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.

Setting the (police) record straight. People experiencing psychosis are still capable of accurate memory. Discounting the recall of people who experience psychosis leaves them vulnerable to ongoing abuse , violence. Revisiting experiences of psychosis can be empowering and validating. “If I correctly fill out Joe Biden’s 2020 cabinet, will you let me go?” I ask. It’s 12:45 a.m. on February 16, 2019, and I’m handcuffed and kneeling on the ground of the second-floor lobby at the Warfield Theater in San Francisco with a police officer ’ s hand firmly on my back. “How about Corey Booker as Attorney General?” The police officers ignore me. “Are you guys strippers?” “Ma’am, you’re being placed under arrest for theft .” “Theft? You mean because I didn’t ask my mom first before I borrowed her shoes? She wasn’t home!” Years later, on October 21st, 2021, I read the report the police officers wrote of our encounter during my first severe manic and psychotic episode. One paragraph in particular stood out: Littlefield appeared to be under the influence of unknown type of narcotic. Littlefield would make nonsense remarks, then attempt to leave, then would complain about the 2016 election and the state of U.S. politics and other topics. Littlefield did not appear to understand that she was being placed under arrest but did admit she was wearing her mother’s sandals. These are the most validating words I’ve ever read in my life. When I tell the story of that night—the story of breaking into houses, of climbing on top of cars, of getting tackled by police officers—people often ask me, in disbelief, “And you remember all of that?” As though my brain completely broke when I was in psychosis. As though I were incapable of logical thought, reason, and encoding memories. As though, on some level, I ceased to be a person and became nothing but a mental illness. My dehumanization was reinforced by all the doctors who dismissed me, who talked to me like I was five and incapable of any complex cognitive process. All just because I believed a team of psychologists had assumed control of my life and was experimenting on me against my will. I think that’s why I wanted to obtain my police records. I wasn’t sure what I was looking for or what I’d find. But I had to know what really happened. I had to know whether my memories matched everyone else’s reality. I had to know if I was crazy after all. I was scared to read the report. What if it contained stigmatizing language that mirrored the worst of my internalized ableism, born out of my diagnosis of schizoaffective disorder , bipolar type? What if the narrative of the report was completely off-base from my memories, in which case I’d have to admit my brain had essentially ceased to function during psychosis? I had my mother read the report first so that she might soften the blow in case any of the above came to fruition. But when she called me after I sent it to her, she told me it was fine–humorous, even, which goes to show the enormous amount of privilege I exuded in this situation as a white woman. Moreover, she told me, “It was pretty much what you told me happened during the conversation we had when you were in the psych ward. Save for the part about the psychologists, of course.” I let out a deep, cathartic breath, hung up the phone, and opened the file that contained the police report. And there it was—proof that my account of the night was valid. As I read the police officer’s notes from his interview with the woman whose backpack I stole, I remembered how I found the backpack inside a janitor’s closet at the Warfield. A woman had exited the small, inconspicuous door, looked me in the eyes, and winked and smiled at me. Surely, it was a sign from the psychologists. So maybe the psychologists never existed. Maybe the signs I thought were their breadcrumbs guiding me on a wild adventure through the streets of San Francisco were actually just run-of-the-mill, everyday objects. But everything else about my memories of that night, from the blue Jacksonville Jaguars beanie I’d found in the backpack, to their obsession with my mother’s shoes, to my rants about U.S. politics, was real. This police report documented it all. I always had a hunch that my memory of that night held up better than most people thought, but for years, others’ skepticism about my account of the night in question had slowly eroded my confidence that ‘Psychosis Sally’ had been capable of encoding actual memories. Even in psychosis, as my mother confirmed, I was still able to give an accurate account of the events that transpired, even if it was through a fictitious lens of an all-consuming psychological experiment. And this police report proved it. People experiencing psychosis are still capable of logic, of feelings, of love, and, as it turns out, of accurate memories. There’s something at stake here that’s bigger than just my personal, vindictive desire to prove wrong all those people who doubted the validity of my memories of that night. If we brush off the memories of people experiencing psychosis—if we don’t believe their accounts of what they experience—then what happens when their recall is also the only avenue to safety? It devastates me to think about all the people who experience ongoing abuse, violence, and crimes who aren’t believed because we as a society don’t trust the accounts of those who break from reality. I am more than my mental illness, both now and when I was in active psychosis. I was and am a person capable of the full spectrum of thought, emotion, and, it turns out, memory. It’s time we set the record straight: People experiencing psychosis are still people. Let’s give their accounts and perspectives the weight they deserve. Sally Littlefield - Website - References Copyright Sally Littlefield

