Chronic stress breaks down your body and creates illness and disease. Chronic stress causes flight or fight physiology, which creates symptoms, illnesses, and disease. Lowering stress chemistry and increasing safety improves quality of life and allows healing. The focus is on gaining expertise to process stress, not "fixing it." Each of us has been given a profound gift – life. The meaning of life has been the focus of endless philosophical discussions ranging from life having no meaning to being connected to each other and the universe through deep spiritual bonds. However, the bigger question is what is the meaning of your life? Why are you here? What is your purpose? What do you wish this journey to be? What experiences are you looking for? In other words, what is important to you and what do you want? We all have many dreams, but we seldom attain even a fraction of them. What happened? Here is a famous quote from Gabriel Garcia Marquez.1 It is not true that people stop pursuing dreams because they grow old. They grow old because they stop pursuing their dreams. Gabriel Garcia Marquez This is a wonderful quote except I have a different take on it. People grow old because their dreams are crushed by anxiety . Stress Stress is the sum total of the obstacles we face every minute to stay alive. When your body is in a flight or fight state, the sensation is called “anxiety.” This reaction is present in every living species, but humans have language and can name it. It is challenging to achieve your dreams and experience the life you wish while feeling stressed. Your creativity and choice are compromised while you are in a survival mode; the blood flow in your brain shifts from the neocortex (thinking centers) to the limbic system (flight or fight). The Holmes scale 2, developed in the 1960s, quantifies levels of stress connected with life events. A score of 300 points or more correlates to an 80% chance of a health breakdown within 24 months. In spite of overwhelming data connecting chronic stress with illness, disease, and early mortality, we are generally taught that stress and anxiety are “psychological” issues. Nothing could be further from reality. Why does chronic stress cause mental and physical illnesses? A close friend and I were discussing the role of stress leading to health problems. He had been dealing with an unspeakable number of challenges for several years. His stress score was 435 and then he told me that he had been diagnosed with advanced cancer a few months earlier. Safety We want to feel safe. In this state our body’s chemistry consists of anti-inflammatory molecules called cytokines. Fuel consumption is lowered (metabolism). There are about 80 billion neurons in your brain that communicate by molecules called neurotransmitters. When feeling safe, these molecules are calming. Hormones include dopamine (reward), serotonin (mood elevator), growth hormone, and oxytocin (social bonding). Emotions represent feelings generated by your physiological state (how the body functions) and safety creates a sense of connection, contentment, and joy. Another term describing this state is “rest and digest.” Your body must refuel, regenerate, and heal in order to sustain life and health. Threats When you don’t feel safe, your body goes into various levels of threat physiology (flight or fight) to optimize survival. It deals with acute threats effectively and quickly, but it doesn’t do well with unrelenting challenges. The core of chronic mental and physical disease is a sustained stressed state.3 Activated inflammatory cytokines fire up your immune system. In addition to fighting off viruses, bacteria, and other foreign materials, your own tissues are attacked.4 Neurotransmitters switch from calming to excitatory and your nervous system is hyperactive. Fuel is consumed from every cell in your body, including your brain. Chronic disease states cause physical shrinkage of your brain.5 Fortunately, it regrows as you heal. Stress hormones include adrenaline, noradrenaline, histamines, and vasopressin, which shift your body from thinking to fleeing. This situation can be likened to driving your car down the freeway at 65 mph in second gear. It will break down more quickly than if you are cruising in 5th gear. The driving force behind chronic mental and physical disease is sustained exposure to stress physiology. The solution lies in using approaches to increase “cues of safety.” Dynamic Healing Sustained stress translates into threat physiology, which creates symptoms. In mainstream medicine, we are just treating symptoms instead of addressing the root cause being the interaction between your stresses and nervous system. We don’t have time to know you, understand the nature of your circumstances, or how we can help you calm down. Treating only symptoms is similar to putting out an oil well fire with a garden hose. It is no wonder that the burden of chronic disease and suffering continues to skyrocket.6 In fact, you often feel more stressed while interacting with the medical system. We introduce the concept of “dynamic healing. Dynamic Healing is a framework that categorizes interventions that decrease exposure to threat and increase safety. The three portals are: Input – processing your stresses in a manner to have less impact on your nervous system The nervous system – there are ways to lower its reactivity The output – directly stimulating your body to go from stress to calming physiology. This model organizes known research to both clinicians and patients. You can regain control of your care and create a partnership with your provider. Why not become a “professional” at living life? Consider the process as becoming a “professional at living life.” It is similar to acquiring any skill such as playing the piano. You must learn the basics, incorporate them into your daily life, and then continue to deepen your expertise with practice. Mastery is critical, and as they become habituated and automatic, life becomes easier to navigate. Additionally, the power of neuroplasticity (changing your brain) is powerful and unlimited. You can program your brain in whichever direction you wish, away from unpleasant survival circuits. Modern stresses Times have changed since 1962 regarding the Holmes-Rahe scale . The industrial revolution occurred only about 200 years ago. The level of daily sensory input dramatically increased. Now we are in the information revolution that began in 1980’s forcing us to process magnitudes more information. Smart phones came online in 2007, and along with the barrage of social media, we are on a massive sensory overload. The human brain has not evolved to keep up with it. So, we have ongoing stress levels that weren’t present even several hundred years ago. It is somewhat perverse that we have so many anxiety-related problems when we have access to more physical comforts than any generation in history. One fallout is that of teen suicide, “deaths of despair,” have risen dramatically correlating with the advent of the bi-directional smart phone.7 A healing sequence Healing happens by learning two separate skill sets effectively dealing with adversity and nurturing joy. As you lower your time feeling stressed and increase your sense of safety, your body will regenerate and heal – mentally and physically. Your brain physically changes (neuroplasticity), pleasurable circuits strengthen, and pain (mental and physical) regions atrophy. You can reprogram your brain away from almost anything with repetition. The exciting aspect of neuroplasticity is that at some tipping point, your healing continues to build on itself and there is no limit as to what life (brain) you wish to create. What do want out of this life? Decrease your exposure to threat physiology, increase time in safety, enjoy your life, heal, and thrive. David Hanscom - Website - Resources - References 1. Gabriel García Márquez. Cien años de soledad (One Hundred Years of Solitude. 1967. Editorial Sudamericanos, S.A., Buenos Aires. 2. Holmes TH, Rahe RH. The Social Readjustment Rating Scale.J Psychosom Res (1967); 11:213–8. doi:1016/0022-3999(67)90010-4 3. Furman D, et al. Chronic Inflammation in the etiology of diseases across the life span. Nature Medicine (2019); 25:1822-1832. 4. Cole SW, et al. Social Regulation of gene expression in human leukocytes. Genome Biology (2007); 8:R189. doi: 10.1186/gb-2007-8-9-r189 5. Seminowicz DA, et al. “Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function.” The Journal of Neuroscience (2011); 31: 7540-7550. 6. Bezruchka S. Increasing Mortality and Declining Health Status in the USA: Where is Public Health?Harvard Health Policy Review [internet]. 2018. 7. Miron O, et al. Suicide rates among adolescents and young adults in the United States, 2000-2017. JAMA (2019); 321: 2362. doi:10.1001/jama.2019.5054 – Connection with cell phones made by Dr. Rob Lustig lecture on 12.1.21 -

Making space for emotions goes a long way towards improving mental health. Suppressing our emotions can lead to physical and mental health problems. Likewise, expressing our emotions all the time, everywhere, can also worsen our health—and our social functioning. To better manage our emotions, we can acknowledge their existence, tune into what they're trying to tell us, and make space for them. The more we practice accepting and responding to our emotions, the easier they become to tolerate. Not every emotion is a pleasant experience. Because of how difficult some emotions can be—especially shame, anger, fear, and sadness—many people try to suppress them. Suppression may seem appropriate in certain situations. You may be upset your date didn't text you back, but your best friend tells you her father just passed away, so you pipe down about your problems to be present for her grief. But too much reliance on suppression can harm us—literally, by increasing our risk of dying earlier , if we're not careful. It also doesn't work. We're more apt to think about and feel things we try to avoid. Plus, suppressing our emotions deprives us of key information about our values, motivations, needs, and boundaries. Here's a closer look at why emotional suppression backfires, and how you can give emotions the space they need. First, A Primer on Emotions Emotions are physiological states that mobilize us for particular behaviors and communicate important information about our internal and external environments to ourselves and others. Anger mobilizes us to attack, and signals that a boundary, value, or rule has been violated. Fear mobilizes us to freeze or flee and signals threat or danger. Shame mobilizes us to hide and signals low social status. Guilt mobilizes us to make amends and signals remorse. Joy motivates us to approach and signals reward. Emotions differ from feelings in that they can exist