretty.” Even my eye color changes, I’m told, from hazel brown to a gold-flecked green. Of course, when I’m depressed I turn New Yorker in a flash. Thank God black is always the new black; I can look in style, even when I’m suicidal. I do the minimum of maintenance then, which means I’ll run a comb through my hair, but that’s about it. Without any makeup, and swathed in funereal colors, I’m so pale I look like I’m practicing to be a corpse. And since that’s exactly how I feel, somehow the fashion fits. But the night of the party where I met that woman, I didn’t suit either stereotype. Yes, I was in a little black dress. But I was also wearing leopard print shoes, and a bold statement necklace. The outfit didn’t scream, come get me; but neither did it warn all approaches away. I don’t know what color my eyes were that night. But whatever the woman saw in them, to her I must have looked sane. Maybe that’s why I thanked her. But on reflection, I wish I could take that thank you back; I wish I could say to her, “What exactly does bipolar look like?” Maybe I would have made her squirm, but then maybe she would be one less person assuming that mental illness looks the same on everyone. Sometimes it’s only by asking uncomfortable questions that we can worm our way into the dark heart of stigma. Like racial bias, stigma about mental illness can be very subtle; and it can afflict even the most well-meaning, educated, liberal people. Let’s say you’ve never met someone who’s openly bipolar before; maybe you’re a bit apprehensive. What will they say? How will they act? Will you be able to cope? That fear and uncertainty may drive you to stereotype. It’s understandable—but it’s also wrong, and it’s destructive. The truth is, people with mental illness usually don’t look any different from the rest of the population. After all, one in five Americans takes some kind of psychiatric medication. That means your boss, your next-door neighbor, your doctor, a family member, a friend—a lot of them have a diagnosis. It doesn’t always show on the outside. But just because mental illness is invisible doesn’t mean it’s not entitled to the same respect and courtesy as more visible conditions. That woman at the party didn’t mean to hurt my feelings; but ultimately, she did. If I’d told her I had cancer , she wouldn’t have said, “Funny, you don’t look sick.” It wouldn’t be polite. But I contributed to that awkward moment, too, by not calling her out on her ignorance. Instead, the teaching moment passed, and I was just left with a nagging discomfort. We can’t leave it up to the uninformed to eradicate mental health stigma. It’s everyone’s responsibility—mine and yours—to seize the opportunity whenever it presents itself, whether that’s at a lectern or a cocktail party. Let’s make the world squirm a little bit, for the greater good of us all. Terri Cheney - Book -

Personal Perspective: Proper sleep is essential for mood stability. Sleep disturbance is a defining feature of bipolar disorder. Mania is characterized by a decreased need for sleep, while depression often causes prolonged sleeping. A healthy sleep cycle is necessary for bipolar recovery and should be treated as a priority. I was on the brink of snapping at my boyfriend this morning, because his mattress app scolded me that I’d overslept. This opinionated mattress is one of those fancy jobs that hooks up via Bluetooth to your phone and measures all sorts of things you didn’t even know you had, like HRV (heart rate variability). I’d been in bed for a little over 9 hours, and the app took it upon itself to warn me that, “Too much sleep can be a bad thing, so try not to make it a habit.” I showed the text to my boyfriend, thinking we would share a laugh about it. Instead, he said, “Sweetie, sleep is that company’s whole business. They must know what they’re talking about.” He obviously forgot that I’m bipolar . And that I’ve written three books about the subject. And that if there’s one thing, I feel like I’m a semi-expert on by virtue of my illness, it’s the subject of sleep. Sleep disturbance is considered a defining feature of bipolar disorder in all its phases (Harvey, A., American Journal of Psychiatry. 2008 July; 165(7):820-9). A severely decreased need for sleep is one of the most common symptoms of mania, while depression is often characterized by hypersomnia (sleeping for very long periods). It’s possible that sleep issues are so common among bipolar individuals because of a biological vulnerability—i.e., a genetic abnormality in their circadian rhythm system (Wehr, et al., American Journal of Psychiatry. 1987; 144:201–204). I didn’t always understand this the way I do now. For most of my life, I just thought I didn’t know how to sleep like a normal person. Was it something they taught you in nursery school that I had somehow missed? I remember looking around at all the other kids during nap times, wondering how they managed to drift off into dreamland upon the teacher’s command, while I was still tossing and turning and fretting about being awake. Sleep either evaded me completely or drowned me into unconsciousness, depending on what mood state I was in at the time. In periods of hypomania, I would feel a heightened sense of wakefulness—an acute alertness to sounds and stimuli I usually overlooked. I was like a dog let loose for a romp, and the world was one big joyous wonderland of sensory input known only to me. But once that hypomania escalated into full-blown mania, the input overwhelmed me. There was no escaping it—too much light, too much noise, too much tactile information; I couldn’t tune it out for a millisecond. If I tried to close my eyes against the searing brightness, they’d only flutter open again. It was pointless even to try to sleep, so I’d spend days whirling around in a manic spin, my body exhausted but my mind cruelly, savagely awake. One would think the inevitable ensuing depression would come as a relief, but it didn’t. Depression is never welcome, no matter how much one longs for mania to end. True, my world would slow way down then, but the slowness came at an unbearable price: an intense paralysis of thought and action. The lethargy seeped into my very bones until it became nearly impossible for me to do anything but lie motionless in my bed. Sleep became my only escape, and I’d spend days, even weeks, trapped under my covers, haunted by the memory of movement. Thank God, those too-awake days and nightmare-soaked nights are mostly behind me now. Medication, therapy, mindfulness, and years of education have rewarded me with mood stability. But even though I’m now what’s called “euthymic”—meaning my bipolar symptoms are in remission—sleep remains an absolute priority in my life. I know that it’s one of the linchpins of my recovery, and that I could easily backslide if I don’t care for it the way I would care for a treasured possession. That’s why I guard it so fiercely. As I emphatically told my poor boyfriend this morning, nobody and nothing—and certainly not a mattress app!—gets between me and a good night’s sleep. The truth is, bipolar disorder often makes me feel like my mind is not my own. Sleep is one of those rare things that gives me a modicum of control. It would be foolhardy not to treat it like the precious resource it is. Terri Cheney - Book -