How to understand narcissistic traits and tendencies in children. High-achieving child narcissists cope with narcissistic vulnerability through exceptional performance. Child bully narcissists have an underlying “mean streak” that they exercise in controlling others. Manipulative child narcissists use others to achieve their goals, often without regard for their feelings. It is hard to imagine that your precious youngster could be developing in such undesirable ways that they would be considered a narcissist . However, children can reveal certain tendencies and traits that indicate they are on the path to a narcissistic disorde r . Technically speaking, a narcissist cannot be diagnosed until the age of 18; however, specific attitudes and behaviors that presage narcissistic personality disorder (NPD) may be evident earlier. Even so, it is essential to realize that narcissism looks different in an adult than in a child . How to Spot an Adult Narcissist This list isn't exhaustive, but it's a good starting place. A narcissist: needs recognition. believes they're special. overestimates their skills and abilities. thinks far too highly of their own opinion. needs to be "right." lacks interest in things that do not involve the self. becomes overly sensitive to real and perceived slights. idealizes or devalues others. expects special treatment. makes unrealistic demands. maintains superficial and exploitative relationships. fails to take responsibility for their behavior. blames others for errors and misunderstandings. lacks empathy Two major types of narcissists are recognized in adults: vulnerable and grandiose. The vulnerable narcissist presents as more anxious, worried, and sensitive to criticism and is often high achieving. The layperson less frequently recognizes this variety of narcissists. The grandiose narcissist, on the other hand, is earlier to spot, tending toward flamboyant, charismatic, controlling, and manipulative behavior. This second type can be popular, socially prominent, and perceived to be a leader while at the same time being mean-spirited and interpersonally exploitative. Grandiose and vulnerable narcissists don't present the same way, which explains why so many people don't recognize that both these types are suffering from the same negative core qualities of self-centeredness, a sense of entitlement, and a lack of empathy. They also suffer the same negative outcome of problematic and impoverished interpersonal relationships. What a Child Narcissist Looks Like Identifying narcissism in children, rather than adults, is complicated. Emerging child narcissists (N2Bs, or narcissists-to-be) come in all sizes and shapes—or so it seems. While such children generally fall within the broad categories of vulnerable or grandiose, several subtypes within each can be identified. The wide range of types can be challenging. 6 Presentations of Emerging Child Narcissists-to-Be 1. The High Achieving Narcissist (coping with narcissistic vulnerability through winning). High-achieving narcissists cope with their narcissistic vulnerability through exceptional performance. They must be the best or practically perfect in every way. The effort they put into achievement often has a maniacal quality. They work harder because they must perform and be better than everyone else. Areas of exceptionality vary, but these children make straight A's or are the teacher's pet. High-achieving narcissists are the kids most challenging to diagnose as their perfectionistic performance masks any underlying deficiencies or distress. It is important to emphasize that the diagnosis of a high-achieving narcissist is not based on their exceptional performance but rather on what drives the need to achieve. 2. The Non-Achieving Narcissist (coping with narcissistic vulnerability and fear of failure through avoidance). Non-achieving narcissists are the children who value recognition and attention but have been unable to achieve their lofty goals. Frustrated and hurt by their underachievement, they cope through avoidance. Some withdraw from the competition and display a "don't care" attitude. Others will act out in maladaptive ways, trying to get attention through misbehavior or risk-taking. All have given up on the idea that they can succeed in a way that wins recognition and positive regard. 3. The Bully Narcissist (coping with narcissistic vulnerability and values through unchecked aggression). Bully narcissists have an underlying "mean streak" that they exercise in controlling others. They abuse others socially through exclusion and physically through ridicule and teasing, which can turn into hazing in young adulthood. Some are the "queen bees" and the most popular boys on campus. They often mediate inclusion and exclusion in social groups without regard for fairness or honor, with a concern only for their power. Often charismatic and likable, their flaws are difficult to see. Their social skills are strong, so their misbehavior can be hard to catch. 