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There are some surprising reasons for hallucinating, and some are even normal. Key points Hallucinations can be caused by mental and general medical conditions. They can also be normal. Anyone with a new onset of hallucinations should be evaluated in a timely manner by a physician. Children and teenagers can have normal hallucinations, but sometimes they are due to a disorder. Hallucinations are unreal sensory experiences, such as hearing or seeing something that is not there. Any of our five senses (vision, hearing, taste, smell, touch) can be involved. Most often, when we learn someone is hallucinating, we think about psychosis, such as schizophrenia. Hallucinations can also occur in people who have bipolar disorder with psychosis or major depressive disorder with psychosis. While these mental disorders are common causes of hallucinations, there are numerous general medical causes as well. For example, people with a variety of neurological illnesses may hallucinate. Those illnesses include migraine headaches, Parkinsonism, some dementias, delirium, brain tumors, and others. A man appears distressed while speaking during a therapy or counseling session Brain tumors in the frontal lobe often present with a personality change. Another early symptom can be hallucinations of smelling burnt rubber. This is a good example of a hallucination related to the sense of smell. One fascinating cause of visual hallucinations can occur when someone has a severe disease of both retinas in their eyes. For example, there was a patient who had a viral infection in each of his retinas. He reported seeing tiny people and small animals playing and running around his hospital room. Of course, he was having a visual hallucination. The virus stimulated his retinas, which sent signals to the occipital lobe in the back of his brain, where vision processing occurs. His brain interpreted the signals as real images. His general medical doctor worried that he was psychotic. A psychiatric consultant determined that the patient was not psychotic but hallucinated because of his retinal infection. The patient was reassured that his visions were not due to psychosis but were a reaction to his eye infection. No treatment was needed. Substance use disorders are common sources of hallucinations. These substances include alcohol (especially during severe withdrawal known as delirium tremens), amphetamines, and hallucinatory drugs such as LSD and PCP. They can cause a variety of hallucinations, especially visual ("pink elephants"), auditory, and tactile. An example of a tactile hallucination is a sensation of insects crawling under the skin or of internal organs moving around. It is frightening for the patient who believes that it is really happening. Hallucinations can occur in patients who are taking certain medications as a side effect. Examples include some antihistamines, opiates, SSRI-type antidepressants (e.g., fluoxetine), steroids like prednisone, sleeping pills, and many others. Because there are more general medical causes of hallucinations than mental health disorders, anyone experiencing hallucinations for the first time should see a medical doctor soon. The patient may suffer great harm if the underlying medical condition is not diagnosed and appropriately treated. Sometimes, hallucinations may occur in people who don't have a mental health or general medical cause. These hallucinations are normal. One common example can happen after the death of a loved one, such as a beloved spouse. The bereaved spouse may "see" their deceased spouse standing at the foot of their bed at night. These hallucinations are common and normal. However, people who are unaware that this is normal may be frightened and wonder, "Am I losing my mind?" Reassurance from a physician or mental health professional is usually all that is needed. Another cause of normal hallucinations is related to sleep. These individuals usually have visual hallucinations when they are falling asleep. It occurs during the transition from wakefulness to their first dream. We dream about five times each night when rapid eye movements take place. These hallucinations are called hypnagogic hallucinations. People may also hallucinate while they are waking from sleep. These are known as hypnopompic hallucinations. They can be potent enough that the person believes that it really happened. For example, a person who wakes up while having a vivid dream of being kidnapped by aliens and experimented on may think that really happened. This can explain what was going on when someone reports being roused from sleep by aliens. Children and teenagers can have normal hallucinations (Naijer, 2019). They are typically self-limited and are not associated with any other symptom of mental or general medical illness. They are thought to be part of normal development. No treatment is needed. Despite normal hallucinations in children and teens, there is some evidence that a few of these children and teens have an increased risk of suicide. This may be because some of them have a disorder that is not fully manifested. It is reasonable to monitor these children and teens. In summary, hallucinations can be caused by mental health and general medical disorders. In some cases, the hallucinations may be normal. Because hallucinations are caused more often by general medical disorders than mental health disorders, everyone with new-onset hallucinations should be promptly evaluated by a physician, such as a psychiatrist. Peter M. Hartmann, MD, DLFAPA - blog

Three easy micro-resets for your nervous system. Key points Seasonal transitions can knock us out of balance. Micro-resets, or balancing exercises, can help to reset your nervous system throughout the day. Daily rituals, getting earthy, and balancing your breath can help. Recently, my yoga teacher commented that "Fall is a windy time of year." Depending on where you live, the cool wind may pick up or briskness cut the air. This seasonal shift can feel energizing, or rev up your anxiety. But my yoga teacher was not just talking about the external weather forecast. She was also talking about the shift of weather inside of each of us; that is, a feeling of worry, frenzy, and overwhelm that ramps up quite predictably each fall. Not coincidentally, these freshly stirred up feelings might bear relation to the weather around us; after all, we're intimately connected to what philosopher David Abrams calls the "more than human world." A woman looking out a rainy window. A favorite icebreaker in a group that I used to run with teenage girls was: "What's your internal weather report?" "Thunderstorms," "cloudy skies," and "bright and sunny" were all common responses. This question is a great place to check in on your emotional state. Fall coincides with many transitions: back-to-school, back-to-work, changing bathing suits for sweaters in a closet, crop rotations in a garden, etc. For many folks, there's a ramped-up pace of life every September, October, and November: more events, activities, work, social engagements — and the challenge of juggling and multitasking to meet so many demands. Pile on top of that a huge heaping of today's looming existential burdens, be it on the personal level (i.e., health issue) or global level (political unrest). Indeed, there's a strong current of unease and worry that's pervasive and visceral — and, for many folks, it is haunting their bodies with stress accumulation. We can intellectualize this all day long and call it "chronic stress," "collective trauma" or "malignant normality." Nonetheless, the prescription from a mental health perspective will often come back to the body, breath, and allowing unconscious thoughts and feelings to come forward. When we, as a society or as individuals, are distressed or imbalanced, our best way forward is to rebalance ourselves. Fall, though windy, also houses the fall equinox: a day when day and night are approximately the same length due to the positioning of the sun and