Which type of talking treatment is right for you? Key points Psychological treatments for depression are safe and effective. These talking treatments should be first-in-line in the management of depression. The right talking treatment for a given individual depends on a number of factors. Depression is, to varying degrees, self-remitting, but formal interventions can help to speed things up and ensure a more complete and durable recovery—and, in the meanwhile, help to keep you safe. Psychological interventions ought to be first in line in the management of depression. Very often, they offer a safer, more effective, more empowering, more individualized, and more dignified alternative to antidepressant medication. Many people with depression prefer these “talking treatments” on the grounds that they seek to address underlying problems, rather than merely masking superficial symptoms or providing a crutch. Of course, psychological treatments and antidepressant medication are not mutually exclusive, and in some cases, as with depressive psychosis, drugs can be an essential part of recovery. The type of talking treatment that is chosen, if any, depends on your symptoms and their origins, on your personal preferences, and, all too often, regrettably, on the available funding and human resources. If you are struggling to find a therapist or have to wait to access one, there are a growing number of apps out there that offer some of the benefits of therapy. Supportive therapy and counseling At its most basic, psychological treatment involves simple explanation, reassurance, and encouragement. In milder cases of depression, such “supportive therapy” is often the only intervention that is either necessary or appropriate. Counseling is similar to supportive therapy in that it involves explanation, reassurance, and encouragement. But counseling also aims at addressing life problems and is more goal-oriented than supportive therapy. Psychodynamic psychotherapy Exploratory psychotherapy, as the name suggests, aims to delve more deeply into your thoughts and feelings. Two important yet very different forms of exploratory psychotherapy are psychodynamic psychotherapy and cognitive behavioral therapy (CBT). Psychodynamic psychotherapy is built on the psychoanalytic theories pioneered by Sigmund Freud and others. It is similar to traditional psychoanalysis but brief (a few months rather than several years) and less intensive (once a week rather than twice or thrice). Like psychoanalysis, psychodynamic psychotherapy aims at bringing unconscious feelings out into the open, where they can be acknowledged, experienced, and understood and thereby “dealt with.” Unlike CBT (see below), which is based on learning and cognitive theories, psychodynamic psychotherapy normally involves careful consideration of your personal history and can be particularly helpful if your problems appear to be rooted in your distant or not-so-distant past. Cognitive-behavioral therapy (CBT) Developed by psychiatrist Aaron Beck in the 1960s, CBT has become a mainstream treatment for non-severe depression and a number of other mental disorders. In the short term, it is at least as effective as an antidepressant treatment, and in the longer term may be more effective at preventing relapses. CBT is most often carried out on a one-to-one basis but can also be offered in small groups or online. It involves a defined number of sessions, typically between 10 and 20, although much of your progress occurs outside of sessions through “homework.” You and a trained therapist (who may be a doctor, psychologist, nurse, or counselor) develop a shared perspective on your current problems and try to understand them in terms of your thoughts (cognitions), emotions, and behaviors and how these relate to one another. This leads to the identification of realistic, time-limited goals and of cognitive and behavioral strategies for achieving them. In depression, the main focus of CBT is usually on modifying automatic and self-perpetuating negative thoughts. These cognitive biases or “thinking errors” are considered hypotheses, which, through gentle questioning and guided discovery, can be examined, tested, and modified. Behavioral tasks might include self-monitoring, activity scheduling, graded task assignments, and assertiveness training. CBT has garnered a great deal of institutional support on the basis that it is both cheap and effective. But critics question the robustness of the research into CBT for depression and claim that it is, in fact, no more effective than other forms of talking treatment. A more profound criticism of CBT is that, by leaning so heavily on patterns of cognition, it may be mistaking the symptoms of depression for its causes while pretending that depression has little or nothing to do with real-life issues. More introspective or philosophical people can experience this rather superficial, mechanical approach as frustrating and alienating—helping to account for the high drop-out rates from CBT for depression. Mindfulness Some of the concerns with traditional CBT are addressed by mindfulness-based cognitive therapy (MBCT), which combines traditional CBT methods with “newer” psychological strategies, such as mindfulness and mindfulness meditation. In essence, mindfulness, which derives from Buddhist spiritual practice, aims at increasing our awareness and acceptance of incoming thoughts and feelings, and so the flexibility and fluidity of our responses, which become less like unconscious reactions and more like conscious reflections. Mindfulness can be channeled for the treatment of recurrent depression, stress, anxiety, and addiction, among others, but it can also be used more broadly to improve our quality of life by decentring us and shifting our focus from doing to being. Family therapy and interpersonal therapy Family therapy involves the identification and resolution of negative aspects of couple or family dynamics that may be contributing to depression, for example, deep-seated conflict, misunderstanding, or avoidance. It usually calls upon the direct participation, and so the commitment, of each of the major actors. Another talking treatment used in depression is interpersonal therapy (IPT), which involves a systematic and standardized treatment approach to personal relationships and life problems contributing to depression. If you feel that your personal relationships are contributing to your distress, then you might consider the possibility of counseling, family therapy, or IPT. Neel Burton, MD, Website , Book

Stimulation-seeking and missed diagnoses. Depression is deflating, but some sufferers learn to feel energized with risky thrills. The onset of theft, fighting, infidelity, and/or excessive gambling can signal depression. Evaluating for and treating depression could dissolve the problematic activity. Thrills and depression are seemingly unlikely bedfellows, but they're more collegial than one might think. At first, readers might think this refers to depression arousing creative expressive energy. After all, centuries of musicians and writers, for example, have discovered silver linings to their affective plight when it engendered well-crafted songs or prose. While indeed having created these works could buoy the spirits of the artists, there is another variety of more habituated, immediate thrills that become embedded in some patients that may make them seem more characterologically disturbed than depressed. Not the Usual Suspects It's not unusual for teens to be referred for intervention or become court-involved for theft, perhaps even kleptomaniacal activity, or fighting. Relationship therapists encounter infidelity, while family therapists may see parents concerned about their child sneaking out. While all of these scenarios could be accounted for by things like misplaced anger, cluster B personality disorders , stimulation-seeking in severe ADHD , or even, to some degree, age-appropriate rebellion, it must be recognized that these concerning actions do not always occur within such expected confines. Consider the case of Aiden and Jenna (names disguised), a young, married couple I worked with early on. Jenna called for an appointment because she was concerned about recently discovering Aiden’s online gambling and flirtation on pornographic chat rooms. Upon getting to know Aiden, it became clear the onset of these activities coincided with months-long worsening depression spurred by various unfortunate events. His guilt and shame about engaging in these were palpable, and discussing the matters initially lowered his spirits even further. Jenna knew this "wasn't him" and remained understanding as we navigated the fallout of trust issues. What Aiden explained was that the risk-taking of gambling made him "feel alive," while gaining the attention of several women, albeit superficial, made him feel desirable amidst a horribly-low self-image. As I matured in my career, similar scenarios played out across couples, families, genders, and ages. Mason (name disguised) was a college-aged male, referred for plunging academic performance at a prestigious institution. Mason presented and described a classic dysthymic, or chronic, mild-moderate depressive, experience. In the second session, he offered, "I fight a lot." Given many depressed males' dysphoria is irritability instead of sadness, which can cause squabbling in relationships, I was ready to hear about a penchant for argumentativeness. It was surprising to hear he meant he was essentially looking for fist fights. Mason confessed that after a sports event one weekend, an inadvertent brawl seemed to have been an outlet for his frustrated state of affairs. However, he described coming to chase "a charge" that came with the activity. The fighting, which Mason discovered he had a knack for, sustained a sense of superiority and provided stimulation in an otherwise deflated existence. He realized it could eventually lead to legal problems and removal from school, which would create an existential crisis. First Glance It's easy to focus on the problematic activity, given that it led to the referral. However, jumping straight to pointedly trying to eliminate the gambling, stealing, etc. may only bring frustration to the patient and practitioner. Realizing these activities tend not to exist in a vacuum is an important part of treatment. Not unusually, the impetus stems from a bigger clinical complication; essentially, remove the fuel, and the fire subsides. In 2002, Lejoyeux noted