4. The Daredevil Narcissist (coping with narcissistic vulnerability through unchecked grandiosity). Daredevil narcissists are youngsters whose grandiosity has not been softened through the years. In the school-aged years, their grandiosity can be seen in eye-catching clothes or schoolyard feats like riding a bike alarmingly fast down a steep hill. In older children, they can engage in risky behaviors that range from drug or alcohol abuse to dangerous driving and sexual promiscuity. Lack of good judgment is their fatal flaw. 5. The Closet Narcissist (coping with narcissistic vulnerability through association with a narcissist). Closet narcissists do not look like narcissists at all. Aware of their narcissistic vulnerability, they cope by aligning with a powerful narcissistic friend or classmate, basking in the reflected glory they experience from the relationship. Content with attaching to an exhibitionistic or achieving narcissist who has high social value, they are often compliant and ingratiating, working to find a place near the throne of their popular high-status peer. 6. The Manipulative Narcissist (coping with narcissistic vulnerability through the exercise of power, getting one's way). The manipulative narcissist is intent on getting their way. Manipulative narcissists use others to achieve their goals, often without regard for their feelings. Their self-validation comes through wielding power and their ability to control others and the environment. Some manipulative narcissists are gifted leaders who can influence groups to reach higher, more expansive goals, and this type of narcissist often seeks political or other high-status positions. In childhood, some may earn a place on the student council or be elected team captain. Others have an antisocial component, which means they tend to be dishonest or live outside the rules. In childhood, that may mean they steal pencils from the school store or take desired items from a classmate's backpack. Many manipulative narcissists come from families of wealth, prestige, and power. Parents and educators need to realize that the development of narcissism begins earlier than you might think and that understanding the variety of "childhood types" is critical. Hard as it might be to believe, a narcissist who fits the more nerdy, perfectionistic valedictorian category has the same psychological structure as the narcissist who presents as the popular football captain with controlling, manipulative, and bullying behaviors. The good news is that recognizing narcissistic tendencies and traits earlier—rather than later—provides more opportunities to get a child back on course. Early intervention not only makes correction easier but produces far better outcomes. Mary Ann Little, Ph.D., - Website - Book -

Lessons for today from the last 50 years. The American Psychiatric Association deleted homosexuality from the DSM 50 years ago. The process triggered intense debate that research, allies, and activists successfully addressed. Recently, governments in the U.S. and elsewhere are considering record numbers of anti-LGBTQ+ laws. The successes 50 years ago offer vital lessons in how to combat these anti-LGBTQ+policies today. “The normal outcome of male adolescent development is heterosexuality,” a child psychiatry professor told other trainees and I in 1989, during our residency education. “What if you’re gay?” a fellow trainee asked. The professor frowned. “The normal outcome of male adolescent development is heterosexuality,” he repeated with annoyance. I was stunned because 16 years earlier, in 1973, the Board of Trustees of the American Psychiatric Association (APA) had, in fact, deleted homosexuality as a psychiatric condition from the Diagnostic and Statistical Manual, or DSM, the book that dictates what constitutes a mental health disorder. “Just because homosexuality is no longer a disorder,” the professor continued, “doesn’t mean it isn’t a symptom.” To him, it was still pathological. “Why is it so bad?” my fellow resident inquired. “Homosexuality is a disease because it has an increased risk of morbidity and mortality,” due to AIDS. “Anything with an increased risk of morbidity and mortality is a disease.” “But isn’t that partly because it has been seen as a disease? Because it is stigmatized?” the trainee asked. “Mothers would not want their children to be born that way,” he said. “Why would you want your child to differ from others in a way that will induce ridicule?” “What about left-handedness then?” the trainee pursued. “Shouldn’t that then be a disorder, too?” The professor became irate. “Why are you being so recalcitrant and resistant?” he demanded. His voice rose. The resident decided not to push, I have recently been thinking about this interchange for two reasons. First, over the past year, states are now passing record numbers of anti-LGBTQ+ bills, along with anti-abortion laws. Secondly, this year marks the 50th anniversary of the APA’s Board of Trustees historic decision on December 15, 1973. This anniversary marks an important moment for reflecting on how far we have come as a nation, but also how far we still have to go, and for assessing what insights and lessons we might learn about progress in these battles and overcoming obstacles. Despite support on certain issues from the Pope and others, in 2023, state legislators introduced over 520 anti-LGBTQ+ bills and enacted over 70. Large numbers of congregations are leaving the United Methodist Church and other denominations over LGBTQ+ issues, the Supreme Court allowed a website designer to refuse gay couples as clients and hate crimes against LGBTQ+ individuals continue to rise. The spread of such anti-LGBTQ+ policies increasingly frustrate and depresses many members of the LGBTQ+ community. The example of the APA is thus important, both to inspire us that change is possible and to remind us of barriers that can arise and ways of surmounting these. The APA’s decision, occurring just four years after the Stonewall Riot, required courageous, concerted efforts by allies, both LGBTQ+ and straight. Since 1918, the APA had classified all homosexuality as a “disorder,” justifying so-called conversion therapy and