Earth (this year it was on September 22nd, 2025). A few weeks past, we sit in a space of dwindling light each day. More of our day is spent in darkness than sunlight as we move deeper into the winter. As with other mammals, we experience a felt sense of this shift in our bodies, naturally craving more quiet and peacefulness, a desire to slow down, sleep more, and succumb to natural rhythms. The equinox is a good signal of balance. When our lives feel loud, unpredictable, or windy, we can ask ourselves where in our lives we are off-balance. And how do we return to inner equilibrium? One easy answer is: micro-resets — a sincere and compassionate attempt to rebalance our nervous system. This rebalancing is most effective through our physical bodies, not just mental work. Here are three simple balancing exercises you can try this fall (or any time) to feel calmer, more grounded, and more connected: 1. "Book-end" your day Daily rituals are comforting. Whatever the weather inside or outside, your rituals anchor you in the here and now, connecting you to yourself. A daily ritual can be as short as five minutes. Taking this to the next level and "book-ending" your day by engaging in a ritual at both the start and end of the day is even better. A twice-a-day ritual offers a sense of containment, a touchstone for mindfulness, and repetition supports the rewiring of neural networks. The ritual can be the same both times of day, or it can be two different rituals that achieve the same end. Examples: • Sitting meditation, walking meditation, mindful eating • Listening to calming music, playing an instrument, or singing • Journaling 2. Get earthy Humans have evolved for centuries in their natural environments: forests, rivers, coasts, deserts, jungle, and so on. At our deepest core level, experiencing an intimate connection to the more-than-human world is calming and recalibrating. Our egos trip us up over and over again with all of our internal stories and lively narration. When we are immersed in the vastness of our landscapes, in the elements, the chatter in our minds dissolves. What a relief! The late Buddhist monk Thich Nhat Hanh referred to our intrinsic connection to the web of living things as "interbeing." In my new book, Raising Anti-Doomers, I explore "embeddedness" as a central aspect of our mental health and resilience. When we feel separate or distant from the more-than-human world, it can be a slippery slope into a pit of loneliness, grief, and despair. Examples of getting earthy: • Bare feet on earth • Gardening with bare hands • Observing animals, birds, insects, and earthly creatures with your five senses • Finding a tree to look at, imagine your legs as sturdy as trunks growing roots down into the soil. Push gently down through your feet and feel into this metaphor. Imagine your heart and arms growing from that strong foundation. If you can do this outside next to or touching a tree, even better. 3. Balance your breath and posture How we breathe — our quality of breath — dictates how we feel. (And, yes, vice versa too!) Think of a time when you felt nervous or afraid. What happened to your breathing? Likely, your breath became shallow, more rapid, your heart rate increased, and perhaps your eyes opened wide. Posture is also part of the equation. When you feel sad or insecure, you might slump. When you are angry, you might stiffen through the spine, tense your jaw, and coil your fists. Your posture gives you clues about how you are feeling. With both breath and posture, you can make micro-adjustments to restore balance. With breath, you can lengthen your exhales to exceed or match your inhales to help activate your parasympathetic nervous system (i.e., rest and digest). With posture, if you notice where you are holding tension in your body, then you can intentionally soften those areas through movement or gentle self-massage. Breath and posture work in tandem — so you will likely need to adjust both. Examples: • 5-finger breathing • Box breathing (Sama vritti pranayama) • Tai chi, Qigong, Yoga In these coming weeks, in these windy times, try out these balancing exercises and see how they work for you. Make adjustments as needed. Be playful and curious, and don't beat yourself up for forgetting. If you fall out of practice, can you hop back into it the next day? To cultivate a calmer mind and body in unsettling times takes practice and commitment. Every time you do it, you are helping not only yourself, but others too. Limbic resonance mean that when you are calm, it radiates to others around you. Slowing down is half the battle. Ariella Cook-Shonkoff, MFT

It’s almost magical when you look back on how you and your grief have changed. Welcome! Welcome! Welcome! You've gone through the worst kind of hell and made it to the other side of the grief road! I’m so glad to see you here! I wish I could give you a great big hug! Pour yourself a drink, put your feet up, and enjoy the moment. No one deserves it more than you! You’ve been through a lot and have come a long way. As time goes by, the early days of your grief have become fuzzy. You remember the pain, but you don’t really remember. It’s sort of like how some women forget the intensity of childbirth (or so I’ve been told). They forget the physical pain but not the memory of it. A teddy bear by the water at sunset. That’s why it’s important to take a look at how you and your grief have changed. It’s truly amazing, almost magical when you look back on it. You’ve progressed from feeling completely hopeless and in the worst pain you’ve ever felt in your life to cherishing each day you have left. How the hell did that happen? You know how, but even that begins to fade. All the hard work you’ve put in, all the tears you’ve shed, all the dark nights of the soul you’ve wrestled with get packed away in your head and heart because the worst is over, and life rolls on. Whenever I think of those three little words, I think of Rob. I see those words tattooed in cursive on his left forearm. When he was here with us, I thought those words were emblematic of his no-Fs-given attitude, but now I think they’re a message to me and a message to you. The message is something we all know and have always known, and I don’t think I need to spell it out for you, because I think we all feel it deep down inside. We live our lives differently than we have in the past and differently than others who have never experienced anything like the depth of our loss. For us, Life Rolls On has become a way of life. We need to do things that feel important to us and to others. We are more present, slowing life’s roll and amplifying each moment. We appreciate every day we have left on Earth and the day ahead, whenever it comes, when we meet our child again. We still curse out idiot drivers who cut us off on the freeway, we talk too loud and too much on our phones like everybody else, and we often forget to replace the toilet paper roll. We’re not perfect. We f--- up like everyone else. We’re extraordinary but we’re also human. Which, again, is absolutely remarkable given the trauma and drama we’ve endured. We’re still standing and doing our best, and that’s what our kids would want us to do. I know this and you know this because that’s what they tell us every day. They remind us to be happy, they remind us to be kind, they remind us to be grateful, they remind us to be honest, they remind us how much love we have in our hearts and how we should spread it around far and wide but also leave a little leftover for ourselves. And that’s what I’m going to remind you about right now. Do me a favor and close your eyes. Picture your child’s smiling face. Stay with it a moment. Breathe it in. Savor it. Have you ever seen a more beautiful face? Now I want you to remember the day they were born and the first time you set eyes on them and how it was love at first sight. Remember their gorgeous tiny face, and remember how incredible you felt on that wonderful day. Breathe that day in as much as you can. Now fast forward to another happy time in their life. Maybe it was a birthday or a trip to Disneyland or a day at the beach. Picture how happy they look blowing out the candles or frolicking in the waves or whatever they’re doing in the joyful moment you’ve chosen. Now place your hand over your heart and feel them smiling and saying, “Hi Mom! Hi Dad!” Have you ever seen a happier face? Okay, now take a deep breath and imagine their face today. They look all grown up, with a beatific grown-up smile, but if you look closely, you can still see the baby that lives inside them. Now tell them how much you miss them. Say the words out loud. And tell them how much you love them and will always love them. Say it over and over again until you can hear them saying it back to you. Smother them with kisses and hug them tight. Feel their heart beating next to yours. Feel their tears running down your cheek. Now, as gently as you can, let them go and whisper, “Goodbye.” Open your eyes. Larry Carlat - blog, book, website