outside our conscious awareness. Feelings, by contrast, require cognitive appraisal—they are our conscious interpretation and labeling of emotional states and other sensations. There’s some debate over how many emotions exist—some research suggests there are 27 distinct ones—but most can be categorized under the “Big Ten.” The Primary Emotions (present at birth): Anger Sadness Fear Joy Disgust Surprise The Social Emotions (present around age 18 months): Shame (feeling that one is bad) Guilt (feeling the one has done something bad) Embarrassment Pride Why Suppressing Emotion Backfires Suppression entails the purposeful stuffing down or denial of emotions. This differs from modulating emotional expression, which entails recognizing an emotion, allowing it to inform your behavior, and integrating feedback from your environment and memory to adjust the emotion's volume so it doesn't undermine your goals. With suppression, you're trying to negate the emotion's existence—which, it turns out, isn't exactly possible, nor good for you. Suppressing emotions increases our stress levels. Researchers have monitored people's sympathetic nervous system activity (a proxy for stress levels, measured by skin conductance and pulse monitors) while having them watch films eliciting, joy, sadness, and disgust. When instructed to watch the movie freely, participants show no observable sympathetic nervous system activation (a.k.a. little to no stress). When instructed to suppress their emotions, however, sympathetic nervous system activation shoots up (indicating a spike in stress). This increase in stress helps explain why regular emotion suppressers tend to bring higher risks of heart disease and hypertension. Because a major function of emotions is to communicate our internal states with others, it's also no surprise that individuals who suppress their emotions feel less socially connected and satisfied with their friends. They're also more likely to experience anxiety , depression , and other mental health issues. A Healthier Way to Manage Emotions Alas, expressing emotions in all their intensity also doesn't seem to be great for our physical, mental, and social health. Unbridled expression of anger can increase people's risk of heart attack, for example. And being around families with high levels of expressed emotion can make individuals treated for schizophrenia more likely to relapse. Likewise, indulging the same emotion without end (as one does when ruminating out of worry or anger) increases people's risk of mental health issues. What, then, are we to do with emotions? Instead of suppressing or excessively expressing them, we need to accept and respond to them. Accepting and responding to an emotion entails noticing its presence (often, its physical presence in our body), softening our resistance to it, tuning into what it's trying to tell us, and using that information to inform (but not dictate) our behavior. Let's say I'm mad I didn't get a raise. I feel under-appreciated, stressed about money, and think I've worked hard enough to deserve it. I may want to give my boss an earful. But knowing this will undermine my chance of getting a future raise, I recognize and listen to the anger I feel, notice it's trying to tell me a boundary has been violated, and I use this information to guide my behavior. Maybe I take a brisk walk to blow off steam, then set up a meeting with my boss to discuss my concerns—or begin looking for another job. Or, let's say I'm sad about losing a beloved pet. I want to get over it and get back to normal. But instead of denying my sadness, I listen to it, ask what it needs (likely, comfort and consolation), and try to provide myself what it needs, perhaps through my close relationships, a therapist, or a support group. Rather than letting my sadness bar my participation in activities I value, I make space for my sadness and carry it with me to them, even if I'm a bit blue in the process. An Exercise to Help with Difficult Emotions Next time you feel an uncomfortable emotion you want to suppress (or scream about), try doing the following: Notice where the emotion is in your body Notice the emotion's sensory qualities (is it hot, tense, heavy, small? What is its texture? Its shape?) Ask the emotion what it's trying to tell you Ask the emotion what it needs from you (sometimes this can simply be "reassurance" or "acknowledgment") Thank the emotion for the information it's trying to give you Offer the emotion what it needs from you (try saying "may you have ____") Invite the emotion to come with you—in your back pocket, say—as you go about pursuing your daily objectives and obligations. The more we recognize, allow, and make space for our emotions, the greater tolerance we build for them. With greater tolerance, we're better able to modulate our emotions so they don't overwhelm our decision-making abilities or reason or seem so unbearable that we have to suppress them. It may not always feel easy to respond rather than react to our emotions, but each time we try to do so, we get that much better at it. Katherine (Schreiber) Cullen, MFA, LCSW, - Website -

Psychoeducation provides a new tool to combat an impairing condition. Combining psychosocial therapy and medications can improve the outcomes for those with bipolar disorder. Evidence-based therapies emphasize learning about the disorder and practicing illness-management skills. In treatment sessions, family members provide important input into recognizing and preventing new episodes. Bipolar disorder (BD) has traditionally been heavily “biologized.” If one were to go to a bipolar specialty conference, one would find numerous talks about genetic and biological markers, cognitive impairments, sleep research, neuroimaging, and algorithms for prescribing mood-stabilizing and antipsychotic medications. One would not hear as much about how adjunctive psychotherapy can enhance medications in stabilizing mood episodes or preventing recurrences. Yet there is growing evidence of the power of structured psychosocial approaches in the outpatient treatment of BD. Adjunctive psychosocial therapies for BD with supportive evidence include cognitive-behavioral therapy, interpersonal and social rhythm therapy, family-focused therapy , and group psychoeducation. These treatments are usually initiated when the patient is recovering or has fully recovered from a manic or depressive episode and continue on a weekly or biweekly basis over periods of four to nine months. A network meta-analysis of 20 randomized controlled trials of patients with BD (types 1 and 2) indicated that combining structured psychosocial therapies with medications is more effective than usual care (typically medications alone, with or without supportive therapy) in reducing rates of recurrence over one year (Miklowitz et al., 2021). The Psychoeducational Approach Virtually all of the psychosocial approaches with empirical support include psychoeducation. Psychoeducation involves acquainting the patient (and sometimes their family members) with the symptoms, course, causes, treatment, and self-management of BD, with guided practice of illness-management skills. These skills include learning to track one’s daily mood changes, regulate daily rhythms such as sleep/wake cycles, challenge and restructure negative (or overly optimistic) thinking, stay adherent to medications, communicate effectively with one’s family, and solve problems related to the disorder. Psychoeducation is intended as an adjunct to medications rather than as a solo treatment. Clinicians must be aware that many patients with BD refuse medications, especially if they are adolescents or young adults who are not convinced that they have the disorder or that medications are effective. Collaboration with a treating psychiatrist is essential. Family Matters In family-focused therapy (FFT), the treatment we developed at UCLA and later tested at the University of Colorado, patients and their family members (parents, spouse, siblings, or extended relatives) meet together with a clinician and learn to recognize the patient’s “prodromal” signs of manic or depressive episodes (signs that emerge before the onset of major symptoms) and strategies for preventing their full-blown expression. Strategies may be straightforward, such as contacting the patient’s psychiatrist to review and adjust medications, or more complex, such as assisting the patient in managing money, keeping regular sleep/wake habits, or devising strategies to reduce substance use. Family members often recognize prodromal signs well before the patient. In describing these signs, they use observations such as “she stands too close to me and speaks loudly” or “he gets full of himself.” Once the patient and family have some level of agreement on what the early stages of episodes look like, the emphasis in FFT changes to strategies for preventing symptoms from worsening. Some sessions focus on the patient’s and family members’ beliefs about medications, with parents or spouses usually advocating for medication adherence and patients expressing resentment of what they perceive to be encroachments on their independence. In a typical FFT session , clinicians recognize that the patient has a level of expertise in bipolar illness based on their personal experiences. They encourage patients to explain to their relatives what they experience during manic, hypomanic, or depressive episodes, how these states are different from ordinary mood swings, what environmental factors are relevant to new episodes, and when relevant, why they refuse medications. Therapists coach family members to listen and validate the patient’s viewpoint while also adhering to their own view that the continuity of treatment is essential. Similarly, the patient is coached to listen and validate the caregivers’ viewpoint, with the clinician mediating these discussions. Patients and family members role-play the use of basic communication skills, such as listening actively or requesting changes in each others’ behavior. Case Example Karla, an 18-year-old woman in her senior year of high school, entered FFT with two older siblings (a brother, aged 27, and a sister, aged 30) and her mother and stepfather. She was clearly depressed and had a family history of BD. During an extensive diagnostic evaluation, she reported a history of brief (two- to three-day) and recurrent hypomanic episodes alternating with lengthier episodes of depression. She met DSM-5 criteria for “other specified bipolar disorder.” Karla was surprised to learn of this diagnosis and had many questions about the line between full BD and BD spectrum disorders. The FFT clinician obtained Karla’s agreement to discuss the bipolar diagnosis with her family members. The clinician began by encouraging all participants to share their observations about Karla’s symptoms. Each family member had a different explanation for Karla’s depression: her older sister believed it was due to childhood trauma, her mother thought she had inherited it, and her brother simply shrugged, saying, “Hormones, probably.” Although they had heard the term “bipolar” before, no one in the family seemed to think that Karla’s short periods of increased energy, irritability, impulsive behavior , decreased sleep, and hypersexuality were in any way related to her depressive episodes. The family was divided on Karla’s need for medications. Karla was open to a psychiatric evaluation but expressed fear that “there’s something wrong with my brain” and that taking a pill would ruin her chances of getting into a good college. Her mother wanted her to try Lexapro (escitalopram) but hadn’t considered the possibility that antidepressants might not be the first recommendation for a person with a bipolar spectrum disorder. The clinician used the fact that more than one family member had been previously treated for depression and asked those members to tell Karla what their experiences of depression had been like. This intervention made Karla feel much less stigmatized within the family, a key issue hindering her willingness to access treatment. The discussion was especially enlightening for Karla’s stepfather, who had been assuming that she was being lazy and really didn’t want to go to college. Karla eventually agreed to an evaluation with a child psychiatrist in the same clinic and began a trial of lamotrigine, to good effect. Most FFT focused on the family's difficulties with open communication: listening to each other’s expressions of emotional pain or confusion while also being able to request changes in each others’ behavior and balance positive with negative feedback. These exchanges involved role-playing new communication skills between Karla and her siblings or her stepfather or her siblings and their mother. At the end of the four-month treatment, Karla’s depression had stabilized. She remained on lamotrigine and was actively applying to colleges. Format and Setting of Psychoeducation Although the structure and length of psychoeducation vary from patient to patient, family and group formats appear more effective than individual formats in preventing new episodes of depression or mania (Miklowitz et al., 2021). When patients are experiencing prodromal symptoms, close relatives or friends can provide immediate input to the treatment team to inform preventative interventions. In group settings, other individuals with BD can help the patient recognize when they are becoming ill, the importance of social support and avoiding substance abuse, and the role of medications and other “life hacks” in maintaining stability and quality of life. In the best circumstances, other group members provide companionship and hope, especially for patients who experience their lives as an endless series of doctor appointments, therapy sessions, and trips to the emergency room. For many patients, hearing that other people with BD experience the same types of family conflicts, stigma, and shame can be quite eye-opening. David J. Miklowitz, Ph.D. - website - References: Miklowitz, D. J. (2010). Bipolar disorder: a family-focused treatment approach (2nd ed.) New York: Guilford Press. Miklowitz, D. J. (2019). The Bipolar disorder survival guide: what you and your family need to know (3rd ed.). New York: Guilford Press. Miklowitz, D. J., Efthimiou, O., Furukawa, T. A., Scott, J., McLaren, R., Geddes, J. R., & Cipriani, A. (2021). Adjunctive psychotherapies for bipolar disorder: a systematic review and network meta-analysis. JAMA Psychiatry, 78(2), 141-150. https://doi.org/10.1001/jamapsychiatry.2020.2993.

It takes practice, but it can feel like a relief once you do it. Having friendships can benefit your physical and emotional health. Friends can provide emotional support in rough times, act as activity partners when engaging in hobbies, and provide socialization opportunities. For some people, friendships offer levels of intimacy that you may not find in your other relationships. In friendships, knowing where to set healthy boundaries is essential. If you find yourself exhausted or pessimistic about your friendships, it may indicate that it's time to set some limits. What are the benefits of friendships? Friendships can be beneficial to your life for a variety of reasons. Research from 2021 that included a sample of 323,200 participants found that prioritizing friendships was associated with better health and well-being. Additionally, a study examining the quality and intensity of friendships found that friendship relationships are linked to higher life satisfaction, especially when you see your friends often and are satisfied with your relationships. While friendships can benefit your overall well-being, sometimes they can be a source of stress. What are some signs I need to set a boundary in my friendships? In your friendships, if you suddenly notice that you're saying yes to things you don't want to do, not feeling heard, or feeling exhausted by your friends, it may signal that it's time to set a boundary. Many different types of boundaries may come up in friendships, such as: Emotional boundaries Physical/Space boundaries Time boundaries Emotional boundaries encompass what we need to do to protect our mental health. Physical boundaries may include our comfort with personal space or what we will and won't allow someone to do in our homes and belongings. Here are some situations in a friendship where a boundary may need to be set. The friend who puts you down You and your best friend grab dinner at your favorite local restaurant twice a month. You recently went through a breakup and discussed this with your friend in-depth. The last time you went to dinner, your friend became pushy about you returning to the dating scene. You've told her multiple times that it's only been three months, and you're still healing from losing your previous relationship. Your friend is relentless, saying she can't believe you aren't "over your ex." She starts to say things to you like, "You're so sensitive, and if you find someone new, maybe you won't be so hung up on your ex." These comments hurt you, but you say nothing instead of calling her out on this. After you go home from dinner, you find yourself exhausted by your recent interactions with her. You feel sad, angry, and hurt, and wish she would try to have more empathy. The friend who leaves your house a mess One of your close friends living out of state visits you twice a year. It's easier for him to fly to your place because he doesn't have kids, and you do. You and your wife let him stay in the guest room when he visits. The last time he stayed for a week and was disrespectful of your space. He left dirty dishes in the guest room and the bathroom a mess and strung his belongings around your house. You felt stressed and frustrated until he left when you had to spend significant time cleaning up after him. He seems unaware that he did anything wrong and never apologized. The friend who was late driving you to the airport You recently had to fly out of state to attend your grandmother's funeral in another state. One of your friends offered to drive you and your partner to the airport, as you have no family nearby, and the parking fees would be expensive if you left your car there. Your flight left at 10 a.m. on Tuesday, so you asked your friend to be at your house by 8 a.m. so you had plenty of time to get through security. On the day you left, your friend overslept and arrived at your home at 8:35 a.m. You and your partner had to rush through the airport; you barely made your flight before they closed the doors. You're angry at your friend for causing additional stress to an already stressful and emotional trip. How do I set a boundary in my friendships? In each of the above examples, a boundary needs to be set. Boundaries show what we will and won't tolerate in various areas. Sometimes people get limits confused with requests. A request is different than a boundary. Boundaries say what we will and won't do and tolerate. A request is asking someone to start or stop doing something. To set boundaries, you can: Speak assertively Use I statements "I felt ______ when you did ______. If it happens again, I'm doing this________." Be clear and direct Say what you will do if the person doesn't respect your boundaries Let's use the examples above to set a limit. The friend who puts you down Here's how you might set a boundary in this case: "I wanted to talk to you about the last time we went to dinner. I felt sad and angry that you pushed me to date when I was not ready. I also didn't like that you called me too sensitive and stated that I should be over my ex. If we have a conversation where you put me down and push me to date again before I'm ready, I will leave the restaurant." In this situation, you were direct and assertive about how you felt, stated what you won't tolerate, and said what would happen if your friend disrespected your boundaries. The friend who leaves your house a mess Here's how you might set a boundary in this example: "I love the time we get to spend together when you stay with us, though last time you stayed with us, I was extremely stressed out and upset at the condition with which you left our home. It required significant cleaning on our end after you left. If it is left that way the next time you stay with us, I will have to ask you to find a hotel." In this situation, you clearly stated your feelings and told your friend he's not welcome to stay there again if he can't clean up after himself. The friend who was late getting you to the airport Here's how you can set a boundary in this scenario: "I appreciate that you drove me to the airport for my last trip; however, you were late, causing my partner and me almost to miss our flight, and I felt angry that you couldn't honor your commitment. Thank you for the ride, but my partner and I will Uber to the airport from now on." You were clear and direct and told your friend what would happen. Overview Boundaries are more than requests. In our friendships, situations may arise where setting boundaries is necessary and can help enhance friendships. It can be challenging to set boundaries if you've never done it before. Being transparent and assertive with your friends can help lessen resentments and improve your relationships in the future. Setting boundaries takes practice, but it can feel like a relief once you do it. Marissa Moore, LPC, Website Sources: Amati V, et al. (2018). Social relations and life satisfaction: The role of friends; Lu P, et al. (2021). Friendship Importance Around the World: Links to Cultural Factors, Health, and Well-Being.

