What do factors like individualism have to do with seasonal affective disorder? Cultural aspects of individualism vs. collectivism and power shape how sunlight affects our mood. A study that looked at over 38,000 respondents found that winter SAD is linked to individualism. Power distance also affects coping with seasonal mood changes, with high PD linked to winter SAD. "The heat was beginning to scorch my cheeks; beads of sweat were gathering in my eyebrows. It was just the same sort of heat as at [my mother's] funeral, and I had the same disagreeable sensations—especially in my forehead, where all the veins seemed to be bursting through the skin.” This evocative description of emotional apathy in blazing heat comes from Albert Camus' novel The Stranger (L'Étranger) . First published in 1942, the novel follows the protagonist, Meursault, who shows a loss of interest in daily activities, hopelessness, and loss of meaning about his purpose in life with themes of detachment, isolation, and alienation under a blazing and relentless Algerian sun. But what if Meursault was in Alaska instead of Algiers? According to research on seasonal affective disorder (SAD), the first study of its kind showed that cultural context can significantly shape how individuals react to environmental factors like sunlight, which, in the case of SAD, profoundly affects mood and behavior. There are two manifestations of SAD: winter-onset, and summer-onset, which I write about here. Although the research on summer SAD is scarce, and most winter SAD is popularly known, a study in the Journal of Affective Disorders by Joseph Kasof explored how cultural factors influence seasonal depression across different nations. The study looked at two cultural factors: individualism versus collectivism (IC) and power distance (PD). Individualism versus collectivism (IC) is a cultural dimension that assesses whether societies value personal autonomy and individual achievement (individualism) or prioritize group harmony and the collective well-being (collectivism). Power distance (PD) measures how a society handles inequalities among people. In cultures with high power distance, where there are ever-present hierarchies, individuals may feel less control over their lives, whereas low power distance cultures, which favor personal empowerment, might offer more adaptive resources and flexibilities to cope with seasonal mood variations. The study examined 41 articles with samples across 18 countries, which reported frequencies of both winter SAD and summer SAD encompassing a total of 38,408 participants. The median sample size was 252 participants, with a median age of 38.4 years, and was 53.3% female. The research found that experiencing winter SAD, relative to summer SAD, correlated positively with individualism and negatively with power distance, meaning “countries in which winter SAD was more common than summer SAD were significantly more individualistic and less power-distant than countries in which summer SAD was more common than winter SAD.” Why might this be? In individualistic cultures, like Western Europe, Canada, and the U.S., people might experience greater distress during winter when shortened days (and sun exposure) decrease social activity and give no daylight break between working hours. With a high value placed on productivity and individual success, working from what may truly be sun-up to sun-down every workday might change one’s perception of the days and, consequently, life, leading to feelings of exhaustion and hopelessness. Therefore, even though through seasons, one's working hours may not have changed, the perception of having more time in the day, thereby a life apart from work, may protect from summer SAD. In collectivistic cultures, strong community bonds might mitigate some of these changes, possibly explaining the lower prevalence of winter SAD. In countries characterized by low individualism and high-power distance, summer SAD may be more common because of the pressure of maintaining social norms and fulfilling both work and familial obligations during longer days. This study presents an interesting question of how our cultural values may affect how we experience and physiologically respond to seasonal changes in light and weather. While we can never know how the narrative of “The Stranger” may have unfolded if Meursault had seen the sun as a welcome break from an Alaskan winter, considering not just the biological but also cultural underpinnings of how we respond to the environment can help us better understand ourselves and our world. Mariana Bockarova, Ph.D., References Kasof, J. (2009). Cultural variation in seasonal depression: cross-national differences in winter versus summer patterns of seasonal affective disorder. Journal of affective disorders, 115(1-2), 79-86.