How to avoid falling into common workplace misery traps. Key points Although no one wants to be miserable at work, our behavior sometimes contributes to it. Four common experiences often result in negative feelings at work. Taking control of your emotional state at work starts with awareness of self-defeating behaviors. No one wants to be miserable at work—and yet many of us do things that almost guarantee that we’ll feel that way. By identifying the 4 behaviors described here, you can avoid falling into the common traps. A stressed office worker at her desk 1. Continue to Dwell on Upsetting Issues or Events Things happen at work that are upsetting. Thinking about them for the purpose of problem-solving or processing emotions makes sense. Beyond that, though, continuing to rehash negative topics, either mentally or verbally, only results in reigniting negative emotions. Although it’s easier said than done, practice letting go of negative experiences and issues after you’ve done what you could about them. You may well be justified in your upset, or at least feel justified. And there is some self-satisfaction in feeling morally indignant. However, who does your dwelling on the past hurt? Does continuing to dwell on the experience or issue result in anything productive? 2. Focus on Being Treated Unfairly Humans (and other primate species) are tuned to be very sensitive to experiencing unfair treatment. It’s likely that you will feel unfairly treated at work at some point, and it’s upsetting. Unfortunately, there are some inherent biases that prompt us to feel unfairly treated when it may not be the case. For example, because we are aware of everything we do, and not aware of everything someone else does, it naturally feels as though we work harder than our colleagues (or at least some of them). Our distortion in assessing workloads is exacerbated when we are stressed due to our workload. In those times, it is easy to notice coworkers who are not similarly under pressure at the moment, making it feel as though we are carrying an unfair burden of the total work to be done. What can you do? First, recognize the bias described here and remind yourself that it may be at play when you are feeling unfairly treated. Second, because it is very possible that workloads or policies are not being evenly applied, consider having a candid conversation with those who have the power to change it. In this case, it’s important not to come across as whining or complaining, but rather as someone who values their job and wants to do their best work. In that context, it appears to you that there may be some discrepancies in how members of the team are treated, and you want to ensure maximum productivity and positive morale. (I wrote previously about having difficult conversations both here and here.) 3. Do the Same Things in the Same Ways, Day after Day Every job has routine aspects, but if our daily experience is monotonous, we lose interest and engagement, making work a dismal place to be. In a previous post, I wrote about the four universal human needs related to flourishing. These include engaging in meaningful activity, exerting control over our experience, and growing in our abilities. Following a mindless routine is a good way to ensure that these needs are being neglected. You may not have much (or any) control over what your work consists of, but you can exert at least some control over how you work, and there are clear benefits for doing so. In a previous post, I wrote about “job crafting,” which entails modifying your work to better fit with your strengths and interests recognizing ways to introduce greater personal meaning promoting experimentation and growth 4. Engage in Interpersonal Drama If there is more than one person in a particular work setting, there is the possibility for emotional drama. As the number of coworkers increases, so does the likelihood of conflict and hurt feelings. It’s natural. How you respond to both your own experiences of conflict, as well as those of others, determines the amount of angst and disruption caused. When you and a coworker share with each other experiences of emotional conflict with others, what is the purpose of those conversations? Sometimes this form of gossip serves to break up the monotony mentioned above, and gives people something juicy to talk about. Other times, it garners sympathy from the listener or serves to make the “villain” look bad. (In another post, I described the drama triangle and the ways that it is unproductive at best and destructive at worst.) Conflict resolution requires problem-solving, and most of the time, engaging the other person involved in the conflict as a collaborator in that problem-solving. So, to avoid feeling miserable at work, it’s important to engage in conflict resolution, even for relatively small irritations or instances of hurt feelings. When others try to pull you into their drama involving others, you have a choice as to whether to take sides and perpetuate the problem or offer to act as a coach to help your coworker problem-solve. The same is true when you talk with others about your workplace conflicts. What is it that you’re hoping to get from them, and why? There are more than four ways to make yourself miserable at work, but those described here seem to be a set of common experiences. Fortunately, you have control over how much each of these experiences affects you, and the first step is recognizing when they occur. Michael Wiederman, Ph.D - blog

A Personal Perspective: Finding clarity through diagnosis can turn fear into relief. Key points Accurate diagnosis transforms confusion into clarity, reducing emotional distress and self-blame. Validation through testing aligns internal experience with objective data. Research shows that diagnostic certainty improves well-being by easing uncertainty and restoring control. During feedback sessions, when clients and I review their psychological test results together, I often hear how comforting it feels to have their internal experiences validated by objective data. They describe the relief of seeing their struggles reflected in numbers and patterns that make sense. I’ve heard everything from quiet sighs to laughter through tears — “I knew it,” “That explains everything,” “It finally makes sense.” As a clinician, I’ve always loved those moments. They represent the power of assessment done well: data meeting humanity, insight meeting empathy. When I see a client’s shoulders drop in relief, I know we’ve bridged something important between their lived experience and the language of psychology. A therapist attentively listening during a counseling session. This summer, I found myself on the other side of that equation. After years of helping clients find clarity through testing, I suddenly understood, viscerally, what it feels like to be the one waiting for an answer. Early in the year, I began having severe joint pain, pain so consuming that I could hardly sleep or write or even twist open a jar. My hands and wrists swelled until I couldn’t bend them, and