Understand the roots of anger and learn to defuse difficult conversations. Anger often impacts our everyday interactions. Our beliefs lead to irrational, unhealthy anger. Help distressed individuals with empathy, attention, and respect. The middle school's physical education teacher felt like a human punching bag. Once again, an angry parent had called the school, yelling about the "horrible teacher" who made her son participate in gym class when he felt tired and did not want to. According to a recent study by the American Psychological Association, 29% of teachers and 42% of school administrators report incidences of parent aggression. Not surprisingly, 49% of teachers were considering a new line of work. We all have stories of experiencing angry people in stores, cars, workplaces, hospitals, hotels, airports, and meetings. A recent Gallop Global Emotions Report revealed that up to 23% of respondents felt angry every single day. If that includes you, know that you are not alone. We typically believe our anger results from the events that happen around us. Bad drivers and customers make us mad, or so we think. However, the real reason we experience anger is because of what we believe about ourselves and others. We feel the world ought to be as we would like it and that people should treat us fairly. According to the principles of rational emotive behavior therapy (REBT), our unhealthy anger is fueled not by life events but by our inflexible, demanding beliefs. How to Handle Anger Managing anger effectively starts with recognizing the difference between healthy and unhealthy negative emotions. Anger is our response to injustice and boundary violations. If you hear a story of a child being abused, you will likely feel anger. In this instance, anger is a healthy response to the injustice of abuse . Your strong emotion motivates you to protect the innocent. Unhealthy negative emotions do not help us deal with problems of reality—they keep us stuck in self-defeating behaviors, interfere with our ability to reach our goals, distort reality, and make us miserable. In contrast to healthy anger, unhealthy anger is about our blocked personal goals. We want something and get angry when we don't get it. According to Albert Ellis , founder of REBT, there are three core irrational beliefs, each insisting that life must be a certain way. Personal Perfection: I must do well and win others' approval, and I am inadequate and undeserving when I don't do as well as I must. Social Acceptance: Other people should treat me fairly and kindly. If they don't, they are no good and deserve punishment. Comfort and Fairness: I ought to get what I want and not get what I don't want from life. It is terrible if I don't get what I want, and I will be miserable. When these beliefs control our thinking as we experience difficulty, we will be angry with ourselves when we don't measure up and angry with others when they don't give us the recognition and respect, we feel we deserve. What makes a belief irrational? An irrational belief does not correspond with how life actually works. Given that all people are fallible and life is unpredictable, no rules state we or others should be a certain way. We act well at times and poorly at other times. Healthy, rational beliefs express our preference that we perform well and that others treat us well. We do not demand that life be a certain way or insist it is awful when life is not as we would like it to be. How to Handle Angry People We can help our friend who is angry about their latest work assignment, but we struggle to deal with the stranger who explodes for seemingly no reason. The chronically angry person shares the same irrational beliefs as others, but their core beliefs about themselves are different. A chronically angry person may have experienced adverse childhood events where they did not feel safe, accepted, or loved. Belonging and safety are cornerstone developmental experiences and necessary for developing a healthy self-concept and attachment with others. Lack of safety and belonging can leave a person feeling vulnerable to being hurt physically and emotionally. Due to the underlying vulnerability, there can be constant vigilance for the potential threat of rejection, disapproval, or physical harm. The constant feeling of vulnerability creates a perceptual filter that colors how people see the world around them. When a relatively neutral event occurs, such as a receptionist not noticing a new person is standing in line, there is a mistaken assessment of danger (MAD) that is followed by behavior that is aggressive and defensive (BAD). The chronically angry person will immediately assume the receptionist is disrespecting them. Their irrational belief will tell them that others should respect them and that it is terrible that they are being disrespected. As their anger builds, they will behave in ways that make things worse, not better. This defensive behavior then leads directly to negative feedback from the receptionist, which intensifies the mistaken assessment of danger and amplifies the behavior that is aggressive and defensive. If you are in this challenging situation, Bill Eddy, LCSW, suggests three tools for connecting with a distressed, angry person. Empathy: Empathize with the distress the upset person is experiencing. You might say, “I can see how frustrated you are. I want to help.” Attention: Pay attention to the distressed person by making and keeping eye contact, turning toward them, putting down anything in your hands, and nodding your head while you listen. Invite them to talk: “Can you tell me more about what is happening?” Respect: Respect them as a person with concerns. At the core of their distress is a desire to be respected. Point out their strengths: “You have worked hard to solve this problem, and I respect your persistence in seeking answers and solutions.” When that challenging conversation is over, take a deep breath and remind yourself that while you would like to be treated with respect, there is no rule that people will or should treat you well. It is not terrible when you aren’t respected, but it is disappointing—okay, really disappointing. This article was published on Phycology Today - Website - Evan Parks, Psy.D. - Book -

Racquet sports add seven to nine years to your life. Chronic mental and physical illnesses are caused by sustained stress physiology. Racquet sports lower threat chemistry through social connection, exercise, and play. "Working" at getting better is counterproductive. Play causes a healing shift in your body's chemistry. Why not play a racquet sport? The benefits are far greater than many medical interventions. If you want to live a long, healthy life and stay cognitively intact, consider taking up a racquet sport.1 Anyone will do, including ping-pong. Table tennis, tennis, racquetball, and badminton. have all been extensively researched. Studies show they add about seven to nine years to your life, significantly improving cognitive function.2 Tennis seems to have the most impact, but they all have similar benefits. My wife and I started to play ping pong in our backyard about five years ago. We quickly discovered it's relaxing, even for 10-15 minutes. It is also social, and every level of player who grabs the paddle can keep the ball in play. I have played ping-pong since I was 8 years old. My father was a hard-working physician who was not home much. But even when he was dead tired, he would play ping-pong with his four children. It was one of our more enjoyable family activities. About a year ago, we began playing doubles ping-pong with others. At this stage of life, none of us cares whether we win or lose, and we laugh a lot. Most of the data about the benefits of racquet sports come from studies of adults. However, one study focusing on young children caught my attention. It is concluded that a longer tennis experience was associated with better performance in working memory and cognitive flexibility in children between the ages of 8 and 12. Furthermore, tennis experience is positively associated with executive functions. The results of the present study may be of great practical importance for parents and educational settings in designing physical activity programs that target the improvement of cognitive function in children.3 Mental rigidity is a trait that is common to almost all mental health diagnoses.4 Notice the specific mention of improved cognitive flexibility. Physical Health Benefits Table tennis is a highly aerobic activity that improves cardiovascular health, coordination, and reflexes. Aerobic fitness is closely tied to longer life expectancy, and aerobic activities like table tennis, when played regularly, typically contribute to a few extra years of life expectancy. Cognitive and Mental Benefits: Table tennis is especially noted for enhancing cognitive function because it requires quick decision-making, hand-eye coordination, and fast reflexes. Studies on cognitive function and physical activity suggest that engaging in activities that combine physical and cognitive demands (like table tennis) can help prevent age-related cognitive decline, which is linked to overall longer life spans. Racket sports stimulate neuroplasticity of the nervous system by connecting with older and enjoyable learned neurological circuits and stimulating the formation of new ones. Social interaction releases oxytocin, which is a social bonding hormone. It is also highly anti-inflammatory.5 Comparisons to Tennis: Specific data on lifespan increases from table tennis are limited. Due to differences in intensity, the effect on lifespan might be similar, though potentially slightly smaller, than sports like tennis. Table tennis shares many of the benefits that tennis does, particularly social and mental engagement, and is generally considered lower-impact. A family activity Almost every family I worked with that had a member suffering from chronic pain was experiencing a lot of internal chaos. About 50% of parents in this modern era feel stressed.6 Stress increases pain, which in turn aggravates internal family dysfunction. Play is the antithesis of pain and creates a profound physiological shift from threat to safety, which heals. One woman whom I have gotten to know through my coaching practice had an interesting experience with her teenage daughter after she learned about the benefits of racquet sports. Her daughter was in a bad mood about school, and they had slipped into an unpleasant conversational routine. She suggested that they play badminton, which was not initially well-received. However, within a few minutes, not only did everyone's mood change, but the mood shift also began redefining their relationship. They were able to laugh. The same scenario happened the next week She is excited to see where the activity leads. Think of the energy you have spent in chaos and looking for answers. Why not take a few moments and head to the garage to play some ping-pong? It won’t solve your problems, as an isolated intervention, but it is a significant low-risk step. 7 Aging Ping-pong is accessible to anyone at any age. Our ping-pong group has 11 seniors. One of the better players is 80. Another, closing in on 70, was a candidate for the Chinese national team in his teens. We are all well aware that when he wants a point, he gets it. If you are older, especially if you are alone, find a way to engage in a racquet sport. It is an easy way to relax, have fun, deter aging, and meet people. Grab your paddle, and let’s go! David Hanscom - Website - References 1. Schnorr P, et al. Various Leisure-Time Physical Activities Associated With Widely Divergent Life Expectancies: The Copenhagen City Heart Study. (2018); 93: 1775-1785. doi: 10.1016/j.mayocp.2018.06.025. 2. Oja P, et al. Br J Sports Med. (2017) 51:812-817. doi: 10.1136/bjsports-2016-096822.Epub 2016 Nov 28. 3. Xu Y, Zhang W, Zhang H, Wang L, Luo Y and Ni G. Association between tennis training experience and executive function in children aged 8–12. Front. Hum. Neurosci. (2022) 16:924809. Doi: 10.3389/fnhum.2022.924809 4. Giommi F, et al. The (in)flexible self: Psychopathology, mindfulness, and neuroscience. International Journal of Clinical and Health Psychology (2023); 23:100381. 5. Carter SC. Sex, love, and oxytocin: Two metaphors and a molecule. 104948 Neuroscience and Biobehavioral Reviews 143 (2022) 104948. 6. Murthy VC. Parents under Pressure: The U.S. Surgeon General’s Advisory on the Mental Health and Well-Being of Parents. 7. Biz C, et al. Epidemiology and Risk Factors of Table-Tennis-Related Injuries: Findings from a Scoping Review of the Literature. Medicina (Kaunas). (2022); 58(5): 572. doi: 10.3390/medicina58050572

Get rid of clutter and your brain will function better. Clutter reduces the efficiency of the brain. Clutter can be external or internal. Both are detrimental. Clutter can be reduced or eliminated quickly and easily. How often have you looked at a pile of laundry in the living room, dirty plates in the kitchen, or unpaid bills on your desk and thought, “I’ll take care of them later; they’re unimportant.” Maybe to you, but not to the giant vacuum cleaner between your ears: your brain. You may have read that the brain contains more neurons than all the sand grains on Earth’s beaches. “Quite impressive,” you say, patting your head until you remember it allowed you to write $1200 on a check instead of $12.00 while you watched a rerun of Law and Order. Although there may be many reasons for your error, clutter is the primary suspect. Clutter—multitasking in this example—diverted the concentration you needed to be accurate. Some argue that a disorganized mind produces clutter, while others believe cluttering causes disorganization. Regardless of the outcome of this "Which comes first?" debate, you can begin 14 methods today that will reduce or prevent clutter. What Is Clutter? When we think of “clutter,” images of a hoarder saving 1960s newspapers appear. But cluttering takes many shapes. Clutter is simply the accumulation of “stuff,” from a few used plastic cups to dumpster quantities of old magazines. It can consist of useless objects as well as persistent memories. How Does Clutter Affect Processing? It’s been estimated that the brain takes in about 11 million pieces of information per second. But here’s the kicker: It can only process 40 to 50 bits per second. How does it “choose” the bits it will process? One theory is that it selects what’s most prominent. Another is that it finds disorder and tries to impose order on it to run more efficiently. Regardless of which explanation applies, clutter—regardless of its size—asks the brain to sacrifice some of its precious 40 to 50 bits per second needed to understand what you are reading when a pile of dirty laundry enters your visual field against the background of Saturday Night Live blasting from the TV. What many people don’t realize is that the effects of cluttering can be outside of their awareness, either because it is subtle or hidden. It's like a pebble in your shoe. It may not be so annoying that you will remove it before you start hiking; you may not even be aware of it. But after a few miles, it will make your outing less than pleasant. There are two types of clutter that can affect processing: external and internal. External Clutter External clutter is stuff outside of your body that can gum up the workings of the brain. An example is the two-month-old pile of unopened bills on your desk. It can be just a few utility bills or so many that they look like the Leaning Tower of Pisa. It’s not the size of the clutter that gives it importance but rather the effect it has on your thinking. That two-day unopened letter from the IRS may have a greater effect on your ability to drive than the mountain of three-month-old utility bills that cover your kitchen table. 6 Suggestions for Getting Rid of External Clutter It’s usually best with any change program to start with what’s easiest. Your choice. Keep the environment orderly. Bills in one place, magazines in another, etc. Touch it once. When clothes come out of the dryer, they go directly into drawers. Keep what you don’t need out of sight. Place what you don’t immediately need out of your visual field. Finish one uncompleted project a day. Start with the easiest one to perform. Don’t start a new project until at least one old one is completed. Complete a project regardless of how simple it is. Spend only a limited amount of time each day reducing clutter. Start with 5 minutes and build up to 30 minutes. Internal Clutter Internal clutter involves experiences or projections that roll around in your mind and result in you doing something regrettable. For example, after receiving an “if I was you...” criticism, you substitute a half-cup of salt for sugar in a recipe you have used for 20 years. Some of the issues causing internal clutter are long-standing and may require the guidance of a professional counselor. But most are the result of the normal, everyday consequences of living, such as being annoyed you forgot your marketing list, thinking of what you could have said differently in an argument with a friend, etc. In my counseling, I’ve found internal clutter more difficult to trim down than external clutter. And, yes, some clutter—like that IRS letter—can be both. 8 Suggestions for Getting Rid of Internal Clutter Take a physical break between different cognitive activities. Walk, run, bike, or play a musical instrument. Divide long or difficult cognitive activities into separate units. Take a physical or meditation break between units. Meditate. Any form of meditation done every day for 5 to 10 minutes will reduce clutter. Get adequate sleep, nutrition, and hydration. Think of your brain as a muscle. Become more accepting of differences. Be less judgmental. Avoid music while performing cognitive tasks. Music, for most people, interferes with cognitive tasks. If you need music while writing, reading, etc., keep the volume low. Perform cognitive tasks in a quiet environment. When reading, try to find the quietest place possible. Identify a distracting issue and deal with it. If you can't resolve emotional issues on your own, seek the help of a counselor. The Takeaway: The brain doesn’t attach a “social value” to clutter or its most exaggerated form, "hoarding." That's the province of the "mind." Your brain operates in accord with its hardwiring. Reduce or eliminate clutter, and it will thank you by functioning more efficiently. Stan Goldberg, Ph.D., - Website - References Goldberg, S. (2023). Preventing Senior Disorders: How to Stay Alert Into Your 90s and beyond. Lanham, MD: Roman and Littlefield. Understanding Unconscious Bias. NPR. July 15, 2020. GYÖRGY BUZSÁKI. How the Brain ‘Constructs’ the Outside World. Scientific American. June 1, 2022.

How can you prevent social media from stealing sleep hours? Social media is used by children and adolescents before bed and during the night. The use of social media is often arousing and incompatible with going to sleep and staying asleep. While limiting social media use at night is challenging, we should keep trying. There is widespread consensus among sleep experts, pediatricians, and parents that most children and adolescents are not getting sufficient sleep to allow them to function optimally during the day. Poor sleep has been linked to academic underachievement, poor socioemotional regulation, and health problems. While the research linking poor sleep to these problems has been accumulating and getting stronger, there have been few solutions that have been proven to result in better sleep. Remedies for Poor Sleep in Children and Adolescents One remedy that I have written extensively about is the movement to have middle and high schools start later to allow more morning sleep for adolescents who stay up late at night. A considerable number of school districts have changed to later start times, and the evidence so far shows that there are many positive benefits. That said, more research is needed, particularly long-term studies that determine whether the positive results are long-lasting. Another remedy has been to encourage better sleep hygiene in youth. Sleep hygiene refers to all of the factors that facilitate sleep, such as maintaining a bedtime early enough that allows for sufficient sleep, having that bedtime be consistent during the week including weekends, establishing a good sleep environment of temperature, noise, and light, avoiding late meals and late exercise, and numerous others. One suggestion that has been frequently suggested is limiting the nighttime use of devices with screens, including televisions, gaming consoles, personal computers, tablets, and smartphones. Parents are advised to monitor and regulate the use of these devices, but compliance for those who are willing and able to try has been hard to establish and continue. The problems that screen usage at night create are primarily twofold. One is that exposure to blue light from the screens may suppress the release of natural melatonin necessary for falling asleep. The biggest culprit, though, is that excessive cognitive and emotional stimulation is counterproductive for getting to sleep and staying asleep. Scrolling through social media, reading posts, making comments replying to posts, “liking” posts, and so on takes time and energy at times when it is best to be settling down for sleep. Most of the apps are designed to keep your attention longer and longer. Some information read and seen on social media may be emotionally arousing in both positive and negative directions. Adolescents increasingly want to be connected via their social media during all waking hours to follow their friends’ activities and messages, and many leave their smartphones on while they are sleeping, and wake when messages come in during the middle of the night. Fear of missing out is often mentioned as a reason smartphones are left on during the night. For a recent review of the effects of social media on youths’ sleep see Alonzo et al. (2021) in Sleep Medicine Reviews. The problems created by smartphone usage at night for children and adolescents are an example of unintended consequences created by the developers and marketers of these devices. Either or both of the two possibilities occur to me. One, they did not consider that the use of the products would cause this kind of harm, and two, it was considered at some point during the years of development and was deemed unimportant and a hindrance to selling the devices and software that runs them. Given the power of marketing and the appeal of smartphones, surveys indicate that around 95 percent of teenagers own one. I’ve tried to thinkd of ways to help adolescents and their parents manage nighttime usage better. Bear in mind that these suggestions require compliance, and in many cases, there will not be an inclination to follow them. How to Help Adolescents Manage Nighttime Smartphone Usage Many commercial devices are now available at a reasonable price to track sleep. Many of the devices allow measurement of the time it takes to fall asleep, overall sleep duration, and the number and length of nighttime awakenings. Users can be encouraged to keep track of these metrics and work to improve them (longer sleep, falling asleep faster, fewer and shorter awakenings). Goals and rewards may be set to motivate compliance. The smartphones themselves have features that report the number of minutes and hours the smartphone is used for categories of use. Daily data could be tracked to reduce the hours used for social media. Again, goals and rewards could be set. For both of the suggestions, “buy-in” by adolescents is crucial. There are many ways of changing behavior, but unless an individual wants to change, non-coercive methods will be ineffective. I seriously doubt that adolescents would be persuaded by scientific research showing harm. Demonstrable harm such as failing grades, emotional and health problems pointed out by parents, or self-realized might be effective in some instances. If somehow an adolescent’s circle of friends would decide to all cut down on nighttime usage, a competition could be arranged by them with goals and rewards. Since attachment to, and approval from friends and peers, is of great importance in adolescence, this could be an activity that works. Having them decide for themselves, rather than being told to do so by adults is key for this idea to work. If at least one of a circle of friends can convince themselves that this is a good idea, they may recruit others. As has been pointed out before, sleep is one leg of a three-legged stool for health with the other two being diet and exercise. Changing unhealthy diet and exercise patterns is very difficult for persons of all ages. Habits related to sleep quality are equally hard to change. But the difficulty of the task in these domains should not keep us from continuing to try. Joseph A. Buckhalt, Ph.D., References Alonzo, R., Hussain, J., Stranges, S., & Anderson, K.K. (2021). Interplay between social media use, sleep quality, and mental health in youth: A systematic review. Sleep Medicine Reviews, 56.

The science of psychiatry is gaining on the daunting complexity of the brain. Diagnostic models in psychiatry are largely based on clinical experience, with some statistical modeling. Scientific biomedical models are necessary to advance understanding of mental illness. Understanding the biology of mental illness will allow development of better treatments. Personalized analysis of brain networks holds promise for people suffering from depression and anxiety. According to the World Health Organization (WHO), clinical depression affects nearly 300 million people worldwide. The Centers for Disease Control (CDC) estimates that 20 million or more people in the U.S. have depression at any given time, while more than 18 percent of U.S. adults report depression at some point in their lives and more than 12 percent of adults report significant feelings of anxiety . Treatment for depression is of limited effectiveness; only 30-40 percent of those initially treated experience full resolution of symptoms, or remission. What's more, studies show, successive efforts to achieve remission are less and less effective. Understanding the underlying biology of depression, anxiety, and related conditions such as post-traumatic stress disorder (PTSD) is necessary for making correct diagnosis and planning effective treatment. But especially in psychiatry, given the complexities of the brain, diagnosis and treatment are not yet well-grounded in biological understanding. Medical treatment is ideally based on a number of factors, including knowledge of the disease process, the ability to make accurate diagnoses, and an understanding of how individual factors affect treatment planning and outcome. The National Institutes of Health started the BRAIN Initiative (Brain Research Through Advancing Innovative Neurotechnologies) in 2013, calling for neuroscience-based models of disease and health. Understanding the causal factors of disease suggests the levers clinicians can manipulate to provide the most effective treatment possible. Toward a More Scientific Psychiatry Psychiatric diagnosis in the United States is currently based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Although efforts have been made to improve its approach with more specific criteria for mental illness based on statistics and available data, the DSM is not firmly scientifically based. For the vast majority of illnesses described, the diagnostic criteria say little to nothing about the cause of the disease; instead, they primarily reflect long-observed clinical patterns, rendering the DSM a work in progress and of less-than-desirable utility for diagnosis and treatment. Not all causes of psychiatric disease are strictly biological. For example, inheriting a genetic predisposition to depression—and many genes contribute–does not invariably lead to depression. It’s highly likely that social and family factors can also bring on depression—not being productive or social, for example. Current treatments for depression often address biological and social factors, but there is as yet no standard biological testing for depression nor any clear framework for scientifically based treatment. DSM 5 identifies several subtypes of depression, all based on clinical observation and statistical analysis. With unipolar depression (as contrasted with bipolar disorder ), subtypes include atypical and melancholic, and specifiers include severity of symptoms as well as presence or absence of psychotic features. Diagnosis is made by reviewing clinical presentation and history, whether informally through clinical interview or formally via structured, guided interview and review of accompanying information. The same approach applies to anxiety disorders, including generalized anxiety, social anxiety, panic disorder, and obsessive-compulsive disorder , as well as to stress-related disorders such as PTSD. The disorders may be divided into subtypes by specifiers, but a true medical-scientific framework is lacking. Biotyping Depression and Anxiety A recent study of brain networks in depression and anxiety reported in Nature Medicine (2024) is an important step toward establishing an empirical model of "biotypes",; it echoes prior work on depression3 and brain-based personality research4. Researchers Tozzi and colleagues used functional magnetic resonance imaging (fMRI) to look at brain activity in more than 1,000 people with depression and anxiety, measuring “task-free” brain activity. They repeated imaging in a subset of patients who received psychotherapy or pharmacotherapy or underwent a variety of activities. During the imaging, subjects were shown a variety of stimuli—such as sad, threatening, or happy faces—and were asked to perform a variety of cognitive and attention tasks. Cluster analysis was used to identify underlying biotypes based on brain circuit dysfunction, sometimes referred to as “dysconnectivity” in brain networks. Treatment would, therefore, restore "EU connectivity". Notably, the study was transdiagnostic: Given how much depression and anxiety overlap, the study didn't assume they are separate disorders. The analysis was unbiased by preconceived diagnostic models. Participants included those diagnosed with various conventional disorders, including major depression, generalized anxiety, panic disorder, social anxiety, PTSD, obsessive-compulsive disorder, some patients met criteria for more than one diagnosis. Six underlying biotypes of depression and anxiety were identified among participants with clinically significant symptoms. Their labels are complicated, based on activity levels in key brain networks: default mode, or resting state (D); salience, or what stands out as important (S); and attentional (A). In addition to connectivity patterns, research looked at such key factors as negative emotional circuitry in response to sadness and threat (conscious and unconscious), positive emotion circuits, and cognitive circuits. There were no sex differences in response patterns, and minimal differences in age. Biotype DC+SC+AC+. This cluster showed hyperconnectivity among all three networks. This biotype had slow responses identifying sad faces and increased errors in executive function tasks. The response to behavior coaching for wellness was strong. Biotype AC−. This cluster had less connectivity in the attention network, less severe stress compared with other biotypes, and relatively little dysfunction in cognitive control, with faster responses on cognitive measures but more errors, as well as faster priming when viewing threatening faces. Response to behavioral coaching was less robust. Biotype NSA+PA+. This cluster had elevated activity during conscious processing of emotions, with sadness evoking greater negative circuit activity and happiness more positive. This group also experienced more severe anhedonia—inability to enjoy things—and greater ruminative brooding. Biotype CA+. This group showed increased cognitive control under specific conditions. This cluster also showed greater anhedonia, greater anxious arousal, negative bias, and dysregulation in response to threat. Cognitive errors were high, especially with sustained attention. This biotype had a better response to the antidepressant venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI) commonly prescribed. Biotype NTCC-CA−. This small group was characterized by loss of functional connectivity in negative emotion circuits during conscious processing of threatening faces and by reduced activity in cognitive control circuits. This cluster had less ruminative brooding and faster reaction times to sad faces. Biotype DXSXAXNXPXCX. This small group did not show significant circuit dysfunction. There were slower reaction times to implicit threat. Implications While not ready for standard clinical use, the study results build on prior work demonstrating that brain network analysis holds promise for developing biologically based diagnostic testing for depression, anxiety, and stress-related disorders. The study also provides initial proof of concept that psychiatric bio typing could be used in the selection of treatments, with some biotypes responding better to medication and others to psychotherapeutic interventions. Clearly, more work is needed before such models of illness can underpin diagnosis and treatment. Given the complexity of the human experience, it's important to recognize that many of the causes of mental illness are likely to be social or circumstantial, external to the individual. More debatable is how to distinguish psychology from neuroscience, mind from brain, without becoming neuroreductionistic. Personalized scientific approaches to psychiatry on a par with other medical disciplines remain largely aspirational, but current approaches are likely to move the needle. Grant Hilary Brenner, M.D., - Website - References. 1. An important clarification about how the word “causal” is being used here–it is being used to refer to the causes of the problems in the present moment, the precise factors in the complex system which maintain the status quo of health and illness. Notably, we are not necessarily talking about the historical causes–what started the process in motion may not be what is currently causing it to persist. This is a mathematic definition of causality. 2. Causal discovery has been used to look at PTSD among police officers using a process called Protocol for Computation Causal Discovery in Psychiatry (PCCDP). Saxe and colleagues (2020) reviewed a large data set from over 200 police officers. They identified 83 causal pathways with 5 causes: changes (single-nucleotide polymorphisms–SNPs) in histidine decarboxylase and mineralocorticoid receptor genes involved with stress-response, acoustic startle to low perceived threat during training, peritraumatic distress to incident exposure in the first year of service, and general symptom severity during training after one year of service. This study is a proof-of-concept for using causal discovery to identify points for intervention, and clearly could be used preventively–for example, identifying trainees with those features and responding accordingly. 3. Four Biotypes of Depression 4. Brainprint of Basic Mental Activity Citations WHO Depression Fact Sheet CDC Depression Prevalence 2020 CDC Anxiety NIH Brain Initiative Saxe GN, Bickman L, Ma S, Aliferis C. Mental health progress requires causal diagnostic nosology and scalable causal discovery. Front Psychiatry. 2022 Nov 15;13:898789. doi: 10.3389/fpsyt.2022.898789. PMID: 36458123; PMCID: PMC9705733. Saxe GN, Ma S, Morales LJ, Galatzer-Levy IR, Aliferis C, Marmar CR. Computational causal discovery for post-traumatic stress in police officers. Transl Psychiatry. 2020 Aug 11;10(1):233. doi: 10.1038/s41398-020-00910-6. PMID: 32778671; PMCID: PMC7417525. Tozzi, L., Zhang, X., Pines, A. et al. Personalized brain circuit scores identify clinically distinct biotypes in depression and anxiety. Nat Med (2024).

New research highlights how to maintain good mental health through menopause. New research challenges the notion that the time surrounding menopause is synonymous with poor mental health. Still, there are factors that make women vulnerable to clinical depression during menopause transition. Left unchecked, stress and poor social support can contribute to mental health problems. It's vital that women access the support they need to manage their stress. A recent review paper published in the British journal The Lancet pooled data from 12 studies investigating the relationship between clinical depression and the menopause transition—the time starting with the onset of menstrual changes and ending with the final menstrual period. The researchers analyzed data from 600 women globally and “found no compelling evidence for a universal or uniform increased risk of depressive symptoms over the menopause transition.” Indeed, their analysis went further and studied other mental health conditions such as anxiety , bipolar , and psychosis and found no evidence that menopause universally elevates the risk of those mental health conditions either. This study challenges the widely held notion that the time surrounding menopause is synonymous with poorer mental health. A Vulnerable Subgroup at Risk for Depression While these findings are encouraging, the study did identify some of the factors that did make women vulnerable to clinical depression during the menopause transition. There was a higher risk of depression in those who experienced: A longer menopause transition. (This period can last anywhere from 4-10 years) Sleep disruption e.g., frequent hot flashes at night that contribute to chronic insomnia. A prior history of clinical depression, which made them more vulnerable to experiencing a recurrence during the menopausal transition. Stressful life events and low social support Stress and Social Support: Modifiable Risk Factors I’d like to home in on these last factors that put menopausal women at risk for poorer mental health. When it comes to psychological stress, women, more than men, consistently report higher levels with each passing year. As a women’s health psychiatrist, I’ve witnessed how stress is ubiquitous and frequent in the daily lives of women and how this situation is further complicated by lives that have quickened and intensified in the digital era. What’s more, the average age of menopause transition is 47—a time of life that is often associated with stressful events. For example, it’s not uncommon for women of this age to be dealing with other health conditions (e.g., heart disease or cancer ) or the loss of loved ones such as parents, siblings, or close friends. They may be going through many transitions, such as facing an empty nest or changes in the workplace. Often, they are spending many hours in unpaid labor caring for elderly parents and dependent children. To add insult to injury, we live in a culture that does not value women past a certain age, who may not meet a standard of youthful beauty and are no longer capable of reproduction. And in my experience, it is hit or miss if women get the support they need when dealing with stressful situations. This is unfortunate when considering the downstream consequences for their mental health. The bad news, then, is that stressful life events appear to be an integral part of the stage of life that also coincides with the menopausal transition. Left unchecked, this can contribute to mental health problems. The good news is that stress is a modifiable risk factor—meaning it can be managed—as is increasing your social support network. If women can get the support they need to manage their stress, its harmful impacts on their physical and mental health could be mitigated. What Women Going Through Menopause Can Do 1. Be proactive about managing stress. Establish and practice a daily self-care routine. At a minimum, this should include exercise, eating healthfully, and allowing sufficient time for sleep. Now is also the time to think about cutting out unhealthy ways of coping with stress, such as excessive alcohol consumption or nicotine use. 2. Be proactive about building a social support network. Look at the people who make up your social support network. Who is there for you when you need them? Who do you feel you can trust? Who do you feel is invested in you and your well-being? Now is a good time to re-evaluate the time and energy you give to one-sided or unhealthy relationships. If you’re someone who finds it hard to ask for help or verbalize when you’re overwhelmed, now is also a good time to start working on developing that skill. 3. Don’t assume that depression or poor mental health is part and parcel of menopause. In fact, if you’ve never had clinical depression before, then you’re unlikely to have it during menopause. 4. Seek professional evaluation if necessary. If you notice significant signs and symptoms of depression, it’s important that you don’t chalk it up to menopause and seek professional attention. Find a therapist near you in the Psychology Today Therapy Directory. What Partners Can Do People whose partners are going through menopause can be a key source of support. It’s important to: 5. Get educated. There are many good and reliable resources available on the internet from which to get educated about menopause. It is helpful to have knowledge about what menopause is, what common signs and symptoms are, and how they may change over the different stages of menopause. 6. Act rather than speak. If you know your spouse is overloaded or taking on a disproportionate burden of certain duties—including childcare, caregiving, and household tasks—say directly, “Tell me what I can do to help,” and then be ready to follow through. 7. Prioritize kindness, compassion, and outward displays of affection or affirmation. Anything that fosters optimism, a healthy self-image, and perceived control has been found to be protective of mental health across the menopause transition 8. Get proactive about self-care. Mid-life is a time when consistent self-care is nonnegotiable for anyone. If you are not doing so already, now is the time to make basic self-care a priority; that includes exercise, healthy eating, and high-quality sleep. If you know your spouse is struggling in these areas, create a buddy system: Sync your calendars so you can exercise together, divvy up tasks (i.e., shopping, preparation, and clean up) associated with healthy home cooking, and set up a similar time for going to bed and waking up so you can keep each other accountable when it comes to sleep wellness. 9. Schedule regular communication or check-ins: The menopause transition is an ever-evolving situation that may take place over many years. Make sure you make time to stay connected on this issue. Keep this time free of distractions or interruptions. 10. Cultivate a “We’re in this together” philosophy: Viewing this as a “you problem” is inherently unhelpful and insensitive and can leave your spouse feeling isolated and lonely. Be a partner on this journey. Advocate for your spouse if they need help navigating or accessing the healthcare system. If you feel they are delaying getting help and putting the needs of others before their own, nudge them to prioritize their own health and well-being. Shaili Jain, M.D., - Website -

New studies offer critical data on teens questioning their gender. Objective information is lacking about basic demographics of adolescents unhappy with their gender. Two new studies reveal a sizable number of early adolescent's experience dissatisfaction with their gender. While most teens become content with their birth gender as they grow up, some remain unsatisfied. In the landscape of contemporary gender discourse, few topics evoke as much controversy as those concerning transgender issues. From discussions about restroom access to debates surrounding sports participation, the dialogue is fraught with polarization. These discussions often descend into heated exchanges, characterized more by accusations and counteraccusations than reasoned engagement. Amidst the fervor and impassioned opinions, one crucial element remains conspicuously absent: concrete and objective information. Consequently, our conversations about transgender controversies frequently falter in addressing fundamental inquiries. We even don’t have basic statistics and demographics of the transgender community. Fortunately, two recent studies have proved timely, shedding new light and offering fresh perspectives on these complex issues. In a study published in 2021, Jen-How Kuo and Meng-Che Tsai led a team in tracking 1,806 junior high students in Taiwan from 2000 to 2009. They asked a straightforward question: “Are you satisfied with your own gender?” What they found over the nine-year period was quite telling: while the majority (86.5 percent) consistently expressed satisfaction with their genders, 7.8 percent transitioned from dissatisfaction to satisfaction, 4.8 percent shifted from satisfaction to dissatisfaction, and 0.9 percent remained consistently dissatisfied (1). A similar study in the Netherlands, detailed in a 2024 paper by Pien Rawee, Sarah Burke, and their colleagues, queried 2,772 adolescents in their response to a similar but more nuanced statement: “I wish to be of the opposite sex.” They discovered that as many as 11 percent of early adolescents experienced gender dissatisfaction, which decreased to approximately 4 percent by the age of 25. Overall, 78 percent remained content with their genders, 19 percent transitioned from dissatisfaction to satisfaction, and 2 percent became even more dissatisfied with their birth genders as they progressed from early adolescence to young adulthood (2). These findings hold critical significance on several fronts. First, they reveal that a sizable percentage (13.5 percent in the Taiwan study and 22 percent in the Netherlands study) of teenagers experience some level of dissatisfaction with their gender identity. However, most of them tend to resolve this uncertainty as they mature into adulthood, ultimately aligning with the gender they were assigned at birth. Nonetheless, there remains a small yet consistent portion of teenagers who persist in their dissatisfaction or even transition from a state of contentment to dissatisfaction with their gender identity. “These findings indicate,” write the researchers from the Taiwan study, “that healthcare professionals should concentrate on gender non-conforming individuals at early adolescence, navigating them toward a healthy adulthood.” Clearly, they are also significant for parents, caregivers, school teachers, and society at large, providing guidance on how to better care for, assist, and support adolescents, especially those prone to gender dissatisfaction. Undoubtedly, the next crucial question revolves around identifying which adolescents will navigate out of the phase of gender uncertainty and who will persist in their dissatisfaction. While such data is currently lacking, an evidence-based approach holds the promise of transcending ideological debate to a scientific endeavor in developmental psychology. Acknowledgments: I thank Drs. Sarah Burke and Meng-Che Tsai for double-checking the facts quoted in this essay based on their original research. Lixing Sun, Ph.D., - Website - References 1. Kuo, J-H., Albaladejo Carrera, R., Cendra Mulyani, L., Strong, C., Lin, Y-C., Hsieh, Y-P., Tsai, M-C., and Lin, C-Y. (2021) Exploring the Interaction Effects of Gender Contentedness and Pubertal Timing on Adolescent Longitudinal Psychological and Behavioral Health Outcomes. Front. Psychiatry 12:660746. 2. Rawee, P., Rosmalen, J.G., Kalverdijk, L., and Burke, S.M. (2024) Development of Gender Non-Contentedness During Adolescence and Early Adulthood. Archives of Sexual Behavior, pp.1-13.

An expert in ADHD and OCD addresses the unique challenge of living with both. Most people living with ADHD also experience other related conditions, such as anxiety or OCD. When ADHD and OCD occur together, they can exacerbate each other. Effective care starts with recognizing both conditions, and then implementing evidence-based interventions for both. Attention-deficit/hyperactivity disorder (ADHD) is best thought of as a disorder of executive function, skills we use to organize and plan our lives. One important concept to know around ADHD is that of "comorbidity"—when someone has ADHD, it’s likely they have something else, too, like a learning disability or anxiety . It’s even possible to have ADHD, which tends to cause disorganization, and symptoms of an obsessive-compulsive disorder (OCD) at the same time. Dr. Roberto Olivardia is a Harvard psychologist and expert on both ADHD and OCD. I had the opportunity to ask Dr. Olivardia recently what it's like when someone is living with both ADHD and OCD. For starters, Dr. Olivardia, how do you define ADHD, and what leads to a diagnosis of OCD? What separates them both from the type of stuff we all experience at times? ADHD is a condition of neurodiversity marked by dysregulation of attention, executive functioning issues (problems with time management, organization, task initiation, working memory, etc.), and sometimes hyperactivity and impulsivity. Although everyone can relate to having problems paying attention to some things, people with ADHD find it very difficult to regulate their attention when they are not inherently stimulated. The executive functioning issues people with ADHD experience are constant and cause much interference, impairment, and frustration in their lives. That is very different than the occasional forgetting or procrastination people may typically have experienced in isolated incidents. OCD is characterized by obsessions and/or compulsions. Obsessions are persistent thoughts, impulses, or images that are intrusive in nature and cause distress and anxiety. Worries about real-life problems are not the same as obsessions. Even though logic may inform them that this is irrational, it is still very difficult to just pass it off. Compulsions are repetitive physical behaviors (such as checking or hand washing) or mental acts (such as saying words silently, praying, counting, creating images) that a person feels compelled to do in order to undo, neutralize, or cope with the obsession. The compulsion may have nothing to do with the actual obsession. This is constant for sufferers and causes much impairment and interference in their lives. How common is it to have both ADHD and OCD? It is unclear how many people with ADHD also have OCD, but studies have looked at the prevalence of ADHD in OCD populations and estimate that approximately 30 percent of patients with OCD also have ADHD. In my clinical practice, ADHD and OCD tend to be more comorbid in individuals with pure obsessional OCD (also known as "pure-O"), hoarding, tic disorder, Tourette’s disorder, dermatillomania (compulsive skin picking), and trichotillomania (compulsive hair-pulling). It is important to properly diagnose when someone struggles with OCD, ADHD, or both. When people have both, it is common that one disorder is diagnosed while the other goes undiagnosed. Having both disorders can be incredibly challenging, as having both is associated with more severe symptoms of both than having either alone. What’s uniquely challenging, then, about having both ADHD and OCD? Having either ADHD or OCD can be challenging in itself. But having both is greater than the sum of its parts. It is not 1+1=2, as much as it is 1+1=5. The two disorders can feed off each other, like a toxic couple. For example, a student could be in class and getting bored and distractible (ADHD) and then find themselves gravitating to an OCD ritual (like praying silently in the middle of a class). The two conditions can sometimes have a "whack-a-mole" effect, where symptoms of one disorder may be dominant, but then, once those decrease, the other disorder takes over. Someone can be working on impulsive spending (ADHD), and when they find themselves successfully managing the impulsivity, they may lapse into more compulsive thinking (OCD). The challenge is being able to distinguish which diagnosis is "driving the bus" and tailoring interventions to that diagnosis. It is possible to manage these two conditions, but it takes some work and understanding of each condition and how they present when together. What does treatment look like when someone is struggling with both conditions? The most essential treatment for OCD is exposure plus response prevention (ERP). This includes confronting the thought, image, object, or situation that makes a person with OCD anxious. ERP will also include confronting an exaggerated symptom of OCD. For example, if someone fears their mother will get breast cancer if they think of the word “cancer” and either anxiously avoids anything that may trigger that thought or has to ritually pray if they do think of the word in an effort to neutralize the thought, an adequate ERP would include having a person write the word “breast cancer” 100 times, read about breast cancer, and watch YouTube videos about breast cancer, and be prevented from praying. They may even write, “My mother has breast cancer” repeatedly. The goal is to habituate to the anxiety and realize that those thoughts have absolutely no effect on whether their mother would get cancer. Medication is also very helpful and highly effective for treating OCD. The most common class of effective medications are antidepressants known as selective serotonin reuptake inhibitors (SSRIs). They include fluvoxamine (Luvox), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and paroxetine (Paxil). They can help by boosting serotonin levels in the brain. OCD medications do not make ADHD symptoms worse. However, stimulant medication used to treat ADHD can sometimes make OCD worse. Patients with ADHD and OCD sometimes find that stimulants enable them to focus more on their obsessions. At other times, though, ADHD medication positively impacts OCD. Frequently, it neither increases nor decreases OCD symptoms. Working with specialists in ADHD and OCD is essential. Psychotherapy can also be helpful in discussing issues related to OCD, such as shame and self-esteem issues. Couples or family therapy is also recommended, as OCD impacts loved ones as well. Not all therapists are trained in doing ERP with patients. If you have OCD, your therapist should have experience in this treatment modality. Support groups can aid patients with OCD not feel so alone. An understanding of ADHD is also important. If you cannot find a therapist who specializes in both, consider working with both an OCD expert and an ADHD therapist or coach. Proper treatment can pave the way for a healthy, fulfilling life free of tormenting obsessions and time-consuming compulsions. What should I do if someone I know may have both ADHD and OCD? If someone you know is experiencing symptoms of both ADHD and OCD, it is important to validate their concerns and encourage treatment. Living a healthy life is possible. Mark Bertin, M.D., - Website - References Connect your loved one with support like the International OCD Foundation (IOCDF), Children and Adults with ADHD (CHADD), or Attention Deficit Disorder Association (ADDA).

Worrying can, paradoxically, help perfectionists maintain a sense of control. Anxiety can be used to cope with helplessness and hopelessness. Underlying the worry is the belief that worrying is helpful. Perfectionists tend to fluctuate between feeling too much in control and too little. Anxiety can hide shame and existential depression. A sense of hopelessness can be a coping mechanism for anxiety and anxiety a balm for hopelessness. We don't always know which we prefer. Perfectionists tend to fluctuate between feeling an inordinate amount of control and feeling completely despondent. They go from the mindset of "I can do anything" to "I'm completely useless," from taking on too much responsibility to taking on none. It may be challenging to think of anxiety as a way to cope, as most of us search for ways to manage our anxiety rather than increase it. But with anxiety, itself the fear of the unknown and unpredictable, there can also be a great deal of hope. Some even continually find reasons to be anxious, stoking the flames of their worries as they perpetuate their sense of control. Worrying only matters and makes sense (due to how much energy it extracts), if one feels as though it's practical, even if the belief is more unconscious. Worrying is energizing, firing up the fight or flight system to facilitate decision-making. Again, the antithesis of anxiety tends to be hopelessness, which was indicated by two prominent psychologists. Charlotte Nickerson writes, "Martin Seligman and Steven F. Maier first identified learned helplessness as a phenomenon in the 1960s. These psychologists conducted experiments on dogs, finding that, when exposed to repeated shocks that they could not control, the animals refrained from taking action when they could prevent the shocks." Rather than worried, after repeated threats, the pups appeared depressed , becoming completely passive and seemingly numb. Their bodies discontinued exerting the energy needed to survive. In some sense, the dogs realized that worrying was a waste of effort. Many of the patients I've encountered over the years would almost do anything, no matter how absurd, to prevent boredom (refusing to even engage in non-goal-directed activities), because, to them, boredom signified the beginnings of depressive episodes. So, some of them were, one can say, preoccupied or obsessed with anxiety, which was the precursor of activity and purpose, no matter how trivial the worries or frenzied pursuits. Framing anxiety as a compulsive (or soothing) activity can be helpful because it allows patients to accept some degree of responsibility in the maintenance of their worries. They come to realize that their worries help them feel important, effective, and in control, even if the aspects of their lives that they chronically worry about are, in reality, mostly outside of their control. Worrying can be an insidious drug, which needs a higher dosage with each problem you fix. You may worry about your mother's depression, so you resolve to make her happy. But, the personal effect of each new cultivated moment of joy is slowly diminished as you accept how helpless you are in actually curing her. Therefore, becoming resentful at your mild influence on her well-being, you instead seek out a grander problem, whether it's solving your dysfunctional family dynamics or tackling climate change. Each disappointment becomes the basis of a new grander vision. So, when the final fix doesn't occur, which it hardly ever does, the perfectionist is left with her sense of hopelessness and lack of importance. This is where the most difficult part of treatment tends to begin. If you've acknowledged how and why you've used worrying to cope with existential and personal grief, you can now explore and attempt to learn to sit with those relentlessly bubbling feelings. At this stage, the fixer, more often than not, is exposed to her existential circumstances and personal shame. She's faced with the reality of not being special and the disappointment she's brought to those who purportedly love her. She may have achieved, but it was never enough. She may have cared enough to worry, but was still too selfish because she didn't worry enough. She did everything right, yet her life, somehow, turned out completely wrong. Her seeming addiction to worrying betrayed her belief that while wasn't special just yet, she neared approval. Letting go of some of the excessive worry entails discarding your need to be special, or better yet, your need to be perfect. This may also mean your need to be loved by someone who couldn't. Leon Garber - Website - References Nickerson, C. (2024). Learned Helplessness. Simply Psychology.

Does one sibling's alcohol use affect another's? Yes and No. Anger often impacts our everyday interactions. Our beliefs lead to irrational, unhealthy anger. Help distressed individuals with empathy, attention, and respect. A research study on siblings and alcoholic use disorder, The Development Unfolding of Sibling Influences on Alcohol Use Over Time , is worth noting. The researchers, who included professors and a graduate student at Auburn University, along with a professor at The University of Minnesota, found that earlier research has shown siblings are similar in alcohol and substance use, or “partners in crime.” However, these researchers found that older siblings’ use of alcohol may predict younger siblings’ alcohol use, but younger siblings' use only predicted an older sibling’s use if they were close in age and had a close relationship. (Note: The siblings studied were a maximum of five years apart, and adopted children were included as well as biological children.) The researchers concluded that their findings may have ramifications for treatment programs and individual therapy for a sibling who drinks to excess. “There is little attention to siblings in programs aimed to reduce adolescent alcohol or substance use,” one explains, adding that their results “add to a body of literature illustrating how both older and younger siblings are important socializing agents of adolescent and early adult alcohol use.” Moreover, “younger siblings may be just as important socializing agents of their older siblings’ alcohol use.” Thus, “assessing or co-treating siblings for alcohol problems may be an important add-on to existing alcohol prevention and intervention programs,” researchers noted, and at the very least, the programs might consider “assessing sibling alcohol use, relationship quality, as well as facilitation of or co-use.” Researchers also posited that adolescence is a particularly important span for study because if two siblings have a close relationship and neither drinks to excess, it could have a protective effect when the younger one reaches college. But if the older one drinks to excess, then that may negatively affect the younger one when it comes to drinking, especially in the freshman year.” The researchers defined the adolescent age ranges important to the study as early adolescence, ages 13 to16, and late adolescence as ages 17–19. They described early adulthood as ages 21–23. The group cites one limitation of their study, it included mostly White or Asian subjects. It would be interesting to learn what a study that included Blacks would find, and also why the researchers didn’t include this ethnicity. Also, information on gender differences and similarities related to drinking was briefly referred to, from other studies. Pat Olsen

Here's a CBT guide to coping with emotions while caregiving. Caregiving can evoke a mix of emotions from sadness to fulfillment, and all are valid. CBT helps caregivers manage stress by challenging negative thoughts and promoting resilience. Effective communication with parents and family enhances support and understanding. Prioritizing self-care ensures caregivers maintain their well-being and provide better care. As we look toward the future, one of the most significant and emotional periods many of us will encounter is becoming caregivers for our aging parents. This is something I’ve seen both of my parent's experience, and it is a path many of us will walk eventually. This time can be emotionally complex, filled with love, friendship, loss, duty, and often a deep sense of uncertainty. It requires not only physical and logistical adjustments but also significant emotional strength. So, how can we navigate this challenging phase more successfully? Understanding the Emotional Rollercoaster The first step in navigating this time is acknowledging the emotional rollercoaster it entails. Research shows that adult children caring for aging parents often experience a mix of unpleasant emotions, yet many still maintain positive outlooks (Conway, 2019). Caring for aging parents can trigger a wide range of feelings, from sadness and anxiety to gratitude and fulfillment. These emotions are a natural response to the changing dynamics in our relationships with our parents and the confronting reality of mortality. A common emotional challenge is dealing with guilt—whether it’s feeling like we’re not doing enough, feeling frustrated or burdened, or needing a break from our caregiving responsibilities. The Power of CBT in Caregiving Cognitive behavioral therapy (CBT) is a therapeutic approach that focuses on the connection between our thoughts, feelings, and behaviors. It offers several useful strategies for managing complex emotions, such as those experienced when caregiving. By becoming aware of and modifying our negative thought patterns, we can use CBT techniques to approach caregiving with greater resilience and compassion. Here are several steps you can take to help in this process: Recognizing Negative Thought Patterns: Start by observing your thoughts about your caregiving situation. Ask yourself, “Are they overwhelmingly negative?” “Do I find myself trapped in a cycle of guilt or despair?” Recognizing these patterns is the first step toward change. I recommend taking the time to write down or journal your thoughts. This makes them tangible, allowing you to focus on their meaning and how they make you feel. It’s OK that these thoughts are there; they are just an indication of the stress you are under. Challenging and Reframing Thoughts: Once you’ve identified negative thoughts, challenge their validity. Ask yourself, “Is it true that I’m not doing enough, or is that an unrealistic standard I’ve set for myself?” Reframe these thoughts in a more balanced and compassionate way. For instance, instead of thinking, “I’m failing as a caregiver,” try, “I’m doing my best every day, and that’s enough.” Focusing on our thoughts can help us find meaning and make sense of the caregiving role, leading to a more positive experience (Charenkova, 2023). Reframe your thoughts from focusing on difficulties to seeing the value in your role. For example, instead of saying, “This is hard,” try, “This is hard, but the time I have with my parent is invaluable.” This shift can help keep our attention on what’s truly important. Developing Coping Strategies: CBT can also provide practical coping strategies. These might include stress management techniques like deep breathing or mindfulness, setting realistic caregiving goals and boundaries, and improving problem-solving skills for day-to-day challenges. For stress management, I recommend taking intentional pauses throughout the day (aka “pausing on purpose”). These pauses can be as short as 2 to 3 minutes or longer, if possible. Use strategies such as 4-7-8 breathing, progressive muscle relaxation, listening to a favorite song, or reading a calming passage. Use what you find beneficial to provide a short reset. While these practices won’t eliminate stress, they offer multiple opportunities to recharge during the day. Focusing on Effective Communication: Open and honest communication is key—not just with the parent you’re caring for but also with other family members and healthcare providers. Too often, people try to resolve issues without discussing them. Effective communication involves both collaboration and assertiveness. Remember, no one likes to feel powerless, especially as they age. Ensure your parent is included in all discussions and approach concerns collaboratively. Use assertiveness strategies to express your needs and boundaries clearly and without guilt. Avoid arguing or belittling; instead, seek clarity by asking, “Help me understand. Can you tell me more about what you’re thinking or worried about?” This approach fosters a more supportive and understanding relationship. Prioritizing Self-Care: In the demanding role of caregiver, self-care often gets neglected. However, caring for yourself is not selfish; it’s vital. Integrating self-care practices into your daily routine—whether through exercise, hobbies, or socializing—can significantly enhance your well-being and, consequently, the quality of care you provide. I recommend setting personal goals and planning for structured breaks. Focus on the basics—stay active, eat well, and prioritize sleep. Remember, you don’t have to do this alone. Excellent support groups, both in-person and online, and community resources are available to offer support and guidance. If needed, seek help from a mental health professional to process your thoughts, feelings, and experiences. Planning for the Future: While daily tasks can be overwhelming, it’s important to also plan for the future. Engaging in practical and collaborative planning for your parent’s care needs, including legal and financial arrangements, can alleviate anxiety about what lies ahead. Start this process early to make joint decisions more manageable. Having a plan in place can bring peace of mind to both you and your parent, allowing you to focus on spending quality time together. Finding Joy and Meaning Despite its challenges, caregiving can be a profoundly meaningful experience. It offers opportunities for growth, deepening relationships, and engaging in acts of love and service that align with our deepest values (Charenkova, 2023). Even during stressful times, try to find gratitude in the relationship and cherish the moments of clarity and connection. By applying CBT strategies, we can not only manage the stresses of caregiving but also discover moments of joy and fulfillment within the experience. Ultimately, let’s remember that our capacity for love and care is one of our greatest strengths. By approaching caregiving with compassion, resilience, and a willingness to seek support, we can appreciate the intertwined beauty and complexity of life’s final stages. Ray W. Christner, Psy.D., NCSP, ABPP, - Website - References Charenkova J. (2023). “Parenting my parents”: Perspectives of adult children on assuming and remaining in the caregiver’s role. Frontiers in public health, 11, 1059006. Conway K. (2019). The Experience of Adult Children Caregiving for Aging Parents. Home Health Care Management & Practice, 31, 92-98.

The worse the hurt, the more likely a hero's journey. Everyone loves a hero’s journey. A protagonist goes on an adventure, learns a lesson, wins a victory, and returns home transformed, from Luke to Neo to Frodo to Harry. But what if we met our characters while living relatively comfortable lives, with decent relationships and jobs, and facing no imminent existential danger? Would they go on their hero’s journey? Almost certainly not. No one climbs Mordor for fun. It was only due to an intolerable life or existential danger that our heroes found the motivation to initiate the journey that would transform them into the best versions of themselves. Without that motivation, there’s no story and no transformation. While we recognize a hero’s journey in the movies, therapy is a hero’s journey for real life. It is fraught with danger and uncertainty and pain. But due to our unconscious minds, it is also the only path to our best selves. Like every hero’s journey, therapy is very hard to start, and harder to complete, requiring strength we don’t believe we have to overcome obstacles we don't believe we can. Whether battling evil empires or recurring nightmares, the challenges we encounter make us want to quit, badly and often. Most will. Heroes can’t—the alternative is intolerable. That’s how they find the strength to keep fighting. Childhood creates challenges for everyone. But in this paradoxical world, sometimes being born into the deepest holes gives us the very best chance to become the best versions of ourselves. Because the worse the hurt, the more appealing the journey. Talk It Out Why is therapy the only path to our best selves? Left on our own, we can neither feel nor articulate our most painful emotions; our unconscious minds will never allow us to. Their purpose is to shield us from paralyzing pain in the short term. They will always distract us before we can complete a painful thought. In doing so they create a much larger problem. Suppressed pain does maximum damage to the experience of life. Living with enough unexpressed hurt turns life into a funhouse that is never fun, where everything feels disproportionate, always. It is a terrible way to live. It is only in talking with another person, like a therapist, that we are forced to see painful thoughts through to their conclusions. (You can’t trail off mid-sentence talking to someone else, as you can talking to yourself.) “But,” you say, “My spouse/ family /friends are my therapist,” or even more abstract, “My art/animals/work…” No, they are not. As for the non-human options, flow and Zen certainly enhance your life, but they do not surface buried pain. The people in your life are a worse option. You can’t be therapy-honest, and they can’t provide feedback beyond their emotional needs. And neither provide the structure and discipline needed for actual growth. There is only one way to surface suppressed pain—with trained psychologists who know what to do. The only question is: Who’s willing to go on the journey? Universal Doesn’t Mean Everyone There are a few no-win scenarios baked into childhood. Getting everything we need as kids would be awful, leaving us completely unprepared for the real world and motivated to do little. Not getting everything we need as kids is awful, leaving us damaged and forced to suppress emotions that as children we cannot possibly fathom or handle. Adults have context, experience, and stoicism with which to handle failure, rejection, and loss. Kids don’t. Absolutely no one emerges from childhood undamaged. It is impossible and inevitably leads to a skewed perception of reality for us all. The only question is the extent. We all must understand our skews to become our best selves. But while that need exists for everyone, it’s not the same for anyone. The Lucky Ones It’s true that on a certain level, every family is dysfunctional. But how do you differentiate between a parent with too-high expectations vs. one who vandalizes the family home when displeased? A parent who expects too much maturity from a seven-year-old vs. one who says, “If it wasn’t for you, I’d kill myself?” An uncle who gets drunk on holidays vs. being cut off by both sides of the family before graduating middle school. Experiencing the latter leads to very different lives than the former. As a child in agony every day, you embrace any behavior that you believe will help you in the moment. You don’t understand how the same behaviors will work against you in every other environment. You end up attracted to the very hurt that will continue to ruin your life on a loop. At some point, you may question whether life is even worth it, even when it's going ostensibly well. Eventually, though, you are faced with a fundamental choice: a hero’s journey or a horrible life. Sadly, many people are unable to choose the path to their best selves, despite the clarity of the choice. Alternatively, people with relatively happy childhoods do choose the hero’s journey. That choice is even harder because the alternatives are not nearly as stark. And many people live happy lives without therapy. None, I would argue, are living their best lives, which requires surfacing buried pain. But that does not mean that therapy is always worth it. That’s entirely a contextual consideration. But when you’ve suffered enough as a kid, a happy life is an impossibility without it. No one knows why some people can find the inner resources for a hero’s journey and some can’t, regardless of circumstances. But I do know this: Having a terrible childhood makes the choice a lot easier. And it provides the motivation to continue when things feel the most painful and the most hopeless. Enough motivation, even, to reach the journey’s end. I never could have imagined we were the lucky ones. Jordan Scott Birnbaum, M.A.,