that patients with kleptomania and pyromania had significant numbers of depressive episodes. In fact, there's a body of research concerning gambling (e.g., Edgerton et al., 2018; Rogier et al., 2019), stealing (e.g., Fishbain,1987; McElroy et al.,1991; Talih, 2011), and fighting (e.g., Dutton & Karakanta, 2013; Krakowski & Nolan, 2017) being highly correlated with, and even encouraged by, depression. Relationship experts such as David Ley, Ph.D., (2010) have written about how infidelity, for some, evolves as a remedy for depression. Like Aiden, the people Dr. Ley has dealt with reported excitement and higher self-esteem. Ley also explained how someone pursuing an affair is more apt to take care of themselves for appearance’s sake, and may take to exercise and better self-care, which in themselves may be antidotes to depression. Evaluating If Depression is the Root Problem People can, of course, have baseline habits of stealing, fighting, infidelity, fire-setting, or gambling, and experience superimposed depressive episodes. Perhaps the depression is even due to the pickles they find themselves in because of their unsavory activity. In those cases, it will be important to manage the activity of choice in order to curb the depression. It must be evaluated if the reverse is true, however, like in the aforementioned scenarios, as that will dictate a focus on depression to help dissolve the concerning behaviors. The following considerations can help understand the nature of the relationship to depression in evaluating people presenting for impulse control matters, fighting, or infidelity. Make sure the behavior does not coincide with a head injury or other physical complication or initiating a medication. Some SSRIs, for example, have been correlated to cases of onset of impulse control disorders (e.g., Kindler et al., 1997; Gupta, 2014). Is this an occasional burst of behavior, or a long-standing, baseline problematic activity? If sporadic, that may be indicative of occurrence only during mood episodes. If the latter, it is more likely related to things like obtaining drugs or personality disorders. After the above, evaluating for the presence of depression is the foremost consideration. If depression is extant, it is essential to survey if the periods of concerning activity coincide within the confines of the episode(s). If depression is present, is it part of a mixed mood state, as written about in The Spinning World of Major Depression with Mixed Features? If so, referral to psychiatry for a mood stabilizer medication as used in bipolar illnesses may be helpful in controlling the matter, as the hypomanic or manic components would be the culprit. Anthony D. Smith LMHC References Edgerton, J.D., Keough, M.T. & Roberts, L.W. (2018). Co-development of problem gambling and depression symptoms in emerging adults: A parallel-process latent class growth model. Journal of Gambling Studies, 34, 949–968. Fishbain, D. (1987). Kleptomania as risk-taking behavior in response to depression. The American Journal of Psychotherapy, 41 (4), 598-603. Dutton, D., and Karaktan, C. (2013). Depression as a risk marker for aggression: A critical review. Aggression and Violent Behavior, 18 (2), 310-319. Gupta, P.R. (2014). Emergence of kleptomania during treatment for obsessive compulsive disorder with fluvoxamine. Indian Journal of Psychiatry, 56, 100‑101. Kindler, S., Dannon P.N., Iancu I., Sasson. Y., & Zohar, J. (1997). Emergence of kleptomania during treatment for depression with serotonin selective reuptake inhibitors. Clinical Neuropharmacology, 20, 126‑129. Krakowski, M. & Nolan, K. (2017, February 27). Depressive symptoms associated with aggression. Psychiatric Times, 34 (2). Lejoyeux, M., Arbaretaz, M., McLoughlin,M., & Ades, J. (2002). Impulse control disorders and depression. The Journal of Nervous and Mental Disease, 190 (5), 310-314. Ley, D. (2010, October 10). Can infidelity cure depression? Can extramartial sex self-medicate against the effects of depression? Psychology Today. https://bit.ly/3NCPNG7 McElroy, S., Hudson, J., Pope, H., & Keck, P. (1991). Kleptomania: Clinical characteristics and associated psychopathology. Psychological Medicine, 21 (1), 93-108. doi:10.1017/S0033291700014690 Rogier, G., Picci, G. & Velotti, P. (2019). Struggling with happiness: A pathway leading depression to gambling disorder. Journal of Gambling Studies 35, 293–305. Talih F. R. (2011). Kleptomania and potential exacerbating factors: a review and case report. Innovations in Clinical Neuroscience, 8 (10), 35–39.

What stops us from completing the work of sorrow and getting rid of depression? Sadness often accompanies depression, but they are not the same thing. Depression has also been linked to repressed anger and fear. Addressing the many possible components of depression can help people recover from it. I often hear my clients say, "I don't want to discuss this subject—I don't want to be sad and get depressed." Depression is indeed accompanied by sadness, so connecting depression with sadness is common. But so is confusing these two conditions. Sadness vs. Depression Sadness is a normal reaction to adverse situations. It develops when expected gratification is unavailable because of a separation from or loss of something important. We process sadness by means of sorrow and letting go. Depression is a more complex condition. In addition to unremitting sadness, depression is defined by low mood, apathy, lack of joy (anhedonia), and inability to concentrate and stay focused. Corpus Hippocraticum, the classic work published between 500 and 400 BC and attributed to Hippocrates, among other authors, includes one of the first attempts to describe depression as a medical condition. It places fear above sadness as a psychotic symptom of depression, thus postulating that fear can be a more significant factor in depression than sadness (9). Researchers such as John Bowlby, the creator of attachment theory, have concluded that sadness often appears as a reaction to some forms of loss "of a loved person or else of familiar and loved places, or of social roles" (Bowlby, 1980). Depression is also closely related to loss and to fear that this loss will recur. Bowlby described depression as a "real or feared loss of the parent figure, either temporary or permanent," and believed vulnerability to depression derived from these early insecure attachments and experiences of early loss or abandonment. We process sadness by means of sorrow and grieving to accept and let go of the things we cannot change. Grief tends to come in waves. In contrast, depression is unyielding. In this way, depression can be seen as the antithesis of grief. Nancy McWilliams says, "People who grieve normally tend not to get depressed, even though they can be overwhelmingly sad during the period that follows bereavement or loss" (7). The major role of anger in depression has been long known to psychoanalytic researchers and clinicians. In his classic work, Mourning and Melancholia, Sigmund Freud, the founding father of psychoanalysis, a precursor to all modern therapies, viewed depression "as hate turned upon the self after the loss of an important love object" (1). His close associate Karl Abraham noted a propensity towards hatred in patients with depression based on temperament or early experience. The authors speculated two things: 1) the experience of premature loss creates vulnerability to depression, and 2) depression results from anger turned inward in response to loss. The melancholic state that Freud was exploring exhibited lost connections to something important to the extent that the depressed individuals became so identified with this lost object that they kept it firmly within themselves. They were unable to establish a meaningful connection or part from it and grieve its loss. Sadness became inseparable from their condition. In sadness, one knows what they have lost, but in depression, the loss is often indiscernible and can't be addressed consciously. It is often interpreted by the individual as a sign of their own inadequacy, unlovability, or damage. They feel rejected, abandoned, and angry toward themselves in the form of shame, self-criticism, and guilt that their "badness" might have driven this thing away from their life. Thus, they feel inherently corrupt. There Is a Lot of Further Research Connecting Depression With Anger. Friedman, A. S. (1970) found that individuals diagnosed with depression scaled higher on the Resentment subscale of the Buss-Durkee Inventory than non-depressed people. Resentment is defined here as "repressing the experience of the hostile affect from consciousness" (4). Subjects reported significantly less verbal open hostility but significantly more resentment. Becker & Lesiak (1977) found that in clinic outpatients, the severity of depression correlated with covert hostility, including guilt, resentment, irritability, and suspicion, but not with overt hostility. In earlier research by Friedman et al. (10), people were asked if it is ever right to be angry. Hospitalized depressed patients answered "yes" significantly less often than non-depressed control subjects. This suggests difficulty with acceptance and expression of anger or aggression at the time of depression. Riley et al. (1989) concluded in their study that "the results […] generally support the hypothesis that depression is related to an inhibition in anger expression. The depressed group reported higher levels of anger suppression than either the normal or PTSD groups" (11). In another study by Kellner, R., Hernandez, J., & Pathak, D. (1992), 100 participants diagnosed with depression were given an extensive questionnaire about their condition. In all four groups, depression predicted inhibited anger for both sexes. Improvement in all domains of inwardly directed hostility has been reported with the alleviation of depression (Blackburn et al. 1979; Mayo 1978; Friedman 1970). Goldman & Haaga (1995) connected both anger and fear in depression. In comparison to non-depressed subjects, depressed subjects express more anger toward close family members than to others. This finding seems plausible considering the high rates of marital conflicts in couples that include a depressed partner (Schmaling and Jacobson, 1990). The fear of expressing anger to other people was highly correlated with anger suppression because of the fear of the consequences of such expression. Brody et al. (1999) demonstrated that, in comparison to the never-depressed control group, recovered depressed patients reported suppressing their anger and being afraid of expressing it because they viewed it as damaging toward other people. The authors hypothesized that anger inhibition may play a causal role in the recurrence of depression. These findings link both anger and the fear of expressing it, causing depressed individuals to suppress their anger out of fear. Thus, the role of inhibited anger in depressive conditions seems to be crucial. There might also be confusion when we describe sadness as opposed to anger. Castel, P.