stairs became a slow, deliberate climb. I tried everything that seemed reasonable: collagen, fish oil, supplements, dietary changes, gentle movement. I saw doctors, cried from frustration, and scoured the internet for clues. Nothing fit. Then came a morning when I woke unable to move. I couldn’t bear weight on my knees or ankles, couldn’t crawl because my wrists throbbed, and sat frozen in bed, terrified. My partner was out of town, and the dogs needed me. I texted my sister, who urged me to go to the hospital, but I stayed, immobilized by pain and logistics. Eventually, I crawled to the freezer, gathered ice packs, and began documenting everything — what I ate, how I slept, what hurt most, how my mood shifted. When a trusted nurse practitioner finally ran an extensive blood panel, the results came back: rheumatoid arthritis. And for all the fear that diagnosis carried, I also felt a strange calm. The data matched what my body had been screaming and the puzzle had a name. That moment of validation mirrored what my clients often describe: the peace that comes when your lived experience finally aligns with objective truth. For my clients, a diagnosis of ADHD or autism often brings tears first and relief second. For me, the rheumatoid arthritis diagnosis felt exactly the same. Understanding why my joints burned and swelled didn’t make it easy, but it made it comprehensible. Once the problem had a name, I could act. For my clients, that next step might mean medication that helps the world quiet enough for focus to return; for me, it meant treatment that transformed nights of sleepless pain into manageable aches. Their reports become roadmaps for therapy, lifestyle changes, and self-compassion. My medications and medical team now serve that same function. What has surprised me most is how much identity can settle after clarity arrives. Before my diagnosis, every new pain felt like a personal failure and an uncertain future. Afterward, the pain had context. For many clients, the same shift occurs once they see their cognitive profile on paper. The test results don’t define them; they explain them. And that explanation opens a doorway to action and grace. Across psychology and medicine, accurate diagnosis plays a vital role in restoring a sense of coherence and reducing affective load for clients. According to Merle Mishel’s Uncertainty in Illness Theory, when individuals can't make meaning of their symptoms or condition, the state of uncertainty acts as a cognitive stressor that undermines adaptation (Mishel, 1988). Her work showed that sources of uncertainty, such as unpredictable symptom patterns or lack of credible information, heighten distress, whereas diagnosis, information, and credible support help reduce it (Mishel & Braden, 1988). Integrating this lens helps us understand why the moment of diagnosis can bring relief: the internal chaos of “I don’t know” gives way to clarity and a framework for action. I’ve found deep power in my own diagnosis. I moved from fear and confusion to empowerment and strategy. My clients often describe the same trajectory: beginning the assessment process anxious and unsure, then leaving with renewed self-understanding and agency. Testing, when done with care, isn’t about assigning categories. It’s about returning people to themselves with clearer language for what they’ve already known in their bones. Diagnosis, at its best, is the beginning of understanding. When a client receives results that finally mirror their lived reality, or when a patient learns the name of what their body has been fighting, the world calms just enough for healing to begin. A correct diagnosis doesn’t change who you are; it restores faith in your own experience. It reminds you that the signals you’ve been feeling were never imagined, they were data waiting to be understood. And once they are, both clinician and client can finally meet in the same language of truth, relief, and possibility. Melanie McNally, Psy.D - blog

GLP-1 drugs affect reward circuits to reduce alcohol, opioid, and nicotine use. Key points GLP-1 drugs show potential to treat substance use disorders. These effects appear to be mediated at least in part through the modulation of reward pathways in the CNS. Early results show reductions in cravings, substance use, and other related outcomes. Glucagon-like peptide-1 (GLP-1) is a hormone responsible for most of the insulin release after consuming a meal. Its effects are mediated by activation of GLP-1 receptors (GLP-1Rs) in the central nervous system, which help regulate hunger signals that prompt people to eat when hungry and stop when satisfied (Fig. 1). The introduction of GLP-1 therapeutics has revolutionized the treatment of type 2 diabetes and obesity, with other potential indications under investigation. One such additional indication is the treatment of substance use disorder. Because reward pathways that contribute to pathological overeating and obesity are also implicated in addiction (Fig. 1), scientists have begun to explore GLP-1 therapeutics as possible treatments for substance use disorders. Early studies suggest that these drugs may lower cravings and use for alcohol, tobacco, and even opioids. These studies are described in a recent review published in the Journal of the Endocrine Society. Alcohol Studies in rodents and nonhuman primates show that the GLP-1R agonists dulaglutide, liraglutide, semaglutide, and exendin-4 reduce alcohol intake and other alcohol-related outcomes. Anecdotal evidence and pharmacoepidemiological studies in humans report reduced alcohol use by patients using GLP-1RAs for other indications. In a randomized controlled trial, the GLP-1R agonist exenatide showed reduced alcohol intake in a subgroup of people with both obesity and alcohol use disorder. More recently, another randomized controlled trial showed that a low dose of the GLP-1R agonist semaglutide reduced alcohol consumption and craving in people with alcohol use disorder. A subgroup analysis also showed a reduction in the number of cigarettes smoked per day among those individuals with alcohol use disorder who were also smokers. Opioids In animal models, several GLP-1R agonists have been shown to reduce self-administration and relapse behavior for heroin, fentanyl, and oxycodone. Two pharmacoepidemiological analyses using electronic health records have reported that use of GLP-1R agonists is associated with lower rates of opioid overdose. Tobacco Animal studies indicate that GLP-1R agonists reduce nicotine self-administration, relapse, and other nicotine-related outcomes. A study of social media posts showed that around 23 percent of posts about nicotine mentioned a cessation in use in conjunction with GLP-1R agonists. A pharmacoepidemiological study analyzed electronic health records from people with both type 2 diabetes and tobacco use disorder and found that semaglutide was associated with improved smoking-related outcomes. Results from initial clinical trials suggest that GLP-1 medications promote smoking abstinence, reduce nicotine craving and withdrawal, and prevent weight gain that frequently occurs with smoking cessation. Psychostimulants Several animal studies have shown that GLP-1R agonists reduce cocaine-seeking behavior, relapse, and other related outcomes. Other animal studies have found that GLP-1R agonists reduce amphetamine use and amphetamine-induced hyperlocomotion. Next Steps Although more research is needed to confirm how effective GLP-1 medications are in treating addiction, researchers are optimistic. "This research is very important because alcohol and drug addiction are major causes of illness and death, yet there are still only a few effective treatment options," said lead researcher Lorenzo Leggio, MD, Ph.D., of the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. "Finding new and better treatments is critically important to help people live healthier lives." Ed Ergenzinger, J.D., Ph.D - blog