Some say confess to cheating. Some say no. Either way there are consequences. Consider what is known colloquially as a one-night stand, not an affair of any length. Someone had too much to drink, or a long-simmering attraction came to a boil. It could happen when one of the partners is out of town and the perfect opportunity occurs. The lapse weighs heavily on the straying partner, who wants to clear his or her conscience and disclose it to their partner. The cheater’s conscience may be cleared—but the confession may end the relationship . At the very least it will end the partner’s trust. Very often, the one betrayed want to know who, when, where how many times and how they compare as a lover—intimate details of the event the cheater had no intention of sharing. If the sexual partner in this is someone known to them both, the injured party may insist that the person of the event be banished from their lives. If the sex partner is someone met while traveling, it isn’t an issue. But if it’s someone in their regular social circle or a work colleague of the cheater, avoiding future contact can pose many complications. Another option for the guilty party needing to confess is to unburden to someone other than their partner—a good friend, relative, or a member of the clergy. That may open the door to lectures on morality, shaming, and a sense that forever more that person “has something on you.” A third option is to keep the secret of one’s indiscretion, which, my experience as a therapist has taught me, is very difficult for many. Withholding a guilty secret from one’s partner can be like the proverbial elephant in the room, something forever unsaid weighing on the conscience. For some, the option is not even possible for the life of the relationship—it might be blurted out months or years from the lapse itself, perhaps used as a weapon in an argument. In any case, holding the secret may weigh heavily on the one who cheated and doing so may feel like a punishment. In fact, not telling is often punishment for the betrayal of the relationship. Holding a secret one would very much like to tell, keeping a secret from one’s partner, becomes a burden the cheater must shoulder, a difficult punishment. Often the cheater decides that holding the secret is the wisest option but at some point, months or even years later, feels he or she can no longer do so. When a confession comes well after the betrayal, the partner’s response is often worse than a timely confession would have been. The “how could you keep such a secret from me?” accusations tend to be very bitter. So, unless the cheater is positive his or her partner will “understand” or the cheater is willing to take the punishment is meted out by the partner, it may be wise to think more than twice about burdening them with the knowledge. As I have said to many clients over the years, I think that s/he who cheated should bear the burden of the secret. What do you think? Isadora Alman, M.F.T., - Website - Book -

From pressure to peace: Finding balance in the pursuit of excellence. Cultural pressures fuel rising perfectionism, leading to mental health challenges. Perfectionism often causes anxiety , depression , and relationship strain. Recognize perfectionist patterns to begin changing unhealthy behaviors. Adopt mindfulness and self-compassion to embrace imperfection. Initially, perfectionism may seem like a positive trait that drives us to excel and achieve. However, this relentless pursuit of flawlessness can negatively impact mental health. In high-stress environments such as work and school, where the pressure to perform at one’s best is especially overwhelming, perfectionism can be particularly common. Understanding the roots of perfectionism and its profound effects on mental health is essential for addressing this pervasive issue. Understanding Perfectionism Perfectionism is not merely about having high standards or striving for excellence. It involves an unrelenting need to meet impossible standards and a fear of failure that can be debilitating. Research from Curran and Hill (2019) indicates that levels of perfectionism have increased significantly among young people over the past few decades, driven by social and cultural pressures to achieve at all costs. To effectively combat perfectionism, it is crucial to explore its underlying causes and recognize how it manifests in everyday life. By doing so, we can gain insights into why perfectionism develops and how it impacts our mental and emotional well-being. Causes of Perfectionism Cultural and Societal Pressures: Societal norms and expectations often promote the idea that success and worth are tied to being perfect. Media and cultural narratives glorify flawless achievements and set unrealistic standards, leading individuals to internalize these ideals. Family Dynamics: High expectations from family members, or a family environment where love and approval are contingent upon success, can instill perfectionist tendencies from a young age. This conditional acceptance can create a deep-seated fear of failure and a constant need to prove oneself. Personal Traits: Individuals with certain personality traits, such as high conscientiousness, sensitivity to criticism, or a strong desire for control, may be more prone to perfectionism. These traits can make them more vulnerable to the pressures and demands of perfectionist ideals. Fear of Judgment: A fear of being judged or criticized by others can drive perfectionist behaviors. Individuals may strive for perfection to avoid negative evaluations, believing that any imperfection could lead to rejection and social disapproval. Effects on Mental Health Anxiety and Depression: The constant