-H. (2016) indicates confusion between these notions: The very fact of saying "You make me sad" to somebody often expresses not so much sadness as anger and resentment. From a more psychological standpoint, sadness is often consciously experienced as an inward rage barred from public display; anger, similarly, when not fully acted out, commonly reverts to grief and feelings of helplessness. The opposition of inward vs. outward feelings will often reflect socially coded constraints on the legitimacy of the public exhibition of affective states. Agitated and violent children may actually be sad, while passive or submissive women are internally consummated with rage. (2). Researchers such as Arieti, Bemporad, and Bowlby view depression as a sadness that cannot be "metabolized," so the work of sorrow cannot be completed. Inhibited anger, fear of expressing it, and lack of knowledge or positive previous experience on how to express anger constructively might play a crucial role in hindering the process of sorrow to eventually be rid of sadness and the symptoms of depression. When dealing with depression both on a personal and therapeutic level, we need to take into account the possible presence of suppressed anger and equip ourselves and our clients with tools to deal with and express it constructively. Nancy McWilliams (2011) suggests that depressed individuals be in long-term or open-ended therapy instead of a pre-set number of sessions. If they have sufficient time to recognize their anger in a therapeutic environment, they will be able to address it. McWilliams states: Treatments that are arbitrarily limited to a certain number of sessions may provide welcome comfort during a painful episode of clinical depression, but the time-limited experience may be ultimately assimilated unconsciously by the depressive person as another relationship that was traumatically cut short—further evidence that the patient is a failure in maintaining attachments (7). Recognizing inhibited anger in a depressive state, learning to express it constructively in a therapeutic environment, and addressing the fear of losing important relationships due to anger can be salubrious strategies in helping one alleviate the symptoms of depression. Boris Herzberg - Website - References 1. Freud S. (1917). Mourning and Melancholia. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916). 2. Castel, P.-H. (2016). Loss, Bereavement, Mourning, and Melancholia: A Conceptual Sketch, in Defence of Some Psychoanalytic Views. In Sadness or Depression? (pp. 109-119). 3. Painuly, N., Sharan, P., & Mattoo, S. K. (2004). Relationship of anger and anger attacks with depression. European Archives of Psychiatry and Clinical Neuroscience, 255(4), 215–222. 4. Friedman, A. S. (1970). Hostility Factors and Clinical Improvement in Depressed Patients. Archives of General Psychiatry, 23(6), 524. 5. GOLDMAN, L., & HAAGA, D. A. F. (1995). Depression and the Experience and Expression of Anger in Marital and Other Relationships. The Journal of Nervous and Mental Disease, 183 (8), 505-509. 6. Busch FN (2009). Anger and depression. Advances in Psychiatric Treatment, 15(4):271-278. 7. McWilliams, Nancy. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). ISBN 978-1-60918-494-0. 8. Kellner, R., Hernandez, J., & Pathak, D. (1992). Self-Rated Inhibited Anger, Somatization and Depression. Psychotherapy and Psychosomatics, 57(3), 102–107. 9. Azzone, Paolo. Depression as a Psychoanalytic Problem. University Press of America, 2012. 10. Friedman AS, Granick S: A note on anger and aggression in old age. J Geront 18:283-285, 1963. 11. RILEY, W. T., TREIBER, F. A., & WOODS, M. G. (1989). Anger and Hostility in Depression. The Journal of Nervous and Mental Disease, 177(11), 668–674. 12. Allan, S., & Gilbert, P. (2002). Anger and anger expression in relation to perceptions of social rank, entrapment and depressive symptoms. Personality and Individual Differences, 32(3), 551–565.

What you tell yourself matters. Feeling depressed for two weeks or longer may reflect a disorder, which you should disclose to a professional. Self-talk refers to one’s running inner dialogue, and one can engage in either positive or negative self-talk. Flexible, fluid thinking may be helpful if one’s depressed thoughts have become too intense or rigid. The term “depressed” is often used loosely but has clear clinical implications when it refers to clinical depression , or what is known in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) as major depressive disorder. For individuals who have depressed mood for two or more weeks to the point that it interferes with daily functioning, it’s important to embark on a healthy action plan to do what is possible to reduce the depressive feelings . Positive self-talk, or mantras, you can say to yourself, can help a depressed person to feel a little more in control of what they think and how they feel. Consider each of the self-talk reminders below and ask yourself which ones resonate the most with you. “What I say to myself about my depression can make a difference.” If you were to choose only one quote to tell yourself, make it this one. Saying this to yourself is helpful because it reminds you that you have choices and that the choices you make matter. While it can often feel as if there is no choice when you feel depressed, the reality is that one always has choices—even if they are not quickly apparent. “I am teachable through this process.” Feeling depressed is complicated by much of the distorted thinking that presents with it. Feelings often get misinterpreted as facts to the degree that the depressed person becomes certain that their thoughts and feelings are not only true, but will also last forever. Telling yourself that you remain teachable while going through a depressed period can reduce much of the all-or-nothing, rigid thinking that often goes along with depression. Remaining teachable means that you will consider the coping advice of trusted, emotionally stable individuals and that you will seek out a variety of healthy techniques to help combat depression, including reading articles like this one. “I have gotten through difficult times before.” Because depression impacts one’s thinking, it makes sense that the rush of thoughts and feelings swimming around in the mind while depressed can be overwhelming. When you feel overwhelmed , you’re less likely to look rationally at your present circumstances and to make sense of them with a positive or even neutral perspective. One specific technique that can be helpful is to make a list of other difficult periods you have experienced in the past, and to estimate the length of time that difficult period lasted. For example, if you lost a job and had to find a new one, did your difficult period last a few weeks or perhaps a couple of months? Remember that you survived each of these periods, even though you probably were afraid that you couldn’t get through it at the time. “I can sometimes pleasantly surprise myself.” Nothing can help a person get unstuck like flexible thinking, which allows for the changeable, fluid nature of everyday life. And while individuals come with their own set of personality traits , people can also surprise themselves occasionally. If you are someone who defaults to a pessimistic mindset, at times, try to express an optimistic thought with someone the next time your automatic thought is to say something negative. If you’re talking to someone who knows you well, you may get some positive feedback for surprising them with your rosy perspective. What’s most important is that you can also surprise yourself and that the best way to do so is to catch yourself from slipping into easy, old behavior and to engage in the opposite, more positive behavior option instead. “I’m striking a balance between patience with my depression and taking action to deal with it.” This final reminder captures why telling yourself positive things when you’re depressed is so important. The goal is to accept that you are experiencing difficult circumstances but to simultaneously take healthy action to do what you can to make the experience more bearable. In other words, you can still feel low in energy and have a depressed mood while also reminding yourself that these feelings will pass eventually and that you may as well use today to try one or two behaviors you enjoy doing anyhow. Conclusion While confiding in a health professional and sharing your depressed feelings is important and helpful, it’s also important to practice mental discipline yourself by engaging in positive self-talk and reminding yourself of healthy, positive messages. Feeling depressed doesn’t have to take complete control over your life, so adjusting some of the intensity of depression with self-compassion and flexible thinking can help make the experience of feeling depressed less overwhelming. Seth Meyers Psy.D. - Website - Book

The benefits of vacation time, and how to set healthy workplace boundaries. Every year, an alarming amount of paid time off goes unused by North American employees. Research has shown that time away from work is beneficial to our physical and mental health. Setting healthy boundaries at work and focusing on our well-being are key to work-life balance. When it comes to taking advantage of paid time off (PTO), recent statistics tell an alarming tale. According to a recent Pew Research survey, 46 percent of employees take less time off than their employer offers. In 2022, according to Qualtrics research, American workers left an average of 9.5 vacation days unused. Recent Canadian statistics paint an even bleaker picture, with just 29 percent of employees taking full advantage of paid time off. That’s not all. In a 2023 ELVTR poll of 2,300 North American employees, most reported working while on vacation. Many also reported that weekends and nonworking hours are far from off-limits. Furthermore, according to 2023 Pew research , 55 percent of employees reported that they respond to emails and other forms of messages outside of regular working hours. The high cost of stress and burnout When it comes to work-life balance, numerous studies show that the greater the work-life balance the better the physical and mental health of employees. Despite years of research on the importance of creating and maintaining reasonable working hours, achieving such a balance can often be extremely challenging. Often, the pressures of looming deadlines, a demanding workplace culture , and implicit workplace demands on nonworking hours can make work-life balance seem impossible. The value of disconnecting The value of taking that postponed vacation and setting reasonable boundaries around minimizing communication with work colleagues outside of working hours are many, including stress and burnout prevention, gaining new perspectives on workplace stressors, improving mental and physical health , and improved sleep. Furthermore, vacations can be especially effective at raising levels of happiness, making time to reconnect with family and friends, and exploring locations and activities that foster joy and inspiration. Vacation time is also known to reduce the risk of heart attack and stroke. Time away from the daily grind also expands our creative abilities. Building and enforcing healthy boundaries Our time and energy are valuable—and finite—assets. At the end of the day, it is our responsibility to build healthy boundaries around our finite resources. Building healthy boundaries is all about prioritizing our mental and physical health, well-being, and needs, and building awareness of the causes and signs of workplace burnout, including trouble concentrating, exhaustion, irritability, a decrease in productivity, and physical symptoms, like headaches, muscle aches, gastrointestinal issues, and changes in sleep routines. Beyond building healthy boundaries, it is important to communicate and reinforce them. If you have declined to take a much-needed vacation or struggle with workplace demands on your time on weekends and outside of regular working hours, chances are that you are surrounded by a corporate culture that does not understand the value and benefits of vacations and downtime. Healthy boundaries do not reinforce themselves. It is up to each of us to take charge of our time and energy. We need to keep track of what we are entitled to when it comes to paid vacation time and schedule vacation times that work for us and for the people in our lives, rather than around the anticipated needs of our workplaces. We need to learn to say no to requests that place unfair and unreasonable burdens on our time and energies. Time to take unused vacation time off the table We can’t go back and reclaim those lost vacation days, but there is no time like the present to begin to create positive changes for our betterment and growth. Taking that unused vacation time off the table is a great place to start. 6 steps to creating a healthier work-life balance Acknowledge your lack of work-life balance. Awareness is the first step to creating change. If you are shortchanging yourself on vacations and weekends, think about where you can begin to make changes. Prioritize your well-being. Realize that it is in the best interest of your physical and mental health to take a break from your workplace. Schedule vacation time. There is no perfect time to take a break, so schedule your vacation around your preferences. Start saying no to unreasonable demands on your time. While on rare occasions, the final days before a significant deadline may be extra demanding of your attention and time, it’s important to draw the line when your workplace infringes on your downtime. Build healthy boundaries. Just as good fences make good neighbors, healthy workplace boundaries are key to avoiding workplace stress and burnout. Set, communicate, and reinforce healthy boundaries to supervisors and managers. Consider changing jobs, if your workplace is unsupportive of your efforts to maintain a healthy work-life balance. Article featured on Psychology Today and is one in a series of four Monica Vermani, C. Psych., - Website - TEDx Video - References John Corrigan. How many unused vacation days do Americans leave on the table? Human Resources Director. 12 Dec 2022. Just 29% of Canadian workers used all of their vacation time in 2022: survey. Benefits Canada. December 15, 2022 AMERICA’S ALARMING (LACK OF) WORK-LIFE BALANCE. ELVTR Magazine.

Having readily accessible tools for coping can reduce panic's intensity. When panic strikes, it can be difficult to know what to do. The feelings elicited by panic and panic attacks can be so intense that they can knock us off kilter and make us feel like there isn’t much we can do to stop the flood of adrenaline and cortisol, the body’s naturally occurring stress hormone. There are, however, measures we can take to slow the rush of panic and help us get through these intense and uncomfortable feelings. This post will take you through the steps of creating a panic “tool kit,” which you can utilize when you are feeling panicky. The idea is to have readily accessible tools and strategies for coping when we are feeling overwhelmed by panic. Expression. When we hold panic in and keep it to ourselves, we tend to fixate more on its symptoms—which can actually escalate their intensity. Whether it is a partner, friend, family member, therapist, or other trusted person, consider who you can talk to when you are feeling panicky. The simple act of speaking what you are feeling can provide a sense of relief and make panic feel less burdensome. Soothing Activities. Panic tends to freeze us, so overwhelmed are we by its physical intensity. At these moments, it can be helpful to undertake simple activities that can direct our focus away from the symptoms and feelings of panic. These can be as basic as running your hand across a smooth surface and paying attention to the texture, stretching your body, or petting your cat or dog. These are small acts of mindfulness that can soothe the body and cool down the panic rush. If you are looking for something a little more in-depth, you can try a short meditation; even three to five minutes of stillness and focus on your breath will slow down the escalation that can occur during a panic attack. Grounding Techniques . Building on Tool #2, we need to have ready access to techniques for grounding ourselves when we are panicked. Think of panic as a state of escalation, almost as if we have left the solidity of the ground. What we need in these moments is to “come back to earth,” and to ground ourselves. For some people, calming visualization helps (picturing a peaceful and serene scene in the mind); for others, using the five senses can help (identifying 5 things you can see, 4 you can touch, 3 you can hear, 2 you can smell, and 1 you can taste); for still others, holding an ice cube in order to draw attention away from the panic is effective. The point is that whatever grounds you best should have a place in your tool kit. Breathwork. The idea of using our breath to bring about a sense of calm dates back at least to ancient Buddhist teachings. The belief, which still holds today, is that focusing on our breath allows all of the physical systems that get escalated during panic to slow down and return to their normal state of functioning. A simple deep breath in through the nose and out through the mouth, known as a “Buddha breath,” can immediately calm the nervous system. A more involved breath strategy is “box breathing,” or the “4-4-4-4 method,” in which we inhale for 4 seconds, hold the breath for 4 seconds, exhale for 4 seconds, then repeat 1-3 times. Breathwork is an essential tool for returning ourselves to a state of equilibrium and a first-line intervention for panic. Mantras and Affirmations. Panic has a very loud voice: It screams at us and tells us we are in danger. A way to quiet this inner panic monologue is by challenging it with a softer, gentler message. We can do this through the use of mantras, simple statements that can be easily remembered and repeated, and affirmations, slightly longer statements of support and soothing. Mantras for panic attacks might be “I am safe,” “I am OK,” or “I am not in danger right now.” Affirmations might sound like “I have experienced this feeling before and I know exactly what I need right now.” Both types of self-talk can help soothe and calm panic. Your Choice. It is important that part of your tool kit is a space for strategies and methods that you learn during your life, and that you can add to your options for soothing yourself during panic. Because panic can be a unique experience and manifest differently for different people, it is helpful to consider what works most effectively for you and your type of panic. Your toolkit is not a static object: It can continue to be built, adjusted, and updated as you learn what you need and what works for you when you are feeling panicky. Phil Lane, MSW, LCSW, - Website -

Amidst all the confusion women feel, here are ways to cope and transform. There is increasing research shedding light on treatment for the challenging years prior to menopause. Lifestyle factors such as diet and exercise are key to mitigating the effects of perimenopause. Women can benefit from seeing this as a liberating rite of passage rather than just a problem to be fixed. Here I was, a “woman of a certain age” desperately asking my doctor for help as I approached menopause. Here she was, a woman of a younger age, brushing me off by saying I needed to go find a women’s health clinic for that. Here we both were, two women clueless about a transition that half the population undergoes, all because this life transition has been cast in the shadows. Since fits of rage can come naturally to women having hormonal changes in midlife, I could easily rant about the medical field ignoring women’s biological changes in midlife, or how women are rendered invisible in society once they’re no longer considered youthful and perky. But, instead, I’ll share what I’m learning and what I wish I’d known about thriving during this life stage. 5 Tips for Perimenopausal Women (or what I like to call "seasoned" women): Know the basics of perimenopause to manage expectations. On average, perimenopause is the 3 to 10 years leading up to menopause. Menopause is defined as 12 months in a row without menstruating, with the average age being 51. Menopause is not only something that happens to the ovaries; it's considered a "neuroendocrine active state," meaning your brain is impacted just as much as your ovaries. There are typically two phases to perimenopause, the first being one of excessive estrogen, with common symptoms including agitation, mood swings, weight gain, fatigue, and anxiety . The second phase typically presents with a deficit of estrogen, with symptoms of hot flashes, night sweats, trouble concentrating, depression , and vaginal dryness. Both phases can cause mood fluctuations, insomnia, libido changes, and mental fog. Symptoms of attention-deficit/hyperactivity disorder (ADHD ) can also present during this time, as I described in a past Psychology Today post. This is not an exhaustive list of symptoms, and every woman’s journey and timeline can vary. Hormone replacement therapy can be safe and effective for many. Current research on hormone replacement therapy (HRT) debunks older research claiming that it causes breast cancer . This is referencing the Women’s Health Initiative (WHI) study, which is now understood to have a flawed study design, but, unfortunately, it really derailed women’s health. HRT can mean any combination of estrogen, testosterone, estradiol, and progesterone with the most popular being an estrogen patch or progesterone lotion. HRT is particularly helpful for vasomotor issues such as hot flashes and night sweats. Research is also showing it may prevent cognitive decline that can lead to Alzheimer's disease if taken early enough. If you have a history of blood clots or estrogen-based cancers or are beyond your first 10 years of perimenopausal symptoms, you are not a candidate for HRT. HRT is not the answer for everyone and is not the only answer. HRT may vastly improve symptoms for some, but it could worsen symptoms (and introduce additional side effects) for others. I was one of those unlucky people, and my prescribing doctor—one who claimed to specialize in perimenopause—threw her hands up once hormones didn’t work because that was the only treatment she knew. This is why a holistic, whole-body approach to perimenopause is called for. For example, acupuncture and Chinese herbs may help balance hormones. Lifestyle changes are invaluable such as managing stress with exercise, most notably adding strength training to offset bone loss and moderate cardiovascular activity for brain health. Eating more antioxidants and fiber is also shown to help the changing brain during perimenopause. Spending time in nature and having solitude, as well as saying no to others so you can prioritize yourself, are all essential during this time. Beware of medical gaslighting so you can advocate for yourself. Women, people of color, and anyone disenfranchised from the medical system tend to be discounted at their doctor’s office throughout their lifespan but especially during perimenopause because of the way medicine has ignored it until recently. If one doctor is unhelpful, keep looking for another one who is trained in women’s health throughout the lifespan. Also consider other licensed holistic practitioners outside of the standard Western medical model who understand the whole body and whole person and can factor in your entire lifestyle. Honor the transition. As much as people love the quick fix of a pill, we need to tend to the emotional, psychological, and spiritual aspects of this change. Whenever we throw medication at something and don’t take time to process what’s happening, we lose an opportunity to awaken and understand ourselves on a deeper level. Perimenopause is a powerful transformation. And with all transformation, there is a letting go in order to create space for what's new. Menopause is a symbolic death, and grieving is natural. And, yet, with that loss also comes an opportunity to shed the unhealthy programming that came with youth. I personally had a mic drop moment as I recently approached 50: I realized I’d wasted too much time on low-vibration crap. I sighed thinking of all that striving to be who I thought I was supposed to be to fit in. Hitting midlife has been a wake-up call, a call that told me, "Now is the time to live more authentically. This is not a dress rehearsal." Now is the time for higher consciousness, dropping any facade, having loving self-regard, and settling into the ease of being totally myself. Midlife now means to me wisdom, intuition, empowerment, and letting go of vanity, people pleasing, needing approval from others, trying to fit in, or doing things according to antiquated traditions. May women realize they can stop taking responsibility for things that aren’t theirs, that they can flush youth-obsessed cultural programming down the toilet, and that they can step away from the herd mentality to be their bold selves. My hope is women can move through this transition with more confidence, grace, and belonging. Talking to other women about our experiences and cultivating community allows us to support and witness each other through this remarkable rite of passage. Rachel Allyn, Ph.D., - Website - References Gottfried, Sara MD, The Hormone Cure: Reclaim Balance, Sleep and Sex Drive; Lose Weight; Feel Focused, Vital, and Energized Naturally With the Gottfried Protocol, Scribner, 2014. Mingdi Li, Andrew Hung, George Binh Lenon, Angela Wei Hong Yang, Chinese herbal formulae for the treatment of menopausal hot flushes: A systematic review and meta-analysis, PLOS ONE, September 2019. Mosconi, Lisa MD, The Menopause Brain, Avery/Penguin, 2024. Shelley R Salpeter MD, Judish M.E. Walsh MD, MPH, Elizabeth Greyber MD, Thomas M. Ormiston MD, Edwin E. Salpeter PhD, Mortality Associated with Hormone Replacement Therapy in Younger and Older Women, A Meta-analysis, Journal of General Internal Medicine, Volume 19, Issue 7, July 2004.

Don't try to repress unpleasant thoughts, just shift sensory input. When you are suffering for any reason, your mind races, which makes it harder to think clearly. Doing battle with your thoughts or suppressing them makes things worse. Simply placing your attention on a specific sensation for a short time separates you from racing thoughts. The thinking brain functions better, and you can learn to live your life with clarity. The late Harvard psychologist Daniel Wegner wrote a classic paper in 1987 called Paradoxical Effects of Thought Suppression.1 He demonstrated that the more you try not to think about something—the study asked participants to try not to think of a white bear—the more you will think about it. The paper has been nicknamed, “White Bears.” The finding is not news to any of us. But the study also demonstrated a trampoline effect—when you try not to think of a white bear, you actually think about it a lot more. As the patterns of neural activation strengthen with repetition, unpleasant thoughts often become more problematic over time. Ironically, the thoughts are who you are not, otherwise you would not suppress them. A basic tenet of many Eastern philosophies is that worrying about the future and thinking about the past cause internal unrest. There is anxiety around the future and many regrets and frustrations about the past. Staying in the present moment is key, but how do you accomplish it? You cannot control your mind with your mind. When your mind is racing, your body will be tense and tight. The harder you try to calm down your thoughts, the faster your brain will spin. Neural circuits are deeply embedded, especially the unpleasant ones you instinctively fight. Active meditation As you cannot fix, repair, or outrun the repetitive thoughts, one option is shifting from them, activating more functional and enjoyable circuits. This is quickly accomplished by focusing your attention on any specific sensation from your immediate surroundings. Using any sense works—sound, smell, taste, feel, pressure, sight. My term for this tool is “active mediation.” It is an abbreviated version of mindfulness, and you focus on any sensation for a few seconds, up to a minute. You connect your consciousness to the present moment. The intention is to incorporate this practice frequently into your daily routine until it becomes habitual. Three steps from Eastern philosophy Relaxation Stabilization Focusing on a sensation I learned them in a workshop given by Alan Wallace, a prominent researcher in integrating Buddhist contemplative practices with Western science. Active meditation in practice I practiced this daily during my hectic days at work. I often did it with my patients in clinic, especially if I was running behind. We sat back in our chairs, let our shoulders sag, jaws relax, took a long deep breath, and slowly let it go (relaxation). We stayed relaxed for 5-10 seconds (stabilization), while I had patients listen to the ventilation system. Then our attention shifted to voices outside the door, our feet on the floor, and back to the vent. It took about a minute. Invariably, everyone felt more relaxed, and I heard my voice change to a softer pitch. Our attention had shifted from racing thoughts to the current moment through sensory awareness. I encouraged patients to do this often until became automatic. You can also do this much faster for just three to five seconds. Simply engage with any sensation for short periods as often as possible throughout the day. During surgery, I would engage in active meditation with essentially every move I made. My go-to sensation was grip pressure on my surgical instruments. There is more feel and control with a light touch. Eventually, the sensations and moves I made became so automatic that I developed a safe zone, and it would have required a conscious choice to be unsafe. The consistency of my performance improved my enjoyment of the day as well. Listening Another rendition of this tool is listening; I mean really listening in a way that you can visualize the other person’s perspective and realize that the words they are saying mean something different to them than they do to you. It is remarkably more interesting to hear others' perspectives rather than replaying your own. The past is the past You cannot change the past or control the future, and neural circuits are permanently embedded. Trying harder to analyze and fix them stimulates and reinforces them (neuroplasticity). Going to battle with them is deadly. Simply shift your attention to any immediate sensory input. That is it, and it is that simple. David Hanscom - Website - Resources - References 1. Wegner, D.M., et al. Paradoxical effects of thought suppression. Journal of Personality and Social Psychology (1987); 53: 5-13.

An attack-self coping response to shame is prominent in depression. The word “ depression ” is not sharply defined. When someone claims to be depressed, we may vaguely imagine a level of unhappiness ranging from mild dejection to deep despondency. A mainstay in the understanding of depression since the Freudian era is the notion that depression represents anger that is directed toward the self or turned inward. This view assumes that the depleted energy of depressed people is due to anger being shifted internally, and, thus, therapists have searched for methods to release the anger of their depressed patients rather than recognize this anger as a response to other emotions (Nathanson, 1994). In “Mourning and Melancholia,” which some consider Freud’s (1917/1957) classic paper on depression, melancholia (depression) is differentiated from mourning ( grief ) based on the supposition that in melancholia, anger is directed toward the self in the form of self-reproach and self-attack, in contrast to mourning, where anger is directed toward the lost love object. According to Freud, early childhood loss results in the child’s internalization of ambivalent feelings toward the lost parent that become fused with the child’s ego, later leading to a vulnerability to experience self-directed anger when loss is encountered. Echoing Freud’s view of depression as involving aggressive impulses turned against the self, Melanie Klein’s (1930) exaggerated notions of depression related it to persecution as a result of the imagined destruction of the love object by the patient’s envy and aggression, and an identification with the imagined damaged object. The syndrome of depression, including symptoms involving self-attack, is considered to be an attempt by one’s ego to spare a love object from harm: for example, by high levels of internal hostility or rivalry, or as an attempt to spare the love object by sympathizing, sharing, and suffering the imagined pain inflicted upon it (Taylor & Richardson, 2007). The early foundation of Cognitive Behavioral Therapy (CBT) also links depression with anger turned against the self. In his early studies of depression, Aaron Beck (1963, 1964, 1972) found that depressed patients engage in self-blame, self-criticism, and self-dislike to the point of self-disgust and self-hatred. Aligned with Freud’s suppositions about the contribution of emotional memories in depressive disorders, Beck posited that early experiences lead to the development of negatively biased self-referent ideas or schemas (a negative cognitive triad) that may remain latent until activated in adulthood by loss. According to Beck, the thoughts of depressed patients in interpersonal situations are self-derogatory: Others appear to be indifferent; low self-regard is applied to personal attributes, acquisitions, and career performance; and, self-criticisms, self-condemnation, and negative comparisons with others are present. Although self-derogatory cognitions represent typical shame-related attacks against the self, cognitive behavioral therapists, along with their psychoanalytic colleagues, generally do not recognize shame in the pathology of depressed patients, nor focus on shame in the treatment of depression. Indeed, many symptoms of depression directly involve established coping responses to shame: withdrawal (e.g., hypersomnia, not wanting to be in the presence of others or engage in activities); avoidance (e.g., drug and alcohol abuse); attack-other behaviors (e.g., irritable reactions and rages at others or blaming others for causing the negative mood); and attack-self responses (e.g., self-injurious behaviors and suicide attempts). The attack-self coping response to shame is particularly prominent in depression, and when persistent shame and enduring fear arise in close proximity, the resulting guilt will be experienced as anger that is turned against the self (Nathanson, 1994). Shame is often central in the experience of depression (Helen Block Lewis, 1987). Why is shame a prominent component in depressive syndromes? One reason is that depression can be the result of the attenuation of positive emotions, whether caused by internal or external factors. Anything which interrupts positive emotions, without completely reducing it, will activate shame (Tomkins, 1962). Some researchers speculate that depressive symptoms are the result of shame experiences in interpersonal contexts that activate maladaptive cognitive-affective spirals (Thompson & Berenbaum, 2006). In shame-based depressions, patients look both sad and defeated, interpreting what they feel as personal inadequacy (Tomkins, 1963). Many psychologists have long accepted that chronic shame appears as depression (Morrison, 1977; Wurmser, 2015). Nonetheless, the tendency of people to hide shame, in treatment as in their lives, may lead therapists to overlook shame as underlying depressive symptoms (Morrison, 1987). Recent studies have linked depression to central and traumatic memories of shame, indicating that early emotional memories of feeling safe and nurtured within the family can buffer the depressive effects of central shame experiences, but are not as protective in the case of people suffering from traumatic memories of shame (Matos, Pinto-Gouveia, & Duarte, 2013, 2015). All depressions, whether triggered initially by shame or other causes, can create further shame and distress that interact in a negatively spiraling cycle. As a result, the motivation to accomplish things and have fun becomes increasingly difficult. This misguided cultural perception and the judgments that imply one can simply overcome depression may become an additional source—from both self and others—of shame in anyone suffering from this condition. The divided self in shame-based depressions that results in self-attacking behavior, alongside introspective or self-soothing behaviors, enables those who suffer to explore an important upside: Depression turns attention inward in ways that can promote resignation and acceptance (Izard, 1977; Lazarus, 1991). Interestingly, the facial expression associated with sadness signals a need for comfort and enables others to become aware of that need (Ekman, 2003). Moreover, the experience of depression provides an opportunity to consider the necessity of revising one’s objectives and strategies for the future, and it may lead us to grapple with the existential question, “Who am I?” (Henretty, Levitt, & Mathews, 2008). This post is excerpted in part from The Upside of Shame: Therapeutic Interventions Using the Positive Aspects of a "Negative' "Emotion. Mary C. Lamia, Ph.D., - Website - References Beck, A. (1964). Thinking and depression II: Theory and therapy. Achieves of General Psychiatry, 1,561-571. doi:10.1001/archpsyc.1964.01720240015003 Beck, A. T. (1972). Depression: Causes and treatment.Philadelphia, PA: University of Pennsylvania Press. Ekman, P. (2003). Emotions revealed: Recognizing faces and feelings to improve communication and emotional life. New York, NY, US: Times Books/Henry Holt and Co. Freud, S. (1957). Mourning and Melancholia. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud, Volume XIV (1914-1916): On the history of the psycho-analytic movement, papers onmetapsychology, and other works (pp. 67-102). London: Hogarth Press. (Original work published 1917) Henretty, J., Levitt, H., & Mathews, S. (2008). Clients’ experiences of moments of sadness in psychotherapy: A grounded theory analysis. Psychotherapy Research, 18, 243–255. Izard, C. (1977). Human emotions. New York, NY: Plenum Press. Klein, M. (1930). The importance of symbol formation in the development of the ego. International Journal of Psychoanalysis, 11, 24-39. Lazarus, R. (1991). Emotion and adaptation. New York, NY: Oxford University Press.
 Lewis, H. B. (1987). Shame and the narcissistic personality. In D. L. Nathanson (Ed.), The many faces of shame (pp. 93-132). New York, NY: Guilford. Matos, M. Pinto-Gouveia, J., & Duarte, C. (2013). Internalizing early memories of shame and lack of safeness and warmth: The mediating role of shame on depression. Behavioural and Cognitive Psychotherapy, 41, 479-493. Matos, M. Pinto-Gouveia, J., & Duarte, C. (2015). Constructing a self-protected against shame: The importance of warmth and safeness memories and feelings on the association between shame memories and depression. International Journal of Psychology and Psychological Therapy, 15, 317- 335. Morrison, A. (1987). The eye turned inward: Shame and the self. In Donald L. Nathanson, (Ed.), The many faces of shame (pp. 271-291). New York, NY: Guilford Press. Nathanson, D. L. (1992). Shame and pride: Affect, sex, and the birth of the self. New York, NY: W.W. Norton Nathanson, D. L. (1994). Shame, compassion, and the “borderline” personality. Psychiatric Clinics of North America, 17, 785-810. Nathanson, D. L. (1994). The case against depression. Bulletin of The Tomkins Institute, 1, 1-5.ISSN 1075-6930. Taylor, D. & Richardson, P. (2007). The psychoanalytic/psychodynamic approach to depressive disorders. In Glen O. Gabbard, Judith S. Beck, & Jeremy Holmes (Eds.). Oxford textbook of psychotherapy(pp. 127-136). New York, NY: Oxford University Press. Thompson, R. J. & Berenbaum, H. (2006). Shame reactions to everyday dilemmas are associated with depressive disorder. Cognitive Therapy Research, 30: 415-425. Tomkins, S. S. (1962). Affect imagery consciousness. Vol I: The positive affects. New York, NY: Springer Wurmser, L. (2015). Primary shame, mortal wound and tragic circularity: Some new reflections on shame and shame conflicts. International Journal of Psychoanalysis,96,1615-1634.

Readiness, intellect, spirituality, and more. Eight key dimensions contribute to the health and longevity of a romantic relationship. These include intellectual, emotional, physical, values, spiritual, avocations, chemistry, and readiness. These alignments are not static but can evolve. I always find it amazing that love relationships ever come to fruition and sustain themselves. Relationships seem so complicated, particularly those of the romantic variety. There are so many aspects of a relationship that determine or not. Over the years, I cataloged the dimensions that I believe contribute to the quality of a romantic relationship . I have ultimately landed on eight dimensions that have provided a taxonomy for understanding the complexities of relationships. For a long time, I struggled with finding a framework that would describe those dimensions in a way that was intellectually rigorous and emotionally resonant. Only recently did I find that structure. It's conceptualized as the degree to which two people are similar or in agreement as opposed to dissimilar or in disagreement. How aligned two people are along the eight dimensions can determine the health and longevity of a relationship. 1. Intellectual . This alignment refers to how intelligent you want your partner to be. This dimension can be a proxy for educational level, or it might reflect “street smarts” or common sense. For some, high intelligence may be critical. For example, satisfying their needs for intellectually stimulating conversation about a wide range of topics might include philosophy, politics, psychology, world events, and many others. For others, intelligence may be less important than other alignments. 2. Emotional. Emotional alignment may be the most important alignment. Two aspects of emotions play a role in alignment. First, how emotionally accessible is your prospective partner? For genuinely healthy relationships, emotions and vulnerability are essential for meeting each other’s needs, feeling loved, and communicating effectively. At the same time, alignment rather than absolute emotionality may be more important. For example, if you are emotionally defended, you will not likely align with someone who is emotionally open. Though this alignment of emotional defended-ness may not lead to the healthiest relationship (because neither of you will be able to fully “go there.”), it will more likely meet your immediate emotional needs of keeping some distance between you and your prospective partner. 3. Physical. If sex is important to you in a relationship, then physical attraction is necessary. Whatever internal standard of what you find attractive in a partner (in other words, whatever turns you on), whether height, weight, body, type, face, what-have-you, must be met for there to be sexual interest. Of course, your physical attraction to another person can be affected by intellect (perhaps you’re a sapiosexual), emotions (if you feel their love), and chemistry (you just feel this deep connection). 4. Values. Values are the foundation of everything we do in our lives. They act as the signposts that direct and guide us on our life’s journey. Values specify what is important and what we prioritize in our essential values dictate how we spend our time, energy, and money (three of our most essential resources). Given the essential role that values play in our critical, it is not surprising that they are also crucial to forming and maintaining relationships. Values can touch every aspect of your life. They can include educational and career choices, hobbies, religious and political beliefs, the types of relationships you have, where you commit your charitable efforts, your relationship to money, how you believe people should be treated, and so on. Values are so deeply held that they become inextricably entwined with our self-identities. Because of this deep connection between our values and the kind of person we perceive ourselves to be, value alignment seems truly fundamental to the partners we choose. In my experience, it is rare to find two people in a healthy relationship with vastly different and conflicting value systems. 5. Spiritual. Spiritual alignment is often central to a healthy relationship because spirituality frequently informs much of who we are, what we value and believe, and how we view and engage with the world. I use the term “spirituality” in a broad sense. It may indicate a strong belief in a monotheistic God espoused by traditional religions. Or it may refer to a personal journey to find meaning and purpose in life outside of ourselves. In either case, people who value spirituality often need someone who is aligned with them spiritually to feel a deep connection. 6. Avocations. The nature of a committed, long-term relationship is that we spend most of our daily time with our partner for a significant part of our lifespan. This fact, by definition, requires that this time needs to be filled with something, usually activities in which both can participate and share experiences, thus strengthening their connection. Times have certainly changed in recent generations about the activities that partners do together. In previous generations, couples led much more separate avocational lives. Men did “men” activities with their male friends, and women followed suit with their female friends. In recent decades, though, the relationship between partners has become more encompassing, where they are seen as best friends who share their avocations. This shift in loving relationships has resulted in partners spending most of their free time together, sharing and enjoying their aligned activities, thus making avocation alignment far more important for healthy relationships. 7. Chemistry. This alignment may be the most elusive because it can’t be rationally understood or explained; rather, it’s just something we feel. I have often described it as a balance between comfort and excitement. You feel safe and secure with your partner, yet also passionate and stimulated. What aligns chemistry is that both people feel the chemistry at the same level of intensity. Due to its elusive nature, knowing where chemistry comes from is often a mystery. At the same time, it’s not unreasonable to posit that chemical alignment could be the culmination of alignment in the previous five dimensions that influence a relationship. 8. Readiness. Too often, I have seen burgeoning relationships with what appeared to be considerable alignment go off the rails because one or both of the people weren’t ready based on where they were in their life’s journey. Readiness for a healthy relationship can involve exploring and letting go of emotional baggage that prevents them from being a part of a nourishing relationship. Unfortunately, emotional baggage is a part of the human condition that can interfere with the establishment of a nurturing relationship. Common baggage can include not feeling worthy of love, fear of rejection, need to please, and need for control, any of which can cause us to be attracted to people who aren’t healthy for us or that will set up the relationship for failure. Gaining readiness involves acting on your world (and those in it) based on who you are rather than who you once were. Despite the internal alignment that may exist between two people, outside forces may derail the potential that may exist for a nourishing relationship. Geography, career, marriage status, the presence of children or elderly parents, and physical health are just a few of the factors that, if not aligned, can make the previous seven alignments moot. 9 (Bonus) Timing . Despite the internal alignment that may exist between two people, outside forces may derail the potential that may exist for a nourishing relationship. Geography, career, marriage status, the presence of children or elderly parents, and physical health are just a few of the factors that, if not aligned, can make the previous seven alignments moot. Alignments Are Dynamic One important clarification: These dimensions aren’t dichotomous; in other words, they are not “Do they have them or not?” Instead, you should consider each dimension as lying along a continuum in which they might have varying degrees of alignment. Where on the continuum they might lie depends on how important each dimension is to you and how you prioritize any specific alignment in the “meta alignment” of your overall feelings for and relationship with a person. Alignments can also change in a relationship. Alignments can deepen as people evolve in any or all of the eight dimensions. These stronger alignments can result in a relationship growing deeper and more resilient, which can stand the test of time. Conversely, alignments can also weaken or disappear completely as people change in ways that aren’t, well, aligned with their partner. The result is either the two people inhabiting a misaligned relationship or that relationship ending because there are not enough alignments to keep the relationship intact. Jim Taylor, Ph.D., - Website -

The use of a stuffie could lead to a new way of thinking. Oppositional defiant disorder (ODD) in children can cause excessive anger and defiance. ODD can be treated with cognitive-behavioral therapies. Children with ODD can become more cooperative through the use of a stuffed toy. Patients diagnosed with oppositional defiant disorder (ODD) can exhibit constant and excessive anger and aggravation. Symptoms of ODD typically arise by the age of 8, as children become defiant and uncooperative, which can lead to challenging situations in homes, schools, and with authorities. With intervention, improvement can occur within approximately three years. However, if ODD is not treated properly and promptly, future conduct and personality disorders may emerge, such as antisocial personality disorder. Children with ODD may also require treatment for commonly associated conditions such as depression and/or anxiety . But in many cases, ODD is a solitary issue, and behavioral therapies are the main strategies to help children with this diagnosis. Individual and/or group therapies involving cognitive-behavioral therapy have been shown to be helpful. Since living with a child who has ODD can be challenging for caretakers and siblings, family therapy can also be useful. A recent method of group therapy for children has involved the incorporation of stuffed toys, also known as stuffies or plushies. These toys can provide support and comfort to children undergoing unfamiliar or stressful situations. Toys have been used to encourage children to do things they have trouble doing, such as creating better sleeping habits, inspiring them to read more often, and tone down aggression. Hypnosis Therapy In my counseling practice, I have been working with an 11-year-old boy with ODD. His defiance and associated anger when asked to participate in family activities and perform chores has affected the behavior of his three younger siblings and been a source of acrimony within the family. This patient was taught how to use hypnosis to calm himself. In the first session, he learned how to imagine being at his favorite, relaxing, safe place, which he picked as the beach, and to recall his calm feeling when he was not in hypnosis, by crossing his fingers, which was a hand gesture of his choice. He was instructed to practice his hypnotic relaxation on a daily basis for at least two weeks, and to employ the hand gesture as a way of calming himself when he began to become agitated. A month later, the patient and his mother reported that with use of the hand gesture, the patient was able to decrease the intensity of his anger outbursts, but their frequency was still unabated. At a second hypnosis session at that time, the patient was taught how to interact with his subconscious through ideomotor signaling. The subconscious advised the patient that he can control his behavior, and that he can do it through believing in himself. The subconscious also identified itself as “George” (which was not the patient’s name.) Two weeks later there was a slight decrease in the frequency of the patient’s outbursts, but the dynamics at home remained very difficult for the parents to manage. Subsequent therapy with the patient involved rewarding him for improved behavior with Pokémon, food, and favorite activities, and ignoring his negative behavior as much as possible. However, the patient continued to act defiantly much of the time. Stuffie Therapy The patient explained that in general he wanted to follow his parents’ instructions but could not bring himself to do so. Therefore, as toys have been used to help in therapy with children, it was suggested that the patient designate a “Stuffie Spokesperson” every day. His parents were instructed to talk to the stuffie about what they would like the patient to do, rather than addressing the patient directly. The patient’s compliance with his parents’ instructions improved dramatically thereafter. His mother reported that the frequency and intensity of his outbursts decreased by 90 percent. As an alternative to speaking to the stuffie the parents were instructed to speak with “George," which was the designated name of the patient’s subconscious. Speaking to George yielded the same results as speaking to the stuffie. However, when the parents gave the patient direct instructions, the patient remained defiant even when he was instructed to ask George to help him. Subsequently, I worked with a 5-year-old boy who expressed pride in not listening to his parents or his kindergarten teacher. He said, “I was sent to the principal’s office 100 times last year, and if I get sent there 500 times I’ll be expelled.” Given his young age, I elected against teaching him formal use of hypnosis and how to interact with his subconscious. Instead, I offered to teach him how his favorite stuffed toy, Mario from Donkey Kong, could help him. Following my advice, his mother started instructing Mario what the patient should do, and immediately the child became cooperative. We discussed that in school it might be awkward for a teacher to speak with Mario. Therefore, we modified the therapy by having his family buy him a watch with a picture of Mario on the face. The patient then was instructed as follows: “Tap the watch twice, and then I will tell Mario what you need to do.” The patient continued to be cooperative at home and at school with the shorthand version of this phrase: “Tap the watch twice” and follow instructions. Takeaway The observed improvement in behavior with use of stuffed toys or their representations in patients with ODD may be related to a prompted change in their mindset. For example, perhaps addressing the toy or subconscious activates brain pathways that lead to children’s cooperation rather than those usually involved in their reflexive negative ODD-associated responses. Clinical studies are required to document whether use of a Stuffie Spokesperson can be useful in helping many children with ODD become more cooperative. Much of the information in this blog was first published in an article I co-authored in Clinical Pediatrics (Anbar & Zand, 2023). Ran D. Anbar, M.D., FAAP, - Website - References Anbar, R. D., and Zand, N. (2023). A new approach to patients with oppositional defiant disorder. Clinical Pediatrics. doi:10.1177/00099228231191465

What we miss when we assign multiple labels to one person. Many patients with whom I meet for the first time tell me that they have been diagnosed with a laundry list of psychiatric disorders. It is not uncommon, for instance, for a patient to tell me that they have " MDD, GAD, ADHD , and PTSD ." When I occasionally review patients' past records, I find that even formal psychological evaluations conducted by clinical psychologists often list four, five, six (or more!) psychiatric diagnoses. This practice of diagnosing the patient with multiple psychiatric disorders—what I have elsewhere called polydiagnosis —is a relatively novel trend in psychiatry. As my Tufts colleague Nassir Ghaemi (2018) has pointed out, this practice stems from the lack of a diagnostic hierarchy in psychiatry and from the field's wholesale adoption of the DSM diagnostic system, which essentially promotes listing as many diagnoses as possible (with a few limited exceptions, such as listing both schizophrenia and bipolar disorder ). Prior to the publication of DSM-III in 1980, two or more diagnoses were rarely applied to the same patient. The question clinicians asked was, "What type of illness does this patient have?" as opposed to, "Which illnesses does this patient meet criteria for?" Rather than attempting to conceptualize the clinical picture as a whole, many modern clinicians simply seek to see how many DSM criterion sets the patient's symptoms fulfill. This is usually done without considering how a more significant illness can explain the patient's other symptoms. For instance, patients with borderline personality disorder , a severe mental illness, can present with virtually any psychiatric symptom seen in Axis I disorders depressed mood, anxiety , agitation, impulsivity, problems with attention and concentration , psychosis , etc. If diagnosis is applied piecemeal, and the patient's total picture is not taken into consideration, four or five separate psychiatric diagnoses could be listed rather than a single "borderline personality disorder" diagnosis. This happens frequently. So, too, with mood disorders . Patients with mood temperaments or manic-depressive illness (which is now split into the categories of MDD and bipolar disorder) characteristically struggle with problems of attention, concentration, and anxiety. As Ghaemi and I have noted, this does not warrant additional diagnoses of attention-deficit/hyperactivity disorder or generalized anxiety disorder, since these symptoms can be fully explained by the mood illness (Ruffalo & Ghaemi, 2023). The notion of a diagnostic hierarchy, which is a fundamental principle across all of medicine, has been largely forgotten by psychiatry for about the past 40 years. In sum, diagnostic hierarchy refers to the idea that not all diagnoses are created equal—that some are more important or more primary than others. Since the DSM system provides few exclusionary rules, and since clinical criteria for many disorders overlap, multiple diagnoses are frequently assigned simultaneously creating the problem of Poly diagnosis or comorbidity . The problem of Poly diagnosis is not simply a theoretical one. In practice, it can lead to inadequate treatment or overtreatment. Much has been written in recent years about the problem of polypharmacy—the use of multiple psychiatric drugs across drug classes and sometimes within drug classes—but little attention has been paid to one of its main drivers: Poly diagnosis. If multiple, distinct psychiatric disorders are diagnosed, it follows that multiple treatments might be applied: a drug for this disorder, and this one, and this one. In the case of personality disorder misdiagnosed as multiple Axis I disorders; this can lead to "symptom chasing" with medication rather than appropriate treatment with psychotherapy . This is certainly not to say that all psychiatric patients have only a single disorder. While it is best to err on the side of caution, it is conceivable that some patients have multiple forms of psychopathology occurring simultaneously. But 150 years of psychiatric and psychotherapeutic wisdom teaches us that this is largely the exception, not the rule. As disenchantment with the DSM system grows, even within psychiatry, it is time more attention is paid to the theoretical and clinical problems posed by psychiatric Poly diagnosis. Mark L. Ruffalo, M.S.W., D.Psa. - Website - References Ghaemi S. N. (2018). After the failure of DSM: clinical research on psychiatric diagnosis. World Psychiatry: Official Journal of the World Psychiatric Association (WPA) , 17 (3), 301–302. Ruffalo, M. L., & Ghaemi, N. (2023). The making of adult ADHD: The rapid rise of a novel psychiatric disorder. Psychiatric Times, 40 (9), 1, 18-19.