Primitive fear responses can be overwhelming and can worsen anxiety. Key points Learning to assess perceived threat versus tangible threat can help us to control physical anxiety responses. Psychological threats are not necessarily soothed by animalistic physical anxiety responses. The brain can be retrained to more accurately respond to perceived danger. A woman with eyes closed, calmly enjoying sunlight When I was a social work graduate student, one of my professors had the class perform an interesting exercise. For five minutes, she instructed us to clench our fists, close our eyes tightly and sit with our muscles tensed. She then had us observe our physical and emotional feelings. After that, she had us sit for another five minutes with our palms open, our eyes closed gently and our bodies relaxed and untensed. Needless to say, there was a significant difference in the physical feelings following each exercise. Not surprisingly, after the first exercise, I noticed that I was severely uncomfortable; my body felt constricted, my heartbeat tightly and quickly, and I actually felt an overwhelming feeling of fatigue and discomfort. Following the second exercise, I felt comfortable, at peace, and relaxed. Though not scientific, this exercise was representative of the body’s fight response: In a tightened, constricted pose, we tend to feel boxed into our discomfort, like a suitcase packed too tightly or a cup filled to the very brim. When we experience anxiety, our body’s natural, automatic response is to shift immediately into a tightened, constricted state, much like an animal bearing down to protect itself from an attack by a predator. This mammalian response, though instinctual, can in fact be altered through cultivating mindful attention to the actual level of danger or threat rather than to the perceived threat. In his book, Waking the Tiger, Peter A. Levine puts it this way: “Today, our survival depends increasingly on developing our ability to think rather than being able to physically respond…the fundamental challenges we face today have come about relatively quickly, but our nervous systems have been much slower to change.” In simple terms, our world is complex and sophisticated, yet our bodies and nervous systems remain at some level, primitive and animalistic. In my book, Overcoming Panic and Panic Attacks, I explain that “our bodies, as sophisticated as they are, struggle at times to differentiate between something that might happen and something that is happening. In these moments, they elicit an emergency response by releasing cortisol, the body’s naturally occurring stress hormone.” The psychological implications of this commonly experienced confusion of true versus tangible danger include panic attacks, chronic anxiety, disruption of daily life and functioning, and avoidant behaviors. So, if the crux of the matter is that if our bodies naturally, instinctually tighten, bear down, and constrict when we perceive a threat, then the antidote is to learn how to measure these “threats” more accurately, which in turn will retrain the body’s automatic stress response. Were we to simplify things further, we might look at our lives as containing both safety and risk. A Buddhist might posit that this is, indeed, the nature of life and human experience: that two things can be true simultaneously. In some moments, we are completely safe; in others, there is risk or threat. But—and here is the larger point—the threats we face are not like those that our hominid predecessors faced: They are typically not immediate, tangible dangers such as predator attacks. They are, however, more sophisticated “threats” such as humiliation, failure, judgment by others, illness, aging, and other mainly existential threats. These are psychological, not tangible, threats and, therefore, are not necessarily soothed by an animalistic response such as tensing, gripping, or bearing down. In fact, this type of response my cause anxiety to worsen and bring about severe feelings of panic. In his book The Untethered Soul, mindfulness guru Michael A. Singer writes, “stress only happens when you resist life’s events. If you’re neither pushing life away, nor pulling it towards you, then you are not creating any resistance.” In that graduate school exercise, we practiced both pushing and pulling at life (the first exercise of tensing) and allowing life (the second exercise of sitting comfortably.) What does this look like in daily practice? One section of Peter Levine’s book is aptly titled "When the Reptilian Brain Speaks, Listen!” Translation: When we notice our bodies having an automatic response, investigate what underlies the response. For example, if I am noticing my body tightening, my heart rate quickening, and my nervous system acting up, I can consciously take a look at what is going on in my life at that moment—perhaps I am stressed at work, maybe I am tired or dehydrated, maybe I have a pending deadline or something important hanging over my head. While Levine’s reptile is unable to think this way and must simply react, humans possess the ability to be curious about the body’s response and to apply logic to physical experience. And this is how we differ from the reptile and how we can retrain the brain to not unthinkingly jump to its reptilian stress response. Using our sophisticated brains, here are a few questions we can ask ourselves when we notice our bodies entering into that tense, tight, uncomfortable state: What is my body trying to tell me? What is it responding to? What is happening in my life at this moment? What events or situations might be communicating to my body that it needs to tighten up? What is the perceived threat or danger that my body might be responding to? How can I reassure myself that I am, in fact, safe? In this moment, can I remind myself that while my body might be responding in a primitive way, this does not mean that there is an actual, tangible danger? Phil Lane, MSW, LCSW - blog

Helping college-age kids with their mental health is a balancing act. Key points Family continues to be a trusted source of support, encouragement, and guidance for college students. Normalizing common struggles—such as poor grades or homesickness—can help students transition to college. At the same time, college students need space to make their own mistakes without parental involvement. A college student Before they head off to college, families have likely played a central role in students’ lives. If there are mental health issues of any type, the family may have been even more involved. It can be difficult for anyone to switch roles. And as students begin college, the responsibility for both their education and their mental health care shifts to them. This transition can often be a challenge for parents. Yet family continues to be a trusted source of support, encouragement, and guidance. Here are some ways to balance our (formerly) tried and true way of helping our kids with what is actually more helpful for them. 1. Be clear about values. Studies show that students are influenced by their families, even though they might not show it. Inspire your student to discover what mental wellness skills work for them, and what behaviors don’t work for them, just as they are discovering what academic courses they do and don’t enjoy the most. Never forget to let your student know you care about their mental health. We often forget to say this simple but profound message. 2. Refer to campus resources. By serving as a referral source instead of trying to solve a problem for them, you show your commitment to empowering them to take ownership of solving their own challenges. You can help them without doing it for them. 3. Make a safety plan. If your student has struggled with serious mental health issues or suicidal ideation in the past, it’s a useful strategy to mutually agree upon what steps to take in response to personal red flags for their situation, such as changes in behavior or isolation. Setting up care resources on campus before classes even start is a helpful step, so that students can have a plan that is ready and actionable. 