discrimination in countless areas of life, preventing LGBTQ+ individuals from working in schools, the military, and innumerable jobs. Slowly, scientific data helped begin to alter attitudes. In 1948, The Kinsey Report found high rates of LGBTQ+ activity among Americans. In the 1950s, the psychiatrist Evelyn Hooker began to meet with and publish studies about gay men who were not patients seeking psychiatric treatment and were instead well-adapted and satisfied with their sexual orientation. Still, despite these scientific facts, psychiatry continued to categorize homosexuality as a disease. Hence, in 1971, gay activists snuck into the annual APA convention and directly confronted psychiatrists who supported this classification. Only after these activists threatened to confront speakers again at the following year’s annual convention did the APA agree to invite gays and lesbians to speak on a panel. In 1972, this panel included, for the first time at an APA meeting, a self-identified gay psychiatrist. Yet he appeared only as “Dr. Harry Anonymous,” and wore a crude cartoon-like paper bag mask over his head to disguise his identity. Today, this protective measure sounds absurd, but it reveals the depth of the discrimination and fear at the time. Only several years later did Dr. Anonymous publicly reveal his name—John Freyer. The following year, in 1973, APA Trustees cast their historic vote. Heralded on the front page of the New York Times and major newspapers, this decision aided millions of people throughout the U.S. and abroad, leading state governments to eliminate sodomy laws and prompting other professional and religious organizations to end discriminatory policies. Nonetheless, other psychiatrists continued to fight the Trustee’s decision, arguing that it occurred only under pressure from gay rights groups. Opponents demanded a referendum on the entire APA. Such a vote was unprecedented, but the Trustees agreed, and the membership referendum passed, in 1974, by 58 percent, a decisive majority. Some then demanded an investigation into the conduct of the referendum—asking whether a flyer sent to members and paid for by a gay organization had been “unethical.” An APA committee determined that the sponsorship should have been clearer but was not unethical. Yet, as I witnessed during my own training, homophobia persisted in psychiatry into the 80s and 90s. Gradually, through these years, additional LGBTQ psychiatrists spoke out and made themselves known, at times risking their careers. Eventually, resistance abated. In responding to current political threats against the rights of LGBTQ+ Americans, the APA’s decision offers critical lessons. First, it used scientific data, demonstrating that the supposed harms of heterosexuality were largely illusory. Secondly, it took courageous individuals to step forward to engage opponents and tell their stories in panel discussions before wary, if not hostile, audiences. Thirdly, it required hard work and allies, including researchers and APA leaders from both inside and outside the LGBTQ community. Fourthly, this change took time, occurred slowly, and met resistance. In today’s battles, anticipating a realistic timeline can help set appropriate expectations. Fifthly, it took brave activism and non-violent protests, following the examples of peaceful marches for civil rights. When other psychiatric trainees and I heard our professor’s homophobic comments, we were unsure how to respond. Yet, history has shown the problems and errors of psychiatrists' homophobic arguments. Especially given our nation’s current challenges, we should remember and celebrate the APA’s decision and how far we have come since then, and recall the courageous psychiatrists and others who fought, spoke out, and ultimately succeeded. Though restrictive policies are increasing in many realms, progress, even if it meets resistance and takes time, can ultimately succeed. Robert Klitzman, M.D.,

5 tips to stop the time warp. People with ADHD frequently experience a warped perception of the passage of time known as time blindness. People may mistakenly label those with ADHD as unprofessional due to symptoms such as running late. Strategies to cope with time blindness include time logs, planners, and harnessing the tendency to hyperfocus. Do you have ADHD and feel like you are constantly losing track of time? If so, you might be experiencing time blindness, or a warped perception of the passing of time. While time blindness is not listed as an official symptom of ADHD in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it is a common experience for those with ADHD. Usually, people can sense what time it is and how much time has passed using environmental elements like light and sound. Time blindness occurs when the process of perceiving time is disrupted. People with ADHD often struggle with estimating how much time has passed and how much time there is before an event (perceiving time), recounting the order of when events occurred (time sequencing), and replicating a task that has occurred previously in the same amount of time (time reproduction). In German studies on children with ADHD, researchers found that children with ADHD overestimated or underestimated the amount of time that had passed to a much greater extent than children without ADHD. While the reasons behind time blindness are not fully understood, ongoing research is being conducted on the potential mechanisms. One study found that when performing tasks in studies that are perceived as uninteresting or repetitive, participants with ADHD tend to perform worse than participants without ADHD. However, participants with ADHD tend to be