Try this step-by-step process for cleaning up your negative thoughts. Your negative thoughts and self-limiting beliefs prevent you from creating the life you want and deserve. You can take control of your negative thoughts and self-limiting beliefs by challenging their accuracy. Once you identify inaccurate negative thoughts, you can replace them with healthier and more adaptive ones. Everything ever imagined, created, or achieved was first thought. Positive or negative thoughts inform our choices and impact our self-confidence, sense of identity, choices, relationships, and ability to connect to others and ourselves. Everything is great when we feel good, making choices that support our happiness and lead us forward. But when our thoughts support rigid thinking and self-limiting narratives that lead to anxiety , depression , and chronic worrying, and result in a loss of faith in ourselves and our abilities, or prevent us from connecting with others, pursuing careers that hold genuine meaning for us, we need to stand up for ourselves and take control to live the life we truly want. The good news is that when it comes to our thoughts, we can take control of our thoughts, one thought at a time. Negative Thoughts As a clinical psychologist, I have spent my working life helping clients clean up the negative thoughts that hold them back from maintaining healthy relationships with others, achieving the goals they want for themselves, and creating the life they truly want. Together, we work to identify and challenge the negative thoughts in their lives. We then rewrite and replace these thoughts with more accurate, supportive, and healthier ones; we reframe their views about what is possible and what their lives can be. And finally, we bring in supports and strategies to help reinforce and sustain these healthier, more adaptive positive thoughts. When it comes to our thoughts, we have a choice: We can choose to reframe negative thinking by challenging the accuracy of our negative thoughts. We can choose to think about how we think about our lives and ourselves. And we can challenge the truth about our negative thoughts and replace those negative thoughts with positive ones. The process is clear: Challenge, rewrite, and reframe negative thoughts and reinforce the new, healthier, and more life-affirming ones. How to Begin Begin by taking an inventory of your negative thoughts and beliefs: Make a list of your negative core beliefs and automatic thoughts. Consider how these thoughts and beliefs limit and restrict your choices, create obstacles to your growth, and keep you stuck in roles and situations that no longer make you happy. Include in your list situations where you overestimate the probability of bad things happening, when you make excuses and resist challenging yourself to try new things, connect meaningfully with people, and hold yourself back from living the life you truly want for yourself. Once complete, you will have a list of thoughts to challenge, rewrite, and reframe your negative thoughts. A Powerful Process Challenge your negative thoughts. With compassion for who you are today, take a long, honest look at the thoughts and beliefs you have identified as problematic and limiting. Acknowledge where they came from. Realize that they are no longer accurate, no longer serve you, and hold you back from living the life you want. Rewrite these thoughts. Replace inaccurate, self-limiting thoughts with more accurate, adaptive, and supportive ones about your abilities, attributes, and skill sets; you are worthy of love just the way you are, and you deserve to live an authentic, meaningful life. Reframe . Using these new, more adaptive, and accurate thoughts, reimagine the life you want for yourself—and reinforce those thoughts by acknowledging their impact and bringing in support to help you overcome the challenges you encounter as you strive to create the life you want. Your past is in the past; the future is your imagination. So why not reframe your thoughts about your future to imagine good things coming your way? Pay Attention It is important to maintain awareness around your thoughts and to pay attention to the many ways in which your thoughts—both positive and negative—impact your life. Celebrate the positive impact of the new, more supportive, and more accurate thoughts you have worked hard to bring into play. Strive to stay connected to your feelings. Don’t dismiss or ignore negative feelings and thoughts when they arise. Instead, challenge, rewrite, and reframe the thoughts and beliefs that no longer serve you. Remember, you can take control of your thoughts and become a more positive thinker, one thought at a time. Monica Vermani, C. Psych., - Website -

Identifying passive-aggressive behavior is challenging, but it's worth trying. The ambiguity of passive-aggressiveness adds to the challenge of interpreting other people's behavior. Passive-aggressive behavior is often motivated by rebellion, anger , and resentment. It's worth trying to decode passive aggressiveness so we can act to improve our relationships. Decoding people’s intentions so we can interpret their behavior and respond appropriately is challenging, especially when it comes to passive-aggressiveness. Attributional Ambiguity In social psychology, it’s said that “attributions matter.” By this, we mean that when someone does something, how we respond (and what we think about the “actor”) often depends on our explanation (attribution) as to why they did it. The problem, social psychologists note, is that the attribution process is often flawed. How we explain another’s behavior , especially if it’s undesirable, may be biased by a lack of information. Our lenses are also sometimes distorted by our own sensitivities and our history with the actor. This can lead to confirmation bias in which we interpret their behavior in ways that confirm our already-negative view of them. Deciding whether another person is acting passive-aggressively is loaded with attributional ambiguity, adding to the already-challenging task of interpreting others’ behavior. Passive aggression, like direct aggression, involves the intention to harm, but unlike direct aggression, it’s more indirect, leading to attributional ambiguity about whether it was aggressive or not. Did they really “forget”? Did they do a bad job on purpose? Was that an innocent comment or intended to hurt our feelings? Was that behavior simply thoughtless or intended to get back at us for a perceived wrong? Is their procrastination a deliberate rebellious reaction to our request? Are they clueless or deliberately ignoring our needs to punish us? Was that sarcastic joke at my expense funny or mean? Are they busy or giving me the "cold shoulder" to make a point? No two ways about it: Being on the receiving end of what might be a passive-aggressive word or deed is often confusing and maddening. Passive-Aggressiveness as Gaslighting would also argue that in its most egregious form, passive-aggressiveness is a way of wielding power through intentional misdirection. In other words, it’s a tool of the gas lighter who intentionally does things to make a partner doubt reality and even their sanity. The ambiguity of passive-aggressiveness provides the cover of plausible deniability. The gas lighter can easily deny that what they said or did was intended to harm and claim the target of their gaslighting is “crazy.” The Role of Culture Cultural factors may also come into play. Aggressiveness may be enacted passively when social norms prohibit more overt aggression. From this perspective, passive-aggressiveness can be normative when direct aggression is frowned upon. Hence, angry and resentful people may act passively-aggressively. Passive-aggressive behavior may even be more common in some subcultures in which “nice” is valued. For example, in some southeastern parts of the U.S., “bless your heart” often follows critical remarks made in a pleasant tone. It also bears saying that power imbalances may lead to passive aggression. Higher-status people can get away with more overt aggression than lower-status ones, and powerful people who wield their power arbitrarily and insensitively should expect passive-aggressiveness in return. Conclusion So where does this leave us? First, I think it’s clear that we will regularly encounter interpersonal situations where it's unclear whether someone else is being passive-aggressive. It may be worth gently asking the "actor" for help in interpreting their ambiguous behavior while expressing a desire to right and wrong. However, because some passive-aggressive people are uncomfortable with conflict (hence their passive-aggressive expression of their displeasure) or may not feel safe talking about it, they may say nothing is wrong. There is also some question as to whether passive-aggression can be an unconscious expression of anger and whether people may be unaware of their passive-aggressiveness. Second, because passive-aggressiveness is sometimes a response to feeling unfairly or arbitrarily controlled, it’s worth asking ourselves whether we are in fact overly controlling such that we’ve created the need to rebel or created resentfulness and ange r in our partner. Likewise, do we have a history of defensive responses such that they don't feel safe telling us what's really up? That said, it’s not always us, as some people are very quick to rebel against requests from others—even reasonable requests. Third, consider the relationship context, and whether passive aggression is a “relationship red flag.” If there are other hallmarks of gaslighting, it’s time to figure out how to get out before we’re destroyed. Likewise, if you don’t feel safe honestly expressing your concerns such that you act passively-aggressively as the only way to feel you have some power and control in the relationship, maybe it’s time to leave, or time for counseling (or both). Finally, we should “check” our own passive-aggressive behavior. It’s not good for our relationships. Stop with the supposed jokes or snarky remarks that are really targeted barbs. Be honest about what you’re really angry about instead of acting out passive-aggressively. Don't reflexively rebel with procrastination or low-quality work in response to reasonable requests. Own up and apologize when you’ve been passive-aggressive and try to do better. Shawn M. Burn Ph.D. - Book - References Benjamin, L.S. (1993). Interpersonal Diagnosis and Treatment of Personality Disorders. Guilford: NY, NY. Lim, O.Y., & Sun, K.H. (2022). Development and validation of a measure of passive aggression traits: The Passive Aggression Scale (PAS). Behavioral Science (Basel), 12, doi: 10.3390/bs12080273. Pretzger, J.L., & Beck, A.T. (1996). A cognitive theory of personality disorders. In Major Theories of Personality Disorders. Guilford: NY, NY.