Mood shifts in bipolar disorder linked to disrupted neural reward circuits. Mood and emotion affect both what and how we learn and how we adapt to the environment. Disrupted neural activity in reward (striatum) and mood (insula) centers characterize bipolar disorder. Further exploration of the link between mood momentum shifts and RPEs might lead to new targets for therapy. How would you define learning? When we learn something, there is a relatively permanent change in our behavior that comes about because of our experiences with the world around us. Learning allows us to adapt to the environment we find ourselves in successfully. So something that affects learning can affect how well we adapt. Studies have shown that there are a number of factors that affect learning, ranging from what we have already learned (stored in our memories), to the environment we find ourselves in when we learn something new, to our social interactions, and even our socioeconomic status. An important factor that can affect how we learn, and even what we learn, is our emotions and our moods. Paul Eckman, noted for his studies of human emotion, characterizes emotion and mood as differing along five dimensions. They differ in duration (moods last longer than emotions and can be difficult to get rid of), moods can make us more susceptible to experiencing a matching emotional response (a happy mood lowers the threshold needed to trigger the emotion of joy for example, and joy is more easily experienced when we’re already in a happy mood), moods tend not to have non-verbal expression while emotions are universally identifiable through facial expression, and finally, it can be difficult to identify the trigger for a mood, but usually easy to point to a trigger for an emotion (Eckman, 2024). It's this last characteristic that had researchers Moningka and Mason (2024) interested in particular. They wondered about a question that has dogged clinicians and lab scientists alike for quite a while. This question has to do with bipolar disorder and the shifts in mood that characterize this emotional issue. Biopolar disorder results in extreme shifts in mood, cognition and sleep, from emotional pole to emotional pole, extreme lows ( depression ) to extreme highs (mania). Luckily, bipolar disorder responds well to treatment and there are a number of effective treatments available. The question that has persisted has to do with what triggers the shift from one emotional pole to the other, and where in the brain this shift might be happening. Finding answers to these questions would be incredibly helpful in treating the disorder. In their review of the literature, Moningka and Mason reported that there are many studies that have found that individuals suffering from bipolar disorder may be sensitive to rewards in a way that differs from that of non-sufferers. However, they also point out that there are as many studies showings a decrease in reward sensitivity in bipolar patients as there are suggesting an increase in reward sensitivity. They noted that this disagreement in the results might stem from two problems. The first is that making a decision based on the reward received is recursive, involving anticipation and expectation of reward, evaluation of the outcome of behavior, as well as other signals that affect the decision that will be made. One of these other signals that needs to be taken into account is the effect of mood on reward decision making. When we learn something new, we make predictions about the reward we might receive. If the reward we get is better than our prediction, then we create positive reward prediction error (Positive RPE) and our mood improves. This is, after all, what we wanted a better-than-expected outcome. Our confidence increases, and we look for ways to repeat that rewarded behavior. If the reward is worse than our prediction, a negative RPE is created, which impacts mood in a negative direction. We lose confidence and will try to avoid the behavior that led to the disappointing outcome next time. These positive and negative RPEs can accumulate over trials in a learning task, pushing our mood up or down as we succeed or fail. Eldar, Rutledge, Dolan and Niv (2016) say that “Experiences affect mood, which in turn affects subsequent experiences. …First, mood depends on how recent reward outcomes differ from expectations. Second, mood biases the way we perceive outcomes (e.g., rewards), and this bias affects learning about those outcomes” (page 15). This bias is referred to as mood momentum. Moningka and Mason examined fMRI recordings from participants with bipolar disorder and compared them to controls without the disorder. Recordings were made during a roulette task, under two different reward conditions. In the first condition the probability of reward was low (25%). The second had a 75% chance of reward. In addition, the recordings were made at three distinct time periods; making the choice about placing the bet, anticipating the outcome (while the wheel was spinning) and at the outcome itself. They found that the change in mood created by the outcome of the spin of the wheel affected brain activity in reward and mood centers (ventral striatum and anterior insula) more strongly in participants with bipolar disorder than in controls. The connectivity between the ventral striatum (reward) and the anterior insula (mood) was also found to be disrupted in participants with bipolar disorder, suggesting that the momentum of mood might excessively bias the way the striatum tracks RPEs in bipolar participants in particular. Further exploration of the link between mood momentum shifts and RPEs might lead to new targets for therapy. Barbara Blatchley, Ph.D., References Ekman, P. (2024) Mood vs. Emotion: Differences & Traits. Eldar, E., Rutledge, R.B., Dolan, R.J., and Niv, Y. (2016). Mood as representation of momentum. Trends in Cognitive Sciences, 20(1), 15-24. Moningka, H., and Mason, L. (2024). Misperceiving momentum: Computational mechanisms of biased striatal reward prediction errors in bipolar disorder. Biological Psychiatry: Global Open Science, 100330

A Personal Perspective: What some people do once they get over the shock. My friend in Mexico unexpectedly lost her husband. She was inconsolably consumed by grief . It was an enormous effort to sort through important papers and bills. She thought she was imagining things when she found that her husband had been withdrawing large sums of money from their joint account. She had no idea of where the money had gone until one of her husband’s friends told her that he had a gambling problem. She said she felt like someone had punched her in the heart. How could they have been together for 26 years and he kept his gambling a secret? “I felt naïve and stupid and was ashamed to betray him by telling anyone what I discovered about him and how devastated I was,” she confided. “My therapist helped me to see that the problem was my husband’s and not mine. He was too ashamed to tell me about his gambling problem, and his goal was not to deceive and hurt me, but to hide his dark side from me and maybe from himself too. I could certainly tell the truth to a few close friends. They were compassionate and helpful, and they encouraged me to focus on my husband’s good qualities, of which there were many. I am starting to heal.” Another friend in Pennsylvania discovered that his live-in boyfriend of five years had another lover who was 20 years his junior and poor. The boyfriend had been borrowing money from my friend over the last six months, and he had used it to splurge on meals and clothes for his new lover. The revelation led to my friend uncovering the way his partner had lied to and manipulated him the whole time they were together. He raged and swore he would never get suckered into a long-term relationship and would be fine with just hookups. I smile as I write this because despite his initial rage and vow, he is now in a new relationship and seemingly quite happy. Rebecca, who recently relocated to France, divorced her husband in the USA before she moved because he was unaffectionate, unappreciative, and unhappy. It was an amicable divorce which he did not contest. The last time he came to her house to pick up his belongings, he handed her a letter. “When I opened the envelope and read it,” she said, “I almost fell to the floor. It was a profound profession of love and caring, and he told me how much he valued the 13 years we spent tother.” He wrote that it was the happiest he had ever been in his life. He revealed to her for the first time that his father had been in prison for most of his childhood, and his mother railed about what a mistake she made by marrying him. He had a longing to see his father but his mother didn’t let him visit. When he tried to tell his mother how much he missed his father and loved him, he was slapped. His mother became cold and distant, and he realized that he had become that way too. “I have started therapy and learned that my behavior with you was trauma re-enactment,” he wrote to Rebecca. “I reproduced the most painful part of my childhood, and the shock of your leaving snapped me back to the present and the reality of my own behavior.” Rebecca and her ex are now friends, and she said it’s a mutually supportive relationship. If I ever wondered how people can live together for many years and not know that they are being lied to or that their partner harbors terrible secrets, my own life taught me how easily this can happen. Many years ago, when I lived in Switzerland, a friend of mine was having an affair with my first husband. She was so laden with guilt that when I divorced my husband, she offered to testify and tell the truth in a Swiss courtroom. Frankly, my choice of a husband was my own trauma re-enactment, and I wanted nothing more to do with the man I had married, or with the friend who had slept with him. At the time, I wondered how I could ever trust anyone again. But after the shock had passed, I decided that it is detrimental to generalize when someone lies and betrays you. All men are not cheaters and neither are all women or all friends. Shutting down and becoming distrustful is not a good way to enter into future relationships or spend the rest of one’s life. Being observant and present is important, but having a closed heart is detrimental to happiness. It was one of the best decisions I ever made and it led to my long-term marriage which is a blessing in my life. Judith Fein - Psychology Today Article - Book

Mental health is a critical aspect of our overall well-being, yet it is often overlooked or stigmatized. In recent years, there has been a significant increase in the awareness and acceptance of mental health issues. As a result, more individuals are seeking support. But what exactly are the benefits of this support, and how can it lead to improved mental health outcomes? This blog post aims to uncover the importance of mental health support and the various ways it can enhance our lives. The Importance of Mental Health Mental health affects how we think, feel, and act. It's essential for handling stress, relating to others, and making choices. According to the World Health Organization (WHO), 1 in 4 people will be affected by mental disorders at some point in their lives. Understanding mental health is crucial because it forces us to acknowledge that many individuals may be struggling around us. By prioritizing mental health, societies can foster environments of compassion and support. A peaceful space promoting mental well-being This shift towards improved mental health awareness includes recognizing the value of support services. Many people find themselves struggling, whether due to anxiety, depression, or other mental health conditions. The availability of mental health support, in the form of therapy, counseling, or support groups, can have positively transformative effects on people's lives. Types of Mental Health Support Mental health support can take multiple forms, each offering different benefits. Common types include: Therapy and Counseling: Professionals provide guidance on coping strategies and emotional well-being. Many licensed therapists use evidence-based approaches that can lead to improved symptoms and personal growth. Support Groups: These are often peer-led gatherings where individuals share experiences. They create a sense of belonging and connection, helping people feel less isolated. Hotlines and Crisis Services: These provide immediate assistance and support during times of crisis, ensuring individuals can access help when they need it most. Educational Resources: Workshops, seminars, and online materials can be invaluable for individuals seeking to learn more about their mental health and strategies for improvement. Each type of support is designed to meet individuals at their current mental health level and can significantly enhance their coping skills, emotional resilience, and overall quality of life. What are therapy services called? Therapy services can be referred to by various names, depending on the approach and the professional providing the service. Some common terms include: Psychotherapy: This is often used interchangeably with therapy and generally refers to talking therapies that are intended to treat various mental health conditions. Counseling: Counseling tends to be shorter-term and focuses on specific issues or challenges. Cognitive Behavioral Therapy (CBT): A specific type of therapy focusing on changing negative thought patterns and behaviors. Group Therapy: A format where individuals with similar problems come together to share experiences and learn from each other, facilitated by a trained therapist. Exploring these various terms can help demystify the process of finding the right mental health support for each individual. The Benefits of Engaging with Mental Health Support Engaging with mental health support unlocks numerous benefits. Here are some of the most notable ones: Enhanced Emotional Regulation One primary benefit of mental health support is improved emotional regulation. Whether through therapy, counseling, or support groups, individuals learn to identify and express their emotions healthily. This process can lead to: Better decision-making during emotional upheaval. Improved relationships with family and friends. A greater understanding of one's triggers and how to manage them. Increased Resilience Mental health support can significantly boost an individual’s resilience. Resilience refers to our ability to adapt and recover from adversity. By addressing mental health issues head-on, individuals learn coping mechanisms and strengthen their emotional toolkit. Those who regularly engage with support services often report feeling more equipped to handle life's challenges. Resilience training can help decrease the likelihood of experiencing mental health crises in the future. Supportive Relationships One of the greatest benefits of mental health support is the development of a supportive network of relationships. Through group therapy, workshops, or support meetings, individuals often form meaningful connections with others facing similar experiences. This sense of community can alleviate feelings of isolation and loneliness. Networking offers compassionate support, mutual understanding, and encouragement. Individuals frequently find that others experiencing similar struggles feel comforting validation. Tools for Self-Discovery Mental health support encourages exploration and self-discovery. Individuals learn about their emotional state, values, and motivations, leading to greater self-awareness and personal growth. This journey can promote: Improvement in overall self-esteem and self-acceptance. Clarification of values and personal goals. A more profound understanding of how past experiences shape present behaviors. Easier Access to Professional Help As more people seek mental health support, the stigma around it decreases, leading to institutional improvements in availability and access. Many people who may have previously shied away from seeking help now find it easier to approach therapy or counseling services. By utilizing the resources available through therapy services , individuals can access the help they need on a timely basis, reducing the risk of escalating mental health challenges. Building a Support System Creating a robust support system is one of the most empowering steps you can take for your mental health. Here are some actionable tips for building that network: Reach Out: Don’t hesitate to contact friends, family, or colleagues. Express your need for support and share your mental health journey. Join Groups: Search for local or online support groups focused on specific communities or experiences related to mental health. Explore Professional Help: Consider reaching out to a therapist or counselor to understand the options available to you. Participate in Workshops: Engage in mental wellness workshops or educational classes within your community. Be Open to Dialogue: Foster open conversations about mental health with those around you to encourage understanding and support. Gathering for group support can enhance mental wellness outcomes Engaging with these steps not only reinforces your support system but also inspires others to prioritize their mental health. Moving Forward with Mental Health Support Understanding the benefits of mental health support is essential for individuals at any stage of their mental health journey. Accessible resources, be it therapy, counseling, or peer support, can profoundly impact one's quality of life and emotional well-being. Incorporating mental health into our everyday lives creates a community-centric approach that nurtures compassion, understanding, and support. Everyone can play a role in this transformative journey by advocating for mental health awareness and celebrating each other's progress. Making the first step toward mental health support can be daunting; however, the rewards are immeasurable. Prioritize your mental health today and explore the various resources available to fuel your journey toward well-being.

The rise of technology has transformed various sectors, and healthcare is no exception. Virtual counseling, or online therapy, is reshaping how individuals access mental health care. This shift is crucial, especially as the demand for mental health services increases. With barriers to traditional therapy being lowered, we are seeing a promising evolution in how care is delivered. What is Online Therapy? Online therapy refers to mental health services provided through digital platforms. This includes video chats, phone calls, and messaging systems. It enables clients to connect with therapists from the comfort of their homes. The convenience of accessing care online has provided an alternative for those who may face barriers in seeking traditional in-person therapy. A person engaged in online therapy session via laptop One of the standout features of online therapy is its flexibility. Clients can schedule sessions around their work, family, and personal commitments. This adaptability is especially beneficial for those with busy lifestyles or those living in rural areas where mental health professionals may be scarce. Breaking Down Barriers to Access Virtual counseling has fundamentally changed how individuals access mental health care. Many people face barriers such as transportation issues, stigma, and limited availability of professionals. Online therapy eliminates many of these obstacles by providing a platform that is accessible to anyone with internet connectivity. Research indicates that approximately 1 in 5 adults experience mental health issues each year. Yet, many do not seek help due to various barriers. Virtual therapy creates an avenue that is more comfortable and private. People are often more willing to reach out for help with the option to remain in their own safe spaces. A computer displaying a virtual therapy interface Another critical element to consider is that online therapy facilitates access to professionals who may not be available locally. For instance, someone living in a remote area can consult with a therapist from a major city without the need to travel. This broadens the range of expertise available to individuals seeking help. The Privacy Factor Privacy is another significant advantage of virtual counseling. Online therapy sessions can be conducted in private settings, free from the anxiety of running into someone you know in a therapist's waiting room. This helps to combat stigma and makes clients feel more comfortable discussing personal issues. Confidentiality is ensured through secure platforms that comply with health regulations. Mental health professionals utilize encrypted communication methods to keep client information safe. The confidentiality aspect often encourages more individuals to seek help, knowing that their disclosures remain private. A serene home office ideal for virtual counseling Moreover, the availability of messaging and asynchronous communication via chat allows clients to express themselves without being face-to-face. This format can be particularly beneficial for those who find it challenging to convey their feelings verbally. Future of Virtual Counseling As technology continues to evolve, so does the landscape of online therapy. Innovations in artificial intelligence and machine learning are set to enhance the virtual counseling experience. Moreover, many platforms are integrating self-help tools and resources that allow clients to take an active role in their healing process. Apps and online materials for mindfulness, stress reduction, and cognitive behavioral therapy (CBT) exercises complement the therapist’s work. This blend of tools enhances the overall efficacy of therapy. The ongoing global situation has accelerated the adoption of telehealth services, with many services settling into a world where a hybrid model may become the norm. This advancement signifies a shift toward more inclusive, often more affordable, avenues of mental health support. While the transition to more virtual services can be overwhelming, it creates opportunities for individuals to re-engage with their mental well-being in a way that suits them best. For those considering seeking help, exploring options like online therapy in Texas can be a beneficial first step. Embracing Change The benefits that online therapy provides are reshaping how we approach mental health care. Increased accessibility, affordability, privacy, and future enhancements position virtual counseling as a viable solution for many in need of support. As society increasingly acknowledges the importance of mental health, online therapy presents a promising solution to bridge gaps in care. By understanding its offerings and potential, individuals can make informed choices about their mental health journey. In this transformative landscape, it is vital for users to stay informed and utilize resources that best suit their needs. Whether you are new to therapy or looking to continue your journey, consider embracing the shift to online counseling as a step towards improved mental wellness.