quicker at detecting emotionally relevant or situational stimuli than participants without ADHD. While intense emotions can disrupt cognitive functions for people without ADHD, these intense emotions might be what people with ADHD need to perform cognitive functions effectively. In a study comparing the perception of time on neutral and emotionally charged tasks, they found that while participants with ADHD performed poorer than those without ADHD on neutral time perception tasks, they outperformed them on emotionally charged time perception tasks. The findings of this study suggest that time blindness could be connected to attention, emotion, and motivation. Recent research has also linked time blindness with dopamine deficiencies, and dopamine boosters like stimulant medication and monetary rewards can improve time perception in those with ADHD. One study on the influence of medication found that children with ADHD who took medication performed better than those who did not take medication, even when distractions were added to the experiment. Similar results were found when participants were offered monetary rewards for tasks in studies. While everyone runs late occasionally or loses an hour scrolling on social media, time blindness impacts the lives of people with ADHD every day. Time blindness can lead people with ADHD to repeatedly miss deadlines, arrive late even for events they are excited for, lose track of time constantly, have difficulty making and/or sticking to a schedule, experience slow reaction times, and have difficulty regulating their speed of movement. Some of these effects, like running late and missing deadlines, can lead people to view those with ADHD as unprofessional or lazy, but really, they just perceive time differently. How to Cope with Time Blindness So, how can those with ADHD cope with time blindness? Listed below are multiple methods recommended to those with ADHD to improve their focus and accommodate their time blindness. 1. Time Logs: One recommendation for those with ADHD is to time how long it takes for you to complete the tasks you perform in your daily life or that you need an accurate perception of time for. Even though the exact amount of time it takes to complete these tasks can change on a day-to-day basis, it can help people with ADHD gain a better idea of how long it generally takes them to complete the task. 2. Pomodoro Method: The Pomodoro Method is a technique used for studying and completing work tasks. With this method, you set a timer for 25 minutes and work on one task until the time is up. Once the timer goes off, you can take a 5-minute break before returning to your task for another 25 minutes. This pattern of working for 25 minutes and then taking a 5-minute break is repeated until the task is complete. Every fourth round, you can take a longer break, like for one hour. By committing to brief periods of focus, this technique can help people stay on task and avoid taking longer breaks or procrastinating. Another benefit of this method is that it is easily customizable. If you are working on a task that is more mentally draining or you are struggling to focus, you can set a timer for 15 minutes of work time and take a 2-minute break. 3. Timers: Similar to the use of timers in the Pomodoro Method, it can be beneficial to set timers for any activity where you might get lost in time. Setting a timer in advance can help pull you back, remind you to check the clock, and help you externalize how much time has passed. With tasks like cooking, setting a timer before leaving the kitchen will remind you to check on your food and prevent you from overcooking your meal or having your water boil over. With activities like scrolling through social media, setting a timer for a set amount of time will ensure you don’t spend hours doomscrolling on TikTok. Timers can also be used to help prevent you from losing hours to a single task or remind you to eat lunch. Sometimes when a timer goes off, you can ignore it and forget. To overcome this, try setting multiple alarms. If you struggle with leaving on time, you can set one for 15 minutes before and another for 5 minutes before, that way you don’t lose track of time between timers. If you have a difficult time visualizing the passing of time with a timer on your phone, you can use a digital timer that changes color or an hourglass where you can see the sand slip through. 4. Planners: While some with ADHD struggle with planners, they can help others with ADHD visualize what they need to do and how much time they have before a deadline. For a big project, you can use a planner to work backward from a due date, dividing the project into smaller chunks with their due dates. Another way to use planners is to divide a day into chunks and mark out times that you can work on homework or a big project. Using a planner can help you plan things in advance, but it can also help you feel accomplished and more motivated by checking off the tasks listed on paper. 5. Time-Warp Activities: While people with ADHD sometimes have trouble focusing, the opposite can be a problem as well. When a topic or activity particularly interests someone with ADHD, they can hyperfocus or have long-lasting episodes of highly focused attention. Hyperfocus can be beneficial in some situations but can lead to more time blindness. It can be helpful to schedule a time to engage in these “time-warp activities” so that you don’t miss a deadline or event. Kathleen Bogart, Ph.D., and Mollie Greenblum - Website - Mollie Greenblum is an alum of Dr. Bogart’s Psychology of Disability class. She recently graduated from OSU's Honors College with a B.S. in Psychology.