Narcissistic issues can interfere with one's ability to be a good mother. Narcissistic women can have a maternal instinct that leads them to want to mother a child. They may not see their children realistically because they lack whole object relations and object constancy. Lack of emotional empathy can interfere with the ability to attune to a child. It is quite possible for mothers who are diagnosed with narcissistic personality disorder to have a maternal instinct, if we define maternal instinct rather loosely as a desire to mother a child. However, as with other temperamental characteristics, this desire to mother seems to be on a spectrum and is not present in every narcissistic woman. The belief that every woman has a natural maternal instinct is not supported by current research (Conaboy, 2022). We do know that when we look at little girls, some of them want baby dolls as toys and others prefer stuffed animals. And, for many girls who did enjoy baby dolls, this interest in playing a mothering role continues into adulthood and leads them to have their own babies. Other women may not be particularly interested in having a baby but may do so to fulfill cultural or religious expectations. Narcissistic Personality Disorder James F. Masterson (1926-2010), the well-known personality disorder theorist, taught that narcissistic personality disorder is an acquired adaptation, not inborn. However, some people may have traits that make it easier for them to become narcissists, such as low innate emotional empathy. Masterson and other developmental theorists do not believe that people are born with NPD. They believe that the child develops NPD as the result of a misfit between the child’s authentic emotional needs and what their parents can provide (Masterson, 1981; Chess and Thomas, 1984). Masterson identified three factors that can interact to play a role in the development of a narcissistic personality disorder: Nature: the child’s inborn temperament. Nurture: the way the child is parented. Fate: unplanned events that negatively affect the child. Note: In this post, I will be using the terms narcissist and NPD as shorthand for someone who meets the full criteria for a narcissistic personality disorder diagnosis. NPD Can Interfere with the Ability to Be a Good Mother Unfortunately, even if a woman is highly motivated to have children, if she has a narcissistic personality disorder it may be difficult for her to be a good mother. There are three deficits associated with NPD that can interfere with the ability to mother children appropriately. Lack of Emotional Empathy Emotional empathy is the ability to feel something of what the other person feels. For example, if you see someone hit their thumb with a hammer and you wince in sympathy, that is an example of emotional empathy. Without emotional empathy, the narcissistic mother has to rely on her cognitive empathy. Cognitive empathy involves stopping to think about what the other person might be feeling and trying to react appropriately. For example, your friend’s father died, and you never liked the man. However, you are at the funeral, and you try to think of something comforting to say to your friend, such as: “I am so sorry. I know how much you loved him.” The narcissistic mother who wanted a child will do her best to parent the infant, but because of her lack of emotional empathy, she may have trouble attuning to her baby’s needs. Her parenting efforts may relate more to her needs than to the child’s needs. She may be intrusive or neglectful depending on her mood at the moment. Lack of Whole Object Relations Whole object relations (WOR) is the psychology term for the ability to form a stable, realistic, and integrated view of yourself or another person that simultaneously contains both liked and disliked qualities. Without WOR, a person can only see people in a split way as either all-good or all-bad. In the case of a narcissist, all-good equals special, and all-bad equals worthless. From an object relations theoretical point of view, what distinguishes someone with a narcissistic personality disorder from someone who has narcissistic traits is the lack of whole object relations (Greenberg, 2016). Without WOR, the narcissistic mother cannot form a stable and realistic view of her child. As a result, when she is happy with her child, she will view the child as special and perfect and treat her or him accordingly. When she feels frustrated or disappointed with her child, she will switch to seeing the child as flawed and bad, and act mean and devaluing. Lack of Object Constancy Object constancy (OC) is the ability to remember the positive aspects of people you care about (and your past positive history with them and your desire for a positive future) while you are having negative feelings toward them in the moment. This means that when a narcissistic mother is feeling frustrated, angry, or disappointed by her child’s responses to her attempts to mother, she may feel rejected by the child. In this situation, the mother switches from loving to hating her child. In this state, she may become emotionally or physically abusive to the child. Example—Betty and Her Baby Betty had loved playing with dolls as a child and spent many happy hours pretending to be a mother. She had always envisioned herself having children of her own. She married young and started a family immediately. She was thrilled to be pregnant and imagined how enjoyable it would be to have a newborn to take care of. Unfortunately, Betty’s idealized picture of a newborn baby was more like an image of a doll than a real person. She was unprepared for the baby to cry. Dolls do not cry. Betty became frustrated when her attempts to soothe her baby did not always work. This conflicted with her narcissistic self-image of being a perfect mother. She felt narcissistically wounded when her baby did not respond to her mothering attempts. As a result of the above situation, Betty’s child had unpredictable mothering. When Betty was relaxed and happy, she treated her child well and was full of praise. When Betty was displeased or felt her overtures were rejected, she hated her child and venomously withdrew or attacked. Summary Narcissistic women can have a maternal instinct, if we define that as a genuine desire to have and mother a child. However, their ability to mother their children appropriately is severely limited by their narcissistic issues, especially their lack of emotional empathy and their inability to maintain a stable and realistic view of their child. Even the most enthusiastic narcissistic mother will have trouble attuning to her child’s needs and meeting those needs in a loving way. And, if the woman only had children out of a sense of duty, then the situation is likely to be worse. They may have neither the desire nor the ability to fulfill normal mothering functions. Adapted from a Quora post This article was first published in the “Understanding Narcissism” blog on PsychologyToday.com on February 22, 2024. Elinor Greenberg, Ph.D., - Website - References C. Conaboy (2022). Mother Brain: How Neuroscience Is Rewriting the Story of Parenthood. NY: Henry Holt and Co. Chess, S., & Thomas, A. (1984). Origins and Evolution of Behavior Disorder. NY: Brunner/Mazel. J. F. Masterson (1981). The Narcissistic and Borderline Disorders: An Integrated Developmental Approach. NY: Brunner/Mazel. E. Greenberg (2016). Borderline, Narcissistic, and Schizoid Adaptations: The Pursuit of Love, Admiration, and Safety. NY: Greenbrooke Press.