4. Normalize the struggle. Understand the normal struggles of college, so not everything is seen as a crisis. It’s pretty normal, for example, for students who were confident and successful in high school to hit some bumps once they’re surrounded by lots of other high-achieving peers. Getting an average grade for the first time, being unsure about friendships, missing home, etc., can feel discouraging or worse. Families can be helpful by reassuring students that they are on the right track. Refer them back to college resources as necessary. 5. Communicate about communicating. I recommend having a dedicated conversation about how much texting and calling they want to do. Some students love to get texts whenever, but many students can feel interrupted in their lives by getting too many texts or calls from family. Meet your student where they are at and expect many changes over the next few semesters. At the same time, a surprise care package or a favorite treat will always be appreciated. And when you do get a chance to talk or text, never underestimate how much it matters to hear that you’re proud of them—those words of encouragement carry extra weight during this season of transition. 6. Sit on your hands. Unless directly asked for advice, the best advice for parents is to “zip your lip.” Understand that your child needs the space to stumble, face setbacks, and explore their identity and beliefs. These experiences are essential for growth—they teach accountability, build resilience, and help students develop a strong sense of self. Offer support and encouragement, but trust that they have the tools and resources to find their way. 7. Be a role model. I would also argue that parents/families and loved ones of those students are crucial role models, so working on your self-care and wellness benefits not only you but your student. They are watching what you do, not just listening to what you say. By fostering open and supportive communication, you show your student that you respect their growing independence while still being a steady source of care. In doing so, you create the kind of relationship where they feel both valued and understood—and more inclined to seek your guidance when they need it most. Mia Nosanow, MA, LP - Website

How keeping the focus on yourself can transform conflict into connection. Key points When conflict arises, the impulse to focus on your partner can block self-awareness. Keeping the focus on yourself shifts attention from blame to accountability. Real repair begins when each partner takes responsibility for their own part. When couples come to us for therapy, they usually want the same thing: fewer fights, less hurt, more harmony. They imagine that the healthiest relationships are the ones with the least conflict. But that’s not how love actually works. The goal isn’t the absence of conflict (rupture)—it’s how we use the conflict to repair—create and sustain meaningful connection. In our book, Love. Crash. Rebuild, we teach every couple two unexpectedly simple rules. They sound almost too basic to matter, but if you really live by them, they can transform your relationship from the inside out: Rule 1: Keep the focus on yourself. Rule 2: Refer to Rule #1. That’s it. Just two rules that, if practiced with intention, can change everything about how you love. Rule 1: Keep the Focus on Yourself When tension rises, most of us go straight into reflex mode: “You’re making us late.” “You’re not listening.” “You always do this.” It’s a natural human response. We feel uncomfortable, and we believe—wholeheartedly—that our partner is the source of our discomfort. But when we focus on our partner’s behavior, it blinds us from seeing our own contributions to the issue at hand. Keeping the focus on yourself means pausing long enough to ask: What’s happening in me right now? How am I feeling right now? Is this feeling intolerable to me? What am I afraid of, defending against, or needing? It’s not self-blame—it’s self-awareness. And it’s the foundation for real accountability. Example: The Time Cop This one’s personal. I (Mark) have what Haruna affectionately calls my “time cop” mode. I get anxious about being late—whether it’s to a punk show, the opera, or a dinner reservation. If I sense we’re running behind, something in me tightens. I start pacing, muttering about when we need to leave, convinced that every lost minute means disaster. And then, predictably, I’ll say something critical—“Do you have to change your shoes again?”—which immediately changes the mood. Now we’re not talking about time anymore. We’re in a power struggle about respect, control, and who’s right. When I catch myself and come back to Rule 1, I start to notice what’s really happening: I’m anxious. I feel out of control. I’m scared of missing something I’ve been looking forward to. When I can own that instead of projecting it—“I’m feeling wound up about being late”—the energy between us shifts completely. Haruna can respond with empathy instead of defensiveness: “I get it. You hate rushing. I’m almost ready.” The moment I turn the focus inward, the rupture begins to transform—initiates the process of repair. Rule 2: Refer to Rule 1 That’s the whole thing. There isn’t another rule. Every time you forget Rule 1—and you will—come back to it. It sounds almost silly, but it’s not. It’s a commitment to self-reflection even when you’re convinced your partner is wrong. In our marriage, we still use this rule constantly. When one of us starts veering into “you” territory, the other might say, with some degree of humor, “Hey—Rule 2.” It’s not a jab; it’s an invitation. It’s a reminder that the moment we start blaming each other, we’ve already left the road of repair. Not to mention, also giving up our power to contribute to the solution to whatever problem we are having. Example: The Unanswered Text Once, after a long day, Mark texted me (Haruna) asking what time I’d be home. I saw it, got distracted, and forgot to reply. By the time I walked in the door, he was irritated: “You never answer when I text you!” I immediately went defensive: “I was busy! Why are you making such a big deal out of this?” Classic rupture. Later that night, after we both cooled off, I realized I’d missed my own cue to apply the rules. I had made it about his tone instead of my impact. When I went back to Rule 1, I saw what had happened: his message had triggered my guilt—I knew I’d dropped the ball. The next morning, I said, “You were right. I ignored the text and didn’t own it. I think I felt ashamed.” His shoulders relaxed instantly. He said, “I wasn’t angry about the text. I just felt ignored.” That was repair. Not because we avoided conflict, but because we used it. Why It Works The two golden rules may sound overly simple, but they go to the core of what makes relationships thrive: personal responsibility and emotional awareness. When both partners stay focused on themselves, neither has to be the villain. Each person stays accountable for their own feelings and actions. The argument stops being a tug-of-war and becomes a shared inquiry: What’s really happening here? These rules turn conflict into a classroom. Every rupture becomes a chance to learn—not just about your partner, but about yourself. Mark B. Borg, Jr, Ph.D., and Haruna Miyamoto-Borg LCSW - Blog, Website