pressure to meet unattainable standards can result in chronic stress, anxiety, and feelings of inadequacy, potentially leading to depression. A study by Smith et al. (2021) found a significant correlation between perfectionism and anxiety disorders, highlighting the mental health risks associated with this trait. Procrastination: Fear of making mistakes or not achieving perfection can cause individuals to delay tasks, leading to procrastination and further stress that impedes one's professional and personal development. Research shows that procrastination often stems from a fear of failure and perfectionist tendencies, creating a vicious cycle. Burnout: The relentless pursuit of perfection can lead to physical and emotional exhaustion, reducing one’s overall well-being and productivity. Burnout, characterized by feelings of extreme fatigue and cynicism, is often a consequence of perfectionist behaviors , especially in high-pressure environments. Impaired Relationships : Perfectionists may impose their high standards on others, leading to strained relationships and social isolation. This behavior can exacerbate feelings of loneliness and depression, as perfectionists often struggle to connect with others on a deeper, more authentic level. Recognizing the Signs of Perfectionism Recognizing the signs of perfectionism is the first step toward addressing its impact on mental health. Perfectionists may struggle with decision-making, procrastinate due to fear of not achieving perfection, and feel intense pressure to meet unrealistic expectations. Acknowledging these patterns allows individuals to begin the process of change and seek healthier ways to manage their tendencies. Strategies to Challenge Perfectionism Set Realistic Goals: Break tasks into manageable steps and set achievable, realistic goals. Focus on progress rather than perfection and celebrate small victories along the way. Emphasizing growth over flawless achievement can reduce stress and increase motivation. Challenge Negative Thoughts: Identify and challenge perfectionist thoughts. Replace them with more balanced, realistic perspectives. Cognitive-behavioral therapy (CBT) techniques can be particularly effective in reshaping negative thought patterns. Practice Mindfulness: Engage in mindfulness practices to stay present and reduce anxiety about future outcomes. Mindfulness can help you accept imperfections and appreciate the present moment, fostering a more compassionate relationship with yourself. Limit Social Comparisons: Reduce exposure to social media and other sources of comparison. Focus on your unique journey and personal growth rather than comparing yourself to others. Studies show that reducing social media usage can decrease feelings of inadequacy and improve mental well-being. Techniques to Embrace Mistakes Reframe Mistakes: View mistakes as valuable learning experiences rather than failures. Each mistake can be a chance to grow, adapt, and improve. Embracing mistakes as part of the learning process can lead to increased resilience and creativity. Practice Self-Compassion: Treat yourself with the same kindness and understanding you would offer a friend. Acknowledge your efforts and recognize that imperfection is a natural part of life. Self-compassion has been shown to reduce anxiety and increase overall life-satisfaction. Develop a Growth Mindset: Embrace a growth mindset, which emphasizes learning and development over fixed abilities. Understand that skills and abilities can be developed through effort and perseverance, leading to greater achievement and personal fulfillment. Engage in Self-Care: Prioritize self-care activities that promote relaxation and well-being. Regular exercise, adequate sleep, and hobbies can help reduce stress and improve overall mental health. Engaging in self-care can also foster a sense of balance and fulfillment. Conclusion Overcoming perfectionism is a journey that requires patience, self-awareness, and a willingness to embrace imperfections. By understanding and challenging perfectionism, you can lead a more fulfilling and balanced life. Remember, it’s okay to be imperfect – it’s a natural part of the human experience and an essential aspect of personal growth. Embracing your imperfections can lead to a more authentic and joyful life, free from the constraints of perfectionism. Cara Gardenswartz, Ph.D., - Website - References Curran, T., & Hill, A. P. (2019). Perfectionism is increasing over time: A meta-analysis of birth cohort differences from 1989 to 2016. Psychological Bulletin, 145(4), 410-429. Smith, M. M., Sherry, S. B., & Saklofske, D. H. (2021). Perfectionism and depression: A meta-analytic review. Journal of Research in Personality, 87, 103993. Stoeber, J., & Damian, L. E. (2016). Perfectionism and procrastination: A meta-analysis of main, mediator, and moderator effects. Personality and Individual Differences, 95, 80-86. Leiter, M. P., & Maslach, C. (2016). Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry, 15(2), 103-111. Shafran, R., & Mansell, W. (2001). Perfectionism and psychopathology: A review of research and treatment. Clinical Psychology Review, 21(6), 879-906. Neff, K. D. (2011). Self-compassion, self-esteem, and well-being. Social and Personality Psychology Compass, 5(1), 1-12. Dweck, C. S. (2006). Mindset: The new psychology of success. Random House. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822-848. Verduyn, P., & Gugushvili, N. (2021). The impact of social network sites on mental health: A review of experimental evidence. Current Opinion in Psychology, 36, 10-17. Hollender, M. H. (1978). Perfectionism, a neglected personality trait. Journal of Clinical Psychiatry, 39(6), 384-394.