How negative thinking hinders our relationships. Perfectionists' negative thinking patterns contribute to their need to be perfect. Taking responsibility for one's mistakes tends to improve relationships. In learning how to tolerate their mistakes, perfectionists need to learn to trust others. Most of us dislike being criticized, whether the feedback is direct or indirect, as in the form of unsolicited advice. Some of us hate negative feedback so much that we skew it in our minds, complaining about its presentation and even the presenter when, in reality, we wish to banish it forever. Perfectionists struggle mightily with feedback. Sometimes, they even criticize themselves as a way to shield themselves from its blades: "I know I'm bad; but, please don't hurt me." They may fluctuate between denial , usually for something big, and exaggeration, usually for something small: "Oh, I’m the worst." Both tools, or coping mechanisms, are meant to protect one's self-image  and social standing. The problem becomes evident: There's no growth. Perfectionists struggle with several cognitive distortions. They tend to think in black and white, so they may believe that you either control or are controlled. They tend to personalize and overgeneralize, believing they're a terrible person for doing something unethical. They may catastrophize , terrorized by the idea of being abandoned for their innate badness. And they disqualify the positive, remaining certain that they're defined by their misdeeds because their good ones don't count. Yet, for any healthy relationship to work, there has to be a high degree of accountability. This means that perfectionists will have to explore why they want to be perceived as perfect in the first place and the effectiveness of their employed strategies. Perfectionism tends to connote control, security, self-esteem , admiration, and harmony. Yet, in reality, it means few of those things. Control is often perceived as overbearing, denial fosters rebellion and rejection, admiration falls apart under scrutiny, and harmony follows the path of entropy. At bottom, perfectionists don't allow themselves to be human. This means that humans admire and are admired in return. They share responsibilities. They empathize when they've caused harm. And they allow themselves to be vulnerable. Yet, perfectionists struggle with tolerating frailty, in themselves as well as in others. The question most asked by perfectionists: Won't they dislike me if they know who I really am? Like anything else, it depends. First, it depends on the general degree of tolerance of the other individual, in addition to their interests, values, and preferences. And, it depends on the overall image of what you have to offer. Because perfectionists tend to overperform, they usually build up so much goodwill that, contrary to their expectations, their employers, colleagues, and loved ones, feel relieved by their visible imperfections, now discontinuing to compare themselves to them and or feel immense internal pressure to meet their standards. Perfectionists also struggle with thinking, "What have you done lately?" And they often believe they're starting over with each new experience. Their deeds must be immaculate. However, most others tend to view us on the whole, meaning they tally up our successes and our failures while noting how we address each of them. The first step in addressing perfectionistic anxieties is attempting to cultivate an alternative perspective. Ask yourself: Is it possible that others don't expect or want me to always be perfect? Do they prefer I acknowledge my mistakes? Will they take advantage of me if I do? The last question is the most important because it elicits an exploration of what people are for and if they can be trusted. Perfectionists are often rugged individualists because they tend to think the worst of others, which is usually just a reflection of how they see themselves. To them, safety matters more than anything and they perceive most interpersonal risks as inevitable failures, again thinking poorly of themselves and others. Attempting to persuade them otherwise is frequently met with fervent resistance. Therapy  is often misunderstood as a means of cultivating positive thinking . However, fundamentally, therapy is about asking: Is my mental health struggle contributing to my perception of the world? For our patients, that may become the biggest mistake owned. For some, it's a relief to know they can now freely exhibit more personal aspects of themselves. While for others, there's a sense of grief  and shame  over the lives not lived. But, to take responsibility isn't the same as accepting blame. Blame says, "You deserve your punishment ." Responsibility asks, "How can we make this better?" The latter accounts for all of the factors of a predicament, those which are and aren't in your control. It's aid, which you may believe is a disguise for mistreatment. Leon Garber, LMHC - Blog

Which activities make people most (and least) happy? How we spend our time impacts happiness. Some activities make us happier than others. Simply knowing this can help you prioritize your resources and plan accordingly. Time is the great equalizer in life. No matter where you live, what you do for work, or how much money you have, we are all granted 24 hours in a day that we can choose to optimize accordingly. The sobering truth is that a lot of this time is spent on mundane activities ( sleeping , chores) and obligations (work). However, even the busiest of us have some free time to do with as we please. This raises the focal question of this post: What activities are best for making us happy? In a survey conducted for Our World in Data, a project published by the non-profit organization Global Change Data Lab , going to the theater, concerts, sporting games/events, playing with children , and going to restaurants/pubs were the top five activities that make people the happiest on average. Note that all five of these activities are both exciting and typically involve a social component. Seeing a performer we love or a sports team we support can be fun, memorable, and potentially a once-in-a-lifetime event that we cherish and will look back on with a smile on our face for weeks, months, or years. These findings support research showing that spending money on experiences (vs. material goods) boosts happiness . Concert tickets and dining out can be expensive. Activities that are a little lower on the list that are enjoyable without the price tag include sleeping, board games and computer games, religious services, playing sports, hobbies, and walking dogs. If you’re on a budget or looking for something more ordinary on any given day, consider spending time on one of these cheap or free activities to boost your mood . What about the activities that make us least happy ? The top five villains in this case were doing homework, looking/applying for a job, domestic chores (cleaning, laundry), commuting, and working. These activities all fall under the umbrella of tasks we must do. Although these tasks can be unavoidable in some cases, one can be creative in an attempt to make them more fun. Listening to music or an entertaining podcast can make homework, chores, and commuting more enjoyable when paired together. For particularly unpleasant yet important tasks, create a reward for yourself once you’ve finished. For example, plan a dinner out at a restaurant you love or a movie you’ve been wanting to see that evening to help get you through the task. Breaking up unpleasant tasks at home or at work can also be highly effective. Planning to sit down for 4-plus hours straight and work on a difficult or unpleasant task is extremely hard, especially if there is no concrete deadline. I recently bought a timer to track work time, which I usually set for 45 minutes for work tasks. Once the 45 minutes is up, I will go for a short walk, have a snack, or watch a YouTube video before getting back to work. This technique, similar to the Pomodoro method, can help increase enjoyment and motivation . Give it a try. The old adage “knowledge is power" rings true for understanding the activities we can spend our valuable resources of time and money on to increase happiness. By deliberately spending resources more on the positive, less on the negative, and exercising creativity  in finding tricks to make unenjoyable tasks a little more fun, we can become the architects of our happiness. Max Alberhasky Ph.D. , Blog References https://ourworldindata.org/time-use Gilovich, T., Kumar, A., & Jampol, L. (2015). A wonderful life: Experiential consumption and the pursuit of happiness. Journal of consumer psychology , 25 (1), 152-165.