How alcohol fuels the social anxiety cycle—and what to do instead. As the cold beer ran down my throat, the sharpness of my self-conscious thoughts started to lose its edge. The conversation started to flow, and the laughter became easier. The first time I discovered the social lubricant magic of alcohol was at a high school party. The music was loud, and I was anxious. A friend handed me a beer; told me it would help me loosen up. And it did. From then on, I learned to turn to alcohol for a little confidence boost every time the discomfort of social anxiety rises. Why Alcohol Feels Like a Quick Fix for Social Anxiety I am far from the first one who discovered alcohol’s “confidence boost” effect. The fermented juice has long been thought of as a social lubricant for a reason. Acting as a central nervous system depressant, alcohol temporarily eases anxiety by slowing down brain activity, boosting GABA release to prompt calming effects, and shutting off glutamate to lower inhibition. To put it simply, the depressant effect of alcohol does calm the nerves and make socializing seem smoother in the moment. However, it comes with a catch. Alcohol’s help often comes with a hidden fine print in its cost. The Hidden Cost of Alcohol’s “Anxiety Relief” Effect Like a high-interest debt, alcohol offers us the immediate reward with delayed interest. When it comes to its “anxiety relief” effect, the delayed interest is an intensified anxiety cycle over time. Using alcohol to cope with anxiety is essentially a form of avoidance. Numbing up mentally allows us to avoid facing what scares us. While the anxious thoughts magically dissipate, we are left with an unfortunate confirmation that whatever we just avoided—making small talk with a colleague—is indeed dangerous. In CBT, avoidance behaviors are called “anxiety fuel,” as they deny a person the opportunity to sit through their fear and discover that they are actually safe. (Yes, 99 percent of our anxiety, as catastrophic as it may feel, is, in fact, survivable.) Without these opportunities, the anxiety continues to run wild. When facing a similar situation, the internal alarm system screams “danger” even louder. In other words, avoidance behaviors help brew the perfect breeding ground for anxiety to persist and grow. From Confidence Boost to Crutch: The Social Anxiety Drinking Loop That’s why, although alcohol seemed to be a perfect solution for social anxiety at first, over time, one may find they become more and more reliant on alcohol. Toward the end of my drinking career, I found myself heading to the bar the first thing whenever I arrived at a party, barely saying hi to my friends. Sometimes, I would even have a drink or two before leaving home, just to “loosen up” ahead of time. I call this the social anxiety drinking loop. When the need to ease anxiety meets the belief that alcohol can help calm the nerves, and drinking becomes the default coping method, a person becomes trapped by the limiting belief that “I need a drink to survive this social event.” The 10-Minute Rule: A Practical Tool for Alcohol-Free Socializing The only true way to overcome anxiety is by facing what one fears. Anxiety is fueled by the anticipation that something unbearable will happen. In our mind, we fear that if we stay, the anxiety will keep climbing until it blows through the roof and then comes the irresistible urge to do anything to avoid what is about to happen. But the truth is, while the peak of anxiety might be high, it’s also a skinny little thing. Once we reach the peak, it doesn’t keep climbing. Instead, it goes over the top and quickly starts to descend. In fact, most peaks last about 10 seconds to a minute. The best part is that once you get over the top, each time you face a similar situation in the future, the peak will become lower and lower. That’s why I love the 10-minute rule. Make small talk with your coworker for 10 minutes and talk about last night’s game or the weekend plan. Setting a time limit helps calm the anxious anticipation of “this is going to last forever.” As life-threatening as those first minutes might feel, I have never heard of anyone dying from striking up small talk. The 10-minute rule gives your brain an opportunity to discover that what you fear is actually a false alarm, and the alarm may start to lower its volume and shorten its length. Jeanette Hu, AMFT - Website

How memory gaps may affect relationships for people with BPD. Key points Gaslighting increases the instability of relationships where one or both parties has BPD. The symptom of paranoia may cause those who dissociate to see others as gaslighting them. To avoid gaslighting, it is suggested that loved ones not challenge accusations based on BPD-related dissociative memory gaps. Gaslighting is a form of emotional abuse in which efforts are made to make someone feel crazy for believing what's true. When successful, it undermines a person’s self-confidence and weakens their ability to function, making them more vulnerable to manipulation and control by others. Gaslighting is by no means unique to individuals with borderline personality disorder (BPD), but certain symptoms make it more likely for people with BPD to feel gaslighted by others and create circumstances where others feel gaslighted by them. Dissociation Many individuals who cope with symptoms of BPD experience periods where they become less aware of their surroundings while they become inwardly focused or non-focused. Dissociation is also common in other disorders, most notably posttraumatic stress disorder and dissociation disorder, where it is a primary symptom. While experiencing these periods of reduced awareness of their environment, individuals miss events and conversations or parts of events or conversations, resulting in gaps in their recollections. Through the unconscious process of confabulation, they often fill in the gaps with things that might have happened or were said, resulting in a distorted memory of events. When discussing these events with others present, there is often disagreement about the details, resulting in conflict. Following is an example where dissociation resulted in distortion and the experience of gaslighting. Zina: What kind of friend are you? I told you I wasn’t feeling well, and you didn’t even call. Gary: I called you yesterday. Zina: I don’t remember anybody calling me yesterday. Gary: You told me that you were exhausted, and then you went to bed. Zina: Liar. Don’t play with me. Gary: I'm not playing with you. We had a conversation. Zina: Either you're crazy, or you're gaslighting me. Zina did not remember Gary calling. She felt gaslighted because she thought he was lying to make up for not checking in on her while she was sick. And Gary, in turn, ended up feeling gaslighted by her too, because he clearly remembered their conversation, but she wouldn't acknowledge it. The tendency to dissociate is increased in those prone to it by fatigue and/or sickness, weakening cognitive abilities. Zina might have entertained the idea that Gary called her and she had forgotten, but she may also be coping with paranoia, another symptom of BPD. It causes her to choose the most malignant explanation when in doubt. Unstable Relationships Zina’s view of Gary quickly changes from someone close and capable of caring and affection to a liar who doesn’t care about her and gaslights her as an excuse for his neglect. A core symptom of BPD is a pattern of unstable relationships associated with alternating between idealization and devaluation. In the above example, Zina began with an idealized version of Gary—that he will dote over her, especially while she is sick—which led to her being disappointed by his not being as present as she would have liked. Her experience of disappointment was followed by devaluing him. Her behavior towards him changed from receptive and encouraging to aggressive and accusatory. This made her more likely to feel gaslighted and to gaslight Gary, in return a pattern that further destabilizes the relationship. Chronic Emptiness and Fear of Abandonment Several symptoms of BPD increase the likelihood that the affected person and those around them will experience gaslighting in some form or another. The chronic feelings of emptiness and fear of abandonment that most affected people experience predispose them to view communications with people they are close to as either reassuring of the attachment or evidence of abandonment or impending abandonment. In this example, the dissociation—as a symptom of BPD—set up the gaslighting. Once this spark is ignited, other symptoms of BPD make the experience and the relationship worse. BPD is a perfect storm for introducing gaslighting into relationships. Ideally, individuals with symptoms of BPD can learn to accept that they dissociate at times and that this can leave gaps in their awareness and memory. Knowing this can mitigate the paranoid bias and decrease both the experience of feeling gaslit and the volatility of relationships. Unfortunately, many individuals with symptoms of BPD do not acknowledge these symptoms as doing so makes them feel flawed. This tends to add to the tendency to see other people as gaslighting them and makes them generally untrusting. What Loved Ones Can Do People whose loved ones have symptoms of BPD should understand that gaps in memory associated with dissociation are a frequent source of gaslighting and note that their loved one is not deliberately trying to make them feel crazy. Rather, they are searching for an explanation for a memory gap that they are not even aware exists. Trying to correct the memory gap of a person with BPD who dissociates is generally not recommended. They may see acknowledging that they have gaps as admitting that they are flawed, which often increases feelings of self-loathing. Trying to make these corrections typically results in the angry and defensive reaction that Gary experienced. To avoid gaslighting, it is suggested that you not challenge accusations based on gaps. A better outcome will be achieved if you validate their feeling. You should never validate an untrue fact, but you can validate the feeling. For example, Gary might have said to Zina: “I understand that you're disappointed that I didn’t contact you more while you were sick. In the future, I'll try to do a better job of being more attentive.” This allows Gary to authentically validate her feelings and address them appropriately without forcing her to accept that she had a gap in memory that was confusing to her. It spares her shame, and this will benefit the relationship. Daniel S. Lobel, Ph.D. - Website

Eye-level view of a couple sitting together in a cozy living room, discussing their future plans Marriage is a big step. It brings two lives together in a way that changes everything. But before saying “I do,” many couples overlook one important step: couples counseling before marriage. This kind of counseling helps couples build a strong foundation for their life together. It’s not just for couples who have problems. It’s for anyone who wants to start their marriage with clear communication, trust, and understanding. Taking time to work on your relationship before marriage can save you from future struggles. It helps you learn about each other’s needs, expectations, and ways to handle conflict. In this post, I’ll share why couples counseling before marriage is so important, what you can expect, and how it can make your relationship stronger. What Couples Counseling Before Marriage Can Do for You Couples counseling before marriage is a chance to explore your relationship with the help of a professional. It’s a safe space where you can talk openly about your feelings, hopes, and worries. Here are some key benefits: Improved Communication Many couples don’t realize how differently they communicate until they face challenges. Counseling teaches you how to listen and express yourself clearly. You learn to avoid misunderstandings and speak in ways that bring you closer. Understanding Expectations Everyone has ideas about marriage, roles, money, family, and intimacy. Counseling helps you share these expectations honestly. You can find common ground or agree on how to handle differences. Conflict Resolution Skills No relationship is without conflict. What matters is how you handle it. Counseling shows you healthy ways to solve problems without hurting each other. You learn to stay calm, respect each other’s views, and find solutions together. Building Trust and Emotional Safety Trust is the heart of any marriage. Counseling helps you build trust by encouraging honesty and openness. You create a safe emotional space where both partners feel valued and supported. Preparing for Life Changes Marriage brings many changes, like combining finances, living together, or starting a family. Counseling helps you plan for these changes and face them as a team. How to Choose the Right Counseling Service Prioritize Specialized Training General therapy and couples counseling require different skill sets. Look for practitioners specifically trained in evidence-based modalities like Gottman Method Couples Therapy or Emotionally Focused Therapy (EFT). These frameworks provide structured tools for de-escalating conflict and rebuilding emotional safety, moving beyond simple "venting" sessions. Verify Neutrality and Fit A successful counselor must remain a neutral third party. During an initial consultation, assess whether the therapist can balance perspectives without taking sides. You should both feel equally heard and respected. If one partner feels "ganged up on," progress will likely stall. Practical Considerations Logistics: Determine if you prefer the convenience of telehealth or the traditional setting of in-person sessions. Availability: Consistency is key. Ensure their schedule aligns with both of your peak energy times to avoid "therapy fatigue." Goals: Discuss whether you are seeking long-term maintenance, crisis intervention, or discernment counseling. Ultimately, trust your collective intuition; the "therapeutic alliance" is one of the strongest predictors of a successful outcome. What to Expect During Couples Counseling Before Marriage If you’re new to counseling, you might wonder what happens in a session. Here’s a simple overview: Initial Assessment The counselor will ask about your relationship history, goals, and any concerns. This helps them understand your situation. Setting Goals Together, you’ll decide what you want to work on. It could be communication, trust, or planning for the future. Learning Skills You’ll practice new ways to talk, listen, and solve problems. The counselor guides you through exercises and discussions. Homework and Practice Often, counselors give you tasks to try at home. This helps you apply what you learn in real life. Regular Check-ins You’ll meet regularly to track progress and adjust your goals as needed. Counseling is a process, not a quick fix. It takes time and effort, but the rewards are worth it. Close-up view of a notebook and pen on a table during a counseling session Real Stories: How Counseling Helped Couples in Houston I’ve seen many couples who thought counseling was only for problems. But they found it helped them grow closer and feel more confident about their future. Here are two examples: Sarah and James They had different ideas about money and family roles. Counseling helped them talk openly and find compromises. Now, they feel more connected and ready for marriage. Maria and Luis They struggled with communication and often misunderstood each other. Through counseling, they learned to listen without judgment and express their feelings clearly. Their relationship became stronger and more joyful. These stories show that counseling is not about fixing something broken. It’s about building something better. How to Start Couples Counseling Before Marriage Starting counseling is easier than you might think. Here are some steps to help you begin: Talk with Your Partner Agree that counseling is a positive step for your relationship. Research Local Services Look for counselors who specialize in premarital work and have good reviews. Schedule a Consultation Many counselors offer a first meeting to see if you’re a good fit. Commit to the Process Be open, honest, and willing to learn. Remember, counseling is an investment in your future together. High angle view of a couple holding hands while walking in a park Final Thoughts on Preparing for Marriage Marriage is a journey that requires care and attention. Couples counseling before marriage offers a chance to start that journey with confidence and understanding. It helps you build skills that will support your relationship through good times and challenges. Your relationship deserves the best foundation. Counseling can help you create it!