5 myths and truths about PTSD. Trauma symptoms have historically been diagnosed under various terms before PTSD emerged. Misconceptions surrounding trauma and PTSD include the belief that emotional wounds equate to trauma. C-PTSD, distinct from PTSD, is less common and lacks a unified diagnosis criteria. The first recognized diagnosis for the effects of experiencing traumatic events was "hysteria." Historically, hysteria was predominantly associated with women and included a range of symptoms and psychological disturbances. It was believed to stem from the uterus and was often attributed to unmet sexual needs or subconscious conflicts. The diagnosis of hysteria quickly fell out of favor. Some texts assume that the high correlation between sexual trauma and incest may have been one of the reasons why studying trauma became inconvenient. "Shell shock" was the diagnosis that emerged during the World Wars, used to describe the psychological and emotional effects of combat on soldiers. It highlighted visible traumatization symptoms such as tremors, paralysis, and emotional instability experienced by soldiers exposed to the horrors of war. It was also shelved for decades. The term "trauma" itself was not used to describe psychological issues until later. It’s important to clarify: the term “trauma” is not and has not been used as a diagnosis, despite common misconceptions. What became a diagnosis in the 1980s is post-traumatic stress disorder (PTSD) , with the purpose of providing a framework for understanding the effects of traumatic stress, observed mainly in veterans and battered women. Still, for many people, trauma seems to mean a verdict about an unwelcoming future. Let’s try to change that perception by debunking some of the myths about how to name the effects of experiencing traumatic events. Myths About PTSD Myth #1: Trauma and heartbreak are the same. Going through emotionally challenging situations can certainly cause emotional pain and leave a mark, but not all emotional pain constitutes trauma. Trauma includes only those situations that make us feel as if we are confronting irredeemable danger. For instance, feeling heartbroken after a breakup is painful, but it doesn't amount to trauma unless the person's life feels threatened, such as when the partner of a disabled person leaves. If livelihood doesn’t depend on the ex-partner, the person will carry some emotional pain but won’t be traumatized. Enduring emotional pain is a natural part of being human, and our resilience enables us to navigate it over time. Myth #2: All emotional wounds cause trauma. Trauma involves the activation of survival responses after experiencing distressing events that make us feel unsafe even after the event is over and the risk is gone. There are many experiences that can leave emotional marks without necessarily inducing such type of survival responses. Grief and loss, for example, can be deeply painful without any connection to an immediate threat. Similarly, feelings of loneliness, disappointment, frustration, conflict in a relationship, identity issues, or even anger can be emotionally distressing without involving having to extremely protect our lives. While uncomfortable memories and emotions may linger as residue of emotionally painful experiences, our innate capacity to adapt and recover helps us return to normalcy. It’s a matter of integrating those experiences into our lives without being overtaken by them. Myth #3: Trauma and PTSD are synonymous. While PTSD is the disorder commonly associated with the aftermath of experiencing traumatic events, not everyone who encounters adversity or suffers from stress after a traumatic event develops the disorder. Most individuals have resources—such as cognitive schemas and social connections—that promote feelings of safety and security. Using confidence as a guiding force helps to bring their system back to its pre-trauma state even after horrific experiences. Just a minority of those who experience traumatic events develop PTSD. Myth #4: PTSD means dysfunction for life. The diagnosis of PTSD is often stigmatized due to its association with war, rape, and violence. Unfortunately, it’s quite common to assign the PTSD diagnosis to people who experience events considered awful without investigating further. Don’t take a diagnosis at face value. To assign a PTSD diagnosis to someone, multiple and persistent symptoms need to be present over time. Most importantly, even those with a severe PTSD presentation have the capacity to reduce symptoms and stop them from further developing, to return to an almost normal level of functioning. As adaptive beings, our experiences are registered to aid us in the future, allowing us to assign new meanings to past emotions as we move forward. Myth #5: C-PTSD is just a more extreme version of PTSD. While PTSD and C-PTSD—complex post-traumatic stress disorder—share similarities in terms of symptoms and underlying mechanisms, they are two different syndromes with important differences. C-PTSD typically unfolds after prolonged or repeated exposure to traumatic events or adverse circumstances, most often interpersonal in nature. Individuals who have experienced lasting abuse, exploitation, or severe circumstances are more likely to meet the criteria for C-PTSD. In contrast, PTSD typically results from a single, discrete traumatic event or a series of events that occur over a relatively short period. Since C-PTSD develops gradually, it can lead to a different set of symptoms that may include disruptions in self-concept, difficulties in regulating emotional reactions and mood, impaired relationships, and pervasive feelings of shame, guilt, or worthlessness. In contrast, PTSD symptoms often revolve around re-experiencing the traumatic event and avoidance of reminders. I’d like to leave you with an important concept. Both PTSD and C-PTSD share the common feature of becoming a lasting issue once the survival circuits disrupt the nervous system's balanced activity, leading to the development of trauma symptoms. Still, clinicians often diagnose PTSD more frequently because the symptoms of C-PTSD may overlap with other disorders such as BPD, making it more challenging to distinguish and diagnose (Herman, 1992). Antonieta Contreras - Website - Book -