Set and manage boundaries for your professional success and well-being. Boundaries build healthy relationships and are essential for self-care as an individual and as a leader. It is vital to consistently establish, control, and verbalize your boundaries. Effective leadership requires boundary skills to facilitate team, organization, and leader well-being. In today’s hectic workplaces, leaders are increasingly recognizing the importance of setting, communicating, and managing boundaries. These skills are essential, both for maintaining personal well-being and for fostering a productive, positive team and work environment. Overwhelm, burnout, having no time for yourself, daydreaming about running away, avoiding people who might ask for something, resentment, and anger are all signs that you may need to put a boundary in place. Boundaries are our rules of engagement in our relationships or in a given situation. They define what we are comfortable with and how we would like others to behave around us. They are a way to communicate our needs to others as part of creating and maintaining healthy relationships at work and at home. Boundaries facilitate our well-being and our leadership . Yet, many of my clients still struggle with boundaries, particularly with setting and communicating their own. Boundary challenges are often rooted in deep-seated normative and cultural stereotypes coupled with a lack of know-how and practice. One of my clients, a Gen Z Latina leader, has difficulty setting and communicating boundaries at work because she perceives this to be “not nice.” Consequently, she is overwhelmed, exhausted, and deeply unsatisfied with her post. Not only has she fallen victim to cultural and gender stereotypes of what it means for a woman to be “nice,” but this also affects her ability to establish and enact boundaries, leaving her without the boundary-setting experiences and skills she requires in her situation. 3 Steps for Mastering Boundaries at Work It is important that we know how to set, communicate, and manage our boundaries as part of exercising agency and choice. 1. Setting: What boundaries do you need or want to put into place? Start by identifying what you need, then move on to what you would like. Recognize what you are comfortable and uncomfortable with in terms of work hours, communication, and workload. My Gen Z client was constantly bombarded with emails, texts, and interruptions, but she recognized that she needs to have quiet thinking time in her day in order to focus on the creative and strategic work requiring her attention. Practically speaking, this would mean not answering emails and calls or tending to people during certain hours of the day. 2. Communicating: How, when, and with whom will you communicate your boundaries? Once you know your limits, explicitly communicate them to your colleagues and superiors. Be direct and specific about your needs and expectations, ensuring there is no ambiguity in your language. For my client, this meant communicating her boundaries to her boss and her direct reports. My client decided to meet with her boss and explain that in order to carry out the work required, each day she needed to carve out some “thinking time” when she wouldn’t be interrupted. She also assured her boss that she would review her communications as a priority once she had finished her thinking time. With her staff, she decided to share this boundary during one of their weekly meetings, when she explained that several of her responsibilities required deep reflection that she simply could not achieve with regular and multi-channel interruptions. She informed staff that she would not be available during this hour and that she would follow up after this designated time. 3. Managing: What, if anything, needs to be managed or negotiated? Just because we state a boundary, it doesn’t mean it will be acted upon or actioned immediately. In fact, there will be different reactions, ranging from pushback, testing, ignoring, questioning, defensiveness, silence, avoidance and ghosting through to acceptance. We often fall into the trap of thinking that stating something means it should immediately go into effect. In reality, that is usually not how it happens. For some boundaries, stating them might be the beginning of a conversation and even a negotiation. My client initially presented her boundary as two hours of offline time per day, which, for her boss, was “too much” during their peak season. The boundary statement opened up a discussion, which resulted in a win-win outcome for both parties. Tip: Be Consistent. Consistently uphold the boundaries you have set. This means asserting your limits, even when it’s challenging, or when others may not respect them. Consistency helps to establish these boundaries as a norm within your workplace. For my client, this step proved the most difficult. This meant turning off all mobile notifications, putting her phone away, and having to remind staff that she was not available when they “popped in.” Boundaries and Leadership Clear boundaries are essential for effective leadership, enabling leaders to delegate clearly and avoid ambiguity. When boundaries are unstated or vague, it can lead to confusion and unrealistic expectations within a team. Establishing clear boundaries fosters accountability among team members as they understand the leader’s expectations and the repercussions of boundary violations. Leaders who set clear boundaries empower their teams to take responsibility for their tasks. Through proper delegation and refraining from micromanagement, leaders cultivate trust and foster autonomy among team members. Boundaries play a crucial role in defining expectations for both leaders and their teams, promoting a harmonious and productive work environment. Boundaries also help leaders to manage their energy, focus, and time. Setting availability boundaries helps to create and protect time for key strategic activities like innovation and strategic reflection. Clear limits on work hours, communication, and availability promote health and well-being and are an important part of your self-care. Boundary setting is also essential for modeling healthy behavior to your direct reports and teams. For example, my Gen Z client was able to establish a precedent for others to manage their availability and workloads. Boundaries clarify expectations and open lines of communication. Remember—it is up to you to establish, communicate, and manage your boundaries. Practicing this is vital for creating a healthy and productive work environment in which you can enhance your interpersonal relationships, live and model healthy practices, and improve your and your team’s performance. This article originally appeared as a Psychology Today post Palena Neale, Ph.D., - Website - Psychology Today -

Personal Perspective: Our sense of "self" is an illusion. Dualistic thinking creates a self that does not exist in reality. Our brains are stimulus response organs, but we can seldom grasp that because our minds fight that. The illusory mind fights to survive even though it is a phantom. Although death is real, anxiety about death is a useless projection that only humans have. Much of my clinical practice was with individuals who had brain tumors and terminal neurological diseases. While I initially feared what it would be like to work with my patients during this phase of life, I was continually surprised that I found their company to be calming, if not inspirational, as they approached their deaths. At times, I found it to be exhilarating to be around them because there was no fluff or illusions; every moment seemed to count for them. Most of our minds (mine included) operate through dualism. In other words, we develop a sense of self that we believe is different from the cause-and-effect processing that truly is the way our brains work. I have learned this through studying non-secular Buddhism, which I like to call the science of the mind, as well as from my terminal patients. We think that our "self" is our body, perceptions, feelings, thoughts, or consciousness. In fact, we are none of these things. Our organs can survive in another person, our vision and hearing are only a projection of light or sound waves interacting with neuroreceptors, our personality will change if we lose part of our brains, and, most importantly, the process of thinking creates a model of the world that is culturally bound, influenced by a constant stream of environmental stimuli, and is literally not reality. Ancient monks would exhort us to “kill our minds” because they knew that the dualistic sense of self is not a real thing. Yet the mind comes to believe that it is real and that it must survive. It resists any effort that we make to live in the present. As an example, meditation trains the mind to function in the present moment, yet the mind sabotages the meditation process in any way it can. When we try to meditate, the mind says we are crappy at doing it or tries to derail us with boredom, anxiety , frustration, or countless other forms of distraction. We think that we have an "inner CEO" who can willfully produce our next thought, but that is part of the illusion. Thoughts have themselves. At any given moment, there are groups of neurons competing to have our next thought and that what arises is the result of some form of cooperation between committee-like structures; emotions, often hidden, frequently determine what thought comes next. I am often asked whether realizing that our minds are simply illusions is a dark way to look at the world. Why even try if our brains are simply a stimulus-response organ? My answer is that there is something truly liberating in giving up an illusion of control in order to have a deeper sense of it. Ninety-five percent of our brain processing is unconscious, and we make up our minds before having a thought. Fearing death is one of the ultimate examples of this, because once we realize that our minds are ruminating on an illusion of the future that is not real, we can simply observe the process rather than fight it. If our illusory minds fight giving up control through even meditation geared towards being in the present, imagine how our minds fight the concept of death. Anxiety about death is simply a concept. Animals do not sit around ruminating about death because they do not have a cerebral cortex that can anticipate the future (a process that often makes us humans miserable). Anxiety is a future-oriented concept that is simply not reality. There is certainly a great deal of sadness that comes with death, in terms of the loss of relationships and attachments. However, much of the anxiety that characterizes our ruminations is about something that is not real. Our minds do not want to give up control of the illusion they live in. With typical aging, most humans find themselves slowly giving up things that they cherish, including vitality, relationships, hobbies, and many of the things that make us happy. We have a gradual process during which we let go of things that we cherish. Many of my terminally ill patients do not fear death because they have already let go of many of the things that are dear to them. People who “have it all” in terms of family, wealth, possessions, and health often have stronger illusory egos because they have more to lose. Because they have more to lose, they ironically fear death more. If you find yourself fearing death, take heart in knowing that much of what you are afraid of does not exist in reality. David R. Patterson, Ph.D., ABPP, References Patterson, DR and Mendoza, ME. Clinical Hypnosis for Pain Control (2nd edition). American Psychological Association. November release, 2024 Wright, R. Why Buddhism is True. Simon and Schuster, 2018 THE GREAT DISCOURSE ON NOT-SELF (ANATTALAKKHAṆA SUTTA) Venerable MAHASI SAYADAW Translated from Burmese into English by U Ko Lay (Zeyā Maung)