From "I'm an idiot" to "What can I do differently?" Nobody is perfect. Everyone makes mistakes. We are all limited human beings. We can't eliminate shame; it is part of our emotional makeup. But we can transform it. Shame is actually designed to help us deal with our flaws and limitations and create a more loving society. Perfectionism is one way that we defend ourselves against feeling toxic shame. When people feel unworthy deep down, they may find that the only path forward to maintain a sense of self-worth is to strive for an elusive perfection. While toxic shame says, "I'm not good enough; I'm a failure," perfectionism says "I need to be perfect, and I can be. Failure is not an option. Only then can I be OK." I once gave a speech to a group on July 4. I knew that Thomas Jefferson and John Adams both died on July 4. What a great topic for a speech—though it had little to do with the subject I was supposed to be talking about. Impulsively , I mapped out the speech and gave it. It was a disaster. Too intellectual and utterly unsuited to the group. I was dismayed when people actually walked out! As a man with a strong perfectionist streak, I didn't take it very well. My first reaction was toxic shame. I felt terrible. Sick to my stomach. I actually retreated to my bed for several days. I had utterly blown it, failed. I was convinced that I would never be asked to speak again. After several miserable, shame-filled days, I began to reassess. I had always prepared carefully for presentations. I had rehearsed and tried out material on my wife and friends. In this case, I had not prepared well, nor checked with anybody. I had misread the interest of the audience. Toxic Shame vs. Healthy Shame My original reaction had been "I suck at this! I'll never humiliate myself again by speaking in public.” Over time, I gradually become more accepting and kinder to myself. I made a welcomed transition from toxic shame to healthy shame. My healthy shame thought was “Yes, I did blow it. I didn't prepare properly or run it by anybody. And I really didn't understand my audience and what they were looking for. I will do my best not to make that mistake again. I will prepare carefully, and I will be a lot clearer about who I am speaking to. I will also make careful choices about who I speak to.” Instead of ending my career as a teacher, speaker, and presenter, I took steps to become better at it. Being perfect is a tall order, considering that nobody can attain that impossible goal. And while a little perfectionism might help you do a better job, too much creates problems. When things don't go well, the shame comes back twice as strong. As I still remember Mr. Spock saying in a Star Trek episode, “The perfect is the enemy of the good" or, I would add, the good enough. In the incident I described, I reassessed and transformed my frozen, toxic shame, into healthy shame, which helped me move forward. This is not always the case for me—or most people. There are areas in which we all get stuck in toxic shame and have real trouble moving out of it. This is especially true if we were overwhelmed by shame growing up and weren’t invited to recognize our feelings of shame, pain, and isolation. While toxic shame feels horrible and produces a deeply unpleasant state of freeze, healthy shame can actually help you function better. A humorous example of healthy shame is realizing “I can't fly. I wish I could. It would be really nice. I really envy those birds, just soaring through the air. But I can't. I'm human. I have limitations, just as all people have limitations.” This understanding is particularly healthy because it can keep us from jumping off cliffs or tall buildings and personally discovering gravity. While this is an extreme example, healthy shame helps us become aware of our limitations, reassess our actions, and act more appropriately in the future. Healthy shame creates a pause in activity and a temporary retreat from the situation, which allows for a clearer perspective, reassessment, and behaving differently. A Simple Practice Here is a simple practice when something goes wrong and you start to blame and criticize yourself: Slow down and ask yourself, "Rather than beating myself up, what steps can I take to make things better? The concept of healthy shame can be helpful for anyone who keeps trying to get rid of shame entirely. Shame is part of the human condition; it needs to be embraced and worked with wisely, as discussed in our book, Embracing Shame: How to Stop Resisting Shame and Transform It Into a Powerful Ally. Thinking of transforming shame, rather than eliminating it, helps soften the shame by pointing toward an attainable middle ground. Everyone has shame. It is how we hold the shame that makes the crucial difference between staying stuck or growing. Does our shame stop us from functioning—or give us a pause in action and an opportunity to reassess? Are we ashamed of our shame, or can we gently hold it as part of what actually makes us human? Bret Lyon, Ph.D., SEP, - Website - Book - References Bret Lyon and Sheila Rubin. Embracing Shame: How To Stop Resisting Shame and Transform It into a Powerful Ally. Sounds True Adult. 2023.

Unlike a rivalry, abuse is one-sided, and it's too often tolerated. Even professionals often mislabel sibling intimidation or violence as "just rivalry.” Without criteria defining sibling aggression , it's difficult to determine acceptable and tolerable behavior. Abuse tends to be one-sided, with one sibling having an advantage of age, gender, size, or cognitive ability. Parents can create a family culture that does not tolerate aggressive, mean behavior. Sibling maltreatment is the most common form of domestic abuse in Western society—more common than either domestic partner or child abuse, according to Professor Mark Kiselica of Cabrini University in Radnor, Pennsylvania. Kiselica reports that sibling victimization, which he calls “the forgotten abuse,” is three times more common than school bullying, and it often leads to estrangement in adulthood. Among children , it can be difficult to distinguish acceptable play—think roughhousing, wrestling, even a freewheeling game of tag—from actual conflict with intentional aggression, says Professor Corinna Jenkins Tucker of the University of New Hampshire, Durham. Belligerent, potentially injurious behaviors—such as intimidation, making threats, pushing, hitting, scratching, or biting—are common among siblings and often considered normal. Even professionals who work with children often mislabel aggressive sibling behaviors as "just rivalry.” Yet it’s revealing to consider that these actions, when occurring between friends, classmates, or romantic partners, are typically—and often immediately—condemned. “There are no universally accepted criteria regarding sibling aggression,” Tucker explains, “making it difficult to know when to be concerned, intervene in sibling interactions, or seek help. However, it is critical to recognize aggressive and abusive behaviors between siblings because their negative effects on well-being are similar to the impacts of parental child maltreatment and intimate partner violence.” When Is Sibling Rivalry Abusive? Often mischaracterized as "sibling rivalry," sibling bullying and abuse are forms of repeated, intentional, targeted aggression meant to control, overpower, or harm a brother or sister. No matter what their age, the more a person feels powerless, the more inclined he/she will be to take it out on someone even more powerless. Anger and hurt typically produce rivalrous, bullying behavior, which includes shaming, harassing, belittling, gaslighting, name-calling, threatening, insistently teasing, or excluding a victim. Where is the line between sibling rivalry and sibling abuse? Tucker offers these guidelines: Is physical violence (e.g., hitting, kicking, shoving) occurring in children beyond the toddler years? Are sibling conflicts consistently settled by one sibling "winning" the fight? Is the behavior physically or emotionally harmful? Does it carry a genuine risk of harm? Is the behavior planned or patterned, suggesting an intent to harm? Does a sibling feel victimized, targeted, frequently intimidated, and/or afraid? Has the behavior escalated over time, becoming more aggressive and/or injurious? Is there a consistent power differential between the siblings? Sibling abuse tends to be one-sided. Often one sibling dominates, having an advantage of age, gender, physical size, cognitive ability, or other factors. The behavior typically occurs repeatedly over a period of time. The abuser may align with another sibling, friend, or even a parent in the punishing behavior, and the victim eventually may suffer serious injury. If the abuse is psychological, the victim may be demeaned, humiliated, alienated, and/or blackmailed. This, too, can inflict invisible but lasting injuries. “When aggression is normalized in a family—and in society—sometimes the victimized sibling also struggles to identify the harm,” Tucker explains. “Additionally, many siblings are characterized as being both the bully and the harmed child. An unclear power differential can lead to greater acceptance of aggressive sibling behavior [by more than one child]. In these cases, the aggression could be tolerated because it is between ‘equals’ or because the behaviors ‘seem fair.’" Risk Factors for Abuse The risk factors for sibling abuse include: Siblings who are close in age (or development) Early difficulty in establishing solid parent/child attachment Distant parents, who by literal absence or emotional remove are unavailable or uninvolved in their children’s lives A “faraway father” with a low level of involvement or acceptance High level of conflict between parents or step-parents Parents reinforcing competition by playing favorites or comparing children Parents modeling abuse and bullying tactics Children who don’t learn how to handle conflicts What Parents Can Do Conflict between children is inevitable and can even be instructive. It can provide teachable moments in which children learn to listen, consider another person’s perspective, and negotiate differences. These crucial social skills, master's in childhood, become the blueprint to help resolve conflicts in adulthood with siblings, peers, and romantic partners. But parents want to be mindful of constructive versus destructive forms of conflict. It’s their job to help children learn emotional regulation. Toward that goal, parents should consider the following: Parents absolutely can and should stop bullying. Start by establishing a family culture that does not tolerate aggressive, mean behavior. Intervene immediately when one child hits, pushes, or calls another a name. Model healthy ways to relate, teaching children how to treat each other with respect. Monitor and correct aggression as it arises. Be firm and consistent, so children learn what is acceptable and what isn’t. Minimize jealousy. Make sure each child receives recognition and love. Praise children even-handedly for their good characteristics and efforts, so they feel equally valued. Avoid comparing your children, to one another or to others, and steer clear of labeling them by identifying “the athletic one” or “the smart one.” Such labels breed jealousy, competition, and contempt. Hold the bully accountable. Help the bully to see and understand the pain he/she has inflicted. Insist that the bully take responsibility for his/her actions. Enforce consequences—such as mandatory apology, grounding, or loss of privileges—so children understand that bullying will not be tolerated. Cultivate empathy in children. Identify kind, loving behaviors. Encourage children to try to understand others’ feelings. Emphasize collaboration over competition by creating opportunities to work together, supervising for cooperation and harmony. Parents often dismiss toxic childhood dynamics as “normal sibling rivalry” or “just a phase.” But these patterns, which tend to peak in adolescence (10-15 years of age), may continue or even worsen in adulthood. The bully continues to boost his/her fragile sense of self-worth by blaming the victim sibling for all sorts of problems, resisting any attempt at real understanding or resolution. Eventually, most victims simply give up, resorting to a policy of estrangement or going no-contact to protect themselves. Fern Schumer Chapman - Website - Book - References Tucker, Corinna Jenkins, Whitworth, Tanya Rouleau and Finkelhor, David, Fall 2023 "What is the Line: When Does Sibling Conflict, Teasing, and Roughhousing Become Something More Serious?" (SAARA Bulletin #4) University of New Hampshire, Crimes against Children Research Center Kiselica, Mark S., (2007) Sibling Maltreatment: The Forgotten Abuse, Journal of Counseling and Development: JCD 85 (2)

The roles of disposition, engagement, and self-efficacy. More than half of younger workers report feeling burned out. Besides organizational problems, burnout can also involve dispositions and the expectations we bring to work. Beginning with school, the terms of success can virtually foreclose a self-efficacious relationship to work. A former student was in town recently, and we arranged to have coffee and catch up. She is in graduate school, but during our conversation, she mentioned the experience of her friends who took professional jobs right after college. All, she said, are “miserable” and feeling “burned out.” None of them are working in caregiving or service occupations, the fields where burnout has been most reported, especially during the pandemic. And none is older than 26. Could such young people, I thought, already be so depleted and struggling on the job that they feel burned out? Apparently, yes. According to the professional services firm Deloitte, in its 2023 Gen Z and Millennial Survey, 52 percent of Gen Zers (up to age 27) report “feeling burned out.” That number is even higher than for the slightly older millennials (up to age 40), of whom 49 percent feel burned out. Numbers for both groups rose about 5 percent from the 2022 survey, which came at the tail end of the pandemic. That’s a lot of burnout. But what are we talking about? While the concept has changed over time and remains slippery, psychologists commonly define burnout as a job-induced psychological syndrome. Its core, constitutive feature is emotional exhaustion. It arises, they argue, from persistent exposure to unresolvable stress in the workplace, organizational failures such as excessive job demands, or a lack of appropriate resources or recognition. People experience burnout, in this view, because, as one sufferer reported, “work is grinding them down.”1 Of course, adverse features of the work environment can be alienating and emotionally draining. My physician, to give one example, quit (“retired”) last year because the corporate control over his medical practice had made it impossible for him to make decisions and properly care for his patients. For years, he told me, he had been trying to manage by working six days a week, even as the loss of discretionary authority and onerous record-keeping increased. Like a lot of clinicians, his well ran dry.2 Organizational challenges, however, though important, are not the whole story. We must also ask larger questions about the nature of achievement in our society. Occupational burnout is more than simply being overtaxed. It involves dispositions and expectations that people bring to their activities. If we ignore those factors, we miss an important reason so many people feel their work is pointless and they themselves are powerless. The Antithesis of Burnout To begin to understand the importance of dispositions and expectations, we first have to consider the condition or state most antithetical to burnout. According to Christina Maslach, the leading burnout researcher, that condition is “engagement.”3 Business consulting firms such as Deloitte, Gartner, and Gallup appear to agree. When they study workplace trends, they use “engaged” as the ideal and contrast it with forms of active withdrawal or psychological detachment . To be engaged is to apply oneself, to be enthusiastic, to be committed to work and the workplace. The concept of engagement is helpful in thinking about a person’s relationship with an organization, but it is a bit too broad and formulaic to help us understand a person's relationship to work itself. Let me suggest the more interactive concept, encounter, which conveys both the ability to touch and be touched, to speak and be spoken to in one’s relationships, experiences, and activities. When we have a responsive relationship with work, we take an interest in and pursue the satisfactions and rewards, predictable and unpredictable, that are intrinsic to it—in serving this guest, making this presentation, writing this copy. Our goal is to do the job well, gain skills, accept challenges, learn from our failures, and create new possibilities. In other words, we do the things or provide the service that give the work its value and excellence. When our work speaks to us, we gain self-efficacy. We are at risk of burnout when we do not encounter our work, when we cannot find rewarding features in the activities themselves. To repeat, the conditions of our work might be a big part of the problem. But it is also possible that we approach work in a way that virtually forecloses a responsive relationship to it. Why So Tired? In reading studies about millennial and Gen Z workers, one of the more striking findings is how much they desire an encounter with work. They want to do something important and worthwhile, make a difference in their job, and experience themselves as effective in doing so. Work is all the more important given their relatively weak connection to other institutions and traditions. Encounters in other areas of life can make “working for a paycheck” more palatable. Despite the desire, however, young workers’ “engagement” is fairly low, while “quiet quitting” and feelings of burnout are widespread. So is turnover. At any time, half of these workers are actively looking for another job. What’s the problem? At least one source of trouble begins in the school years. During this time, students often learn to pursue achievement in terms of anticipated rewards that lie outside of the activities they engage in. Many students, for example, report that in high school, if not before, the intrinsic goal of learning was heavily subordinated to extrinsic performative concerns, such as doing well on tests, seeking social approval, and competing with peers. A similar utility principle operated in the way they approached extracurricular activities. Leadership roles, playing a musical instrument, sports, volunteering, and other practices were pursued less for their own value than as means to building a winning college resume. These extrinsic concerns—grades, college acceptance, and so on—are not bad things, of course. But when they become the overriding concern, then the essential point is lost. We can see this consequence in both the rampant cheating in school and the testimony of students who can find little real satisfaction or meaning in their day-to-day activities. For many, their life often feels like a continuous hamster wheel. Fatigue is common and most students complain of being overwhelmed and stressed. In a recent survey, for instance, nearly 80 percent of undergraduates say they are experiencing moderate or high stress in their life. They stay constantly occupied, checking off the boxes on their to-do lists, but feel little control over their actions. As they see it, they do what they have to do. Alternatively, they get an early start on quiet quitting. The message about success in school is to focus on results, the payoff will come later. But if that message inhibits a responsive relationship to learning, then how will students be prepared to have an encounter with work? The old hamster wheel might simply be replaced with a new one. Joseph E. Davis - Website - References 1. Jonathan Malesic, The End of Burnout. Oakland, CA: University of California Press, 2022. 2. Victor J. Dzau, Darrell G. Kirch, and Thomas J. Nasca. “To Care Is Human—Collectively Confronting the Clinician-Burnout Crisis.” New England Journal of Medicine 378/4 (January 25, 2018): 312-314. 3. Christina Maslach, Wilmar B. Schaufeli, and Michael P. Leiter. “Job Burnout.” Annual Review of Psychology 52 (2001): 397–422.

Who’s at risk and why. In the United States, 40 to 50 percent of adults report lifetime sexual and physical IPV victimization. Suicide risk is high for IPV victims, relative to the U.S. adult population. Mental health, substance abuse , and/or barriers to help-seeking may explain suicide risk among IPV victims. Intimate partner violence (IPV) is a significant issue in the United States: Fifty percent of women and more than 40 percent of men have experienced contact sexual or physical violence or psychological victimization by an intimate partner in their lifetime (Leemis et al., 2022). Members of the LGBTQIA+ community are at particular risk for IPV, compared to their heterosexual counterparts (Harland et al., 2021). Transgender individuals are found to have an almost two times greater risk of IPV victimization than cisgender individuals (Peitzmeier et al., 2020). IPV begins in late adolescence and reaches its peak in emerging adulthood (i.e., ages 18-29 years; Arnett, 2018; Leemis, 2022). In 2021, there were 48,183 deaths by suicide in the United States. In provisional 2022 data, an approximately 3 percent increase in suicide deaths is reported (CDC, 2023). IPV victimization is associated with an increased risk of fatality, including suicide death. Women and LGBTQIA+ IPV victims are at greater risk of suicide death and behavior than male and heterosexual or cisgender IPV victims (Cavanaugh et al., 2011; Kafka et al., 2022; McManus et al., 2022). Younger age is also associated with death by suicide among IPV victims, which is of concern considering that IPV peaks in emerging adulthood (Leemis, 2022). What accounts for the relationship between suicidal behavior and IPV? Mental Health Correlates of IPV and Suicide IPV victimization is associated with an increased risk of depressive , anxiety , and posttraumatic stress symptoms in both men and women (Spencer et al., 2019). Women are more symptomatic than men (Spencer et al., 2019; Caldwell et al., 2012). Depressive and posttraumatic stress symptom severity may depend on the type of IPV victimization; for example, physical and sexual IPV victimization are associated with more severe depressive symptoms than psychological IPV victimization (Chesin et al., in submission). IPV survivors also have high rates of substance misuse, with 50 percent of women and 10 percent of men who enter substance use disorder (SUD) treatment reporting a history of IPV victimization (Cafferky et al., 2018; Schneider et al., 2009). SUD itself is associated with a significant risk for suicide death, particularly for women (Lynch et al., 2022). Given increased suicide risk with SUD, depressive, and/or posttraumatic stress symptoms (Dore et al., 2012; Østergaard et al., 2017), those IPV victims with comorbid mental health and SUD symptoms may be at particular suicide risk. In general, it may be that the relationships between IPV and suicide behavior are at least in part explained by SUD and/or mental health difficulties. Barriers to Help-Seeking Among IPV Victims Many IPV victims face difficulties with help-seeking; there are many theories as to why this is. Likely, it is a result of a constellation of factors that include the following: Psychological factors, such as learned helplessness, fear and shame, attachment to the perpetrator, and substance use and/or mental health difficulties subsequent to IPV victimization. Limited awareness and access to services, particularly among those who are financially dependent on the perpetrator or have limited material resources. Concerns about systemic issues, including historical failings of the justice system (e.g., not believing IPV victims, inadequate responses to reports). Cultural proscriptions against help-seeking and lack of culturally sensitive resources (e.g., native language services). Additional psychosocial factors may impede treatment engagement by male IPV victims and include internalized concepts of masculinity and internalized stigma associated with IPV victimization and help-seeking for it, as well as services that are predominantly designed for females (Cho et al., 2020; Hien & Ruglass, 2009; Robinson et al., 2020). Moving Forward More research on who among IPV victims is at particular suicide risk as well as research that explores risk factors in specific groups (e.g., psychological vs sexual or physical IPV victims) is needed. Further, studies exploring correlates for minority groups with known increased suicide risk, such as LGBTQIA+ IPV victims (Narang et al., 2018), are needed to better mitigate risk among vulnerable group members. Targeted suicide screening measures are needed, particularly when working with high suicide-risk IPV victims (e.g., emerging adults, women, LGBTQIA+ persons). Culturally relevant intervention programs are needed for IPV victims at suicide risk who are identified. Increased continuing education for mental health providers as it pertains to IPV and suicide can only aid in these efforts. If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the 988 Suicide & Crisis Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory. Kait Gilleran, M.A., is currently a graduate student in the Psy.D. Program at William Paterson University. Their interests and experience include risk assessment and providing psychosocial interventions to adults with serious and persistent mental illness. Megan Chesin, Ph.D., - Website - References For further reading: Chesin, M. S., Cascardi, M., & Gilleran, K. (under review). Associations between PTSD and depressive symptoms and victimization type among U.S. female college students: A latent class analysis. Additional Resources National Domestic Violence Hotline: 1-800-799-7233 Rape, Abuse & Incest National Network: 1-800-656-4673

Understand how perpetrators manipulate families to gain access to children. Perpetrators of child sexual abuse may not only sexually groom the child but also their family. Familial grooming involves the selection of a child due to family vulnerability and the development of trust. Family grooming may be more common when the victim is a child as opposed to a teenager. About two-thirds of all cases of child sexual abuse may involve familial sexual grooming. Child sexual abuse (CSA) is a serious global problem. However, most CSA go undisclosed and undetected. One reason for this is that the perpetrator may use sexual grooming behaviors. Sexual grooming is the deceptive process in which the perpetrator uses manipulative tactics and behaviors to sexually abuse a child while reducing the likelihood that the abuse will disclosed or detected by others. While most of the research on sexual grooming focuses on the behaviors and tactics directed at the minor, it is believed that perpetrators of CSA also engage in the sexual grooming of the minor's parent, guardians, and family —a phenomenon known as familial grooming. What Is Familial Sexual Grooming? Parents, guardians, and families play an important role in protecting their children from CSA by providing guardianship and supervision. To get around this guardianship and gain access to the child, perpetrators may engage in what has been termed "familial grooming. Familial grooming generally refers to the process by which a would-be perpetrator develops a close relationship with a potential victim's family so that they trust the perpetrator and allow them access to their child. For example, a coach could befriend a child's parents so they like and trust him. Consequently, they allow him to drive the child back and forth to practice when he offers to help, and they may allow the child to travel unaccompanied with the coach for away games when they cannot attend. Perpetrators groom parents and guardians for two main reasons: To more frequently and easily access the child To minimize the likelihood of disclosure or discovery from others Does the Child's Age Impact Familial Grooming? The extent of familial grooming may differ based on the age of the child. For example, teenagers have more autonomy and independence outside of their family, and thus, the perpetrator may use text messaging or social media to contact them without their parents' knowledge. Our research shows that familial grooming may not be necessary to have contact with older victims. What Familial Sexual Grooming Looks Like There are two main areas in which a perpetrator may engage in familial grooming: 1. The perpetrator may seek to select a victim based on family vulnerabilities. For instance, children may be targeted if they: are not close to their parents experienced neglect or abuse within the home lack supervision are psychologically vulnerable Family vulnerabilities may include: the presence of marital problems between parents a parent with a medical illness poor interpersonal relationships within the family a single-parent household 2. Once a victim is selected, the perpetrator may seek to gain access to the child through developing a trusting relationship with the family. This may include forming a friendship or romantic relationship with the caregiver(s). Once the relationship has formed, the adult may use that trust to have access to the minor so that they can then emotionally and physically isolate the child from the family. By using these tactics, the perpetrator can create situations in which they are alone with the child, such as taking them on overnight stays or outings without the suspicion of the parents and, in many instances, with parental consent. In cases where the perpetrator develops a romantic relationship with the parent or guardian, the perpetrator can now have unfettered access to the child within the home. Suppose a parent, guardian, and family is groomed. In that case, this can let the perpetrator go forward with the next steps in the grooming process, which involve developing trust with the child and those around them and desensitizing the child to physical touch and sexual content. How Common Is Familial Sexual Grooming? While no studies have explicitly studied familial grooming, research on tactics used by perpetrators of CSA suggests that in about two-thirds of the cases, perpetrators develop or exploit relationships with the family to get access to the minors. For example, one study of perpetrators of CSA found that two-thirds of perpetrators knew the victims through family, friends, or a caretaking role (e.g., babysitting). Another study of survivors found that in more than two-thirds of the cases, the most frequent sexual grooming tactic used was the manipulation of the family in the sexual grooming process. How Can Parents and Guardians Prevent Being Groomed? This is a tricky question because most people who befriend parents or guardians seek to do so because they genuinely care for them and their children. However, parents should be made aware that there are, unfortunately, some people with nefarious intent. Thus, it is important to understand how stereotypes and biases can impact judgment. One of the goals of developing this trusting relationship with parents or guardians is to prevent detection. Perpetrators rely on what is called cognitive dis­sonance—when someone's behavior does not match the image of them that you have in your head —you discount or excuse away the behavior. For example, suppose you see a long-time family friend hugging your child a little too long. In that case, you may tell yourself that the individual just cares about your child and is showing affection and not identifying the prolonged hug as a potential red flag for sexual grooming behavior. Thus, understanding how these types of biases develop can help parents and guardians look at the behavior of those around their child more objectively and follow up on any behavior that may be indicative of sexual grooming. Also, know that there is no profile of who may be a sex offender. Thus, just because someone seems like a nice guy, is a pillar of the community, is a woman, or a minor does not mean that they cannot be engaging in CSA. Make sure to look at their behavior and your child's reactions to them independently of their characteristics and relationship with your family. Elizabeth Jeglic, Ph.D., - Website -