Cranky in the morning? Sufficient sleep is necessary for control of emotions. Emotion regulation is often challenging for adolescents. Poor sleep can impair people's ability to control their emotions. Physiological mechanisms underlying sleep and emotional control have been discovered. Every time I talk about how sleep is important for child and adolescent development; any audience can relate to how they feel and function when their sleep is of insufficient duration and quality. A common experience for all of us is to feel “out of sorts” after too little sleep or a bad night’s sleep. We are often more irritable than usual, and researchers infer that such behavior is due to emotional dysregulation . Adolescence is a time of rapid changes in body, emotions, and behavior, and sleep researchers have demonstrated empirically that poor sleep can amplify negative emotions and affect their control. The implications extend to family relations, adjustment and performance at school, and all too often, mental health problems. Understanding what underlies the relationship between sleep and emotion regulation has been a scientific goal for decades, and advances in technology have accelerated research. One of my favorite studies is one reported in 2007 in Current Biology, “The Human Emotional Brain Without Sleep—A Prefrontal Amygdala Disconnect” (Yoo et al., 2007). In that experimental study, adults were sleep-deprived and then underwent fMRI scans. They concluded that when people were sleep deprived, the parts of their brains associated with emotions—the limbic system and, specifically, the amygdala—had an amplified response. Moreover, there were fewer signs of connectivity between the limbic system and the prefrontal cortex, which is often engaged to regulate intense emotions. Typically, an aroused limbic system is calmed down both during waking hours and during sleep. But when the subjects were sleep-deprived, their emotions were poorly controlled. While fewer studies have been done with children , those that have been done show similar results. In a 2016 study done at Emory University, researchers found that children whose sleep was shorter showed weaker connectivity between the amygdala and the prefrontal cortex. A 2018 review in Sleep Medicine Reviews summarizes this line of research with children and adolescents. Another review published in 2020 looked at how sleep affects brain processes that can be the precursors of later anxiety and depression in adolescents. We now are beginning to understand some of the physiological mechanisms that underlie the link between poor sleep and adolescents’ emotions. Emotion dysregulation is challenging for adolescents, for their parents and teachers, and for their social relations with peers. The take-home message, though, is the same one that we sleep researchers have known for a long time: Sleep of sufficient duration, quality, and regularity is critical for many aspects of adolescents’ daily lives. Joseph A. Buckhalt, Ph.D.,

Personal Perspective: The way you deal with a panic attack can impact its effect. How you deal with a panic attack in the moment can significantly impact its severity. You can do specific things during a panic attack to help it quickly resolve. Often, people's behaviors between attacks inadvertently make them more likely to occur. Suppose the symptoms of a panic attack come on, and you think something like, “I think I’m having a heart attack” or “I’m going to do something out of control.” Those thoughts will only fuel your anxiety and potentially make the panic attack more severe and challenging to deal with. In more extreme cases, people might even go to the emergency room because the symptoms are so scary. However, there is another path that is not as scary and bleak. I have been working in the area of anxiety for over 25 years. I’ve worked on research studies of panic disorder and have treated many people over the years who had panic attacks. Even though I have had all of that experience working with panic attacks, it doesn’t necessarily mean I’m immune to experiencing them myself. In fact, given the right circumstances, virtually anyone could have a panic attack. They are so common that about 28% of the US population will experience at least one panic attack in their lifetime. About a year ago, we decided to put my 19.5-year-old cat Yakkha to sleep. In addition to being very old, his health had taken a decline, and we decided it was best to put him out of his suffering. During his last night with us, my husband suggested we do a “living memorial” where we would sit with Yakkha, tell him how much he meant to us over the years, and look at pictures of him. Although I had mixed feelings about doing this, my husband felt pretty strongly about it, and I felt like it could be a good way for my son to process his grief. I had a head cold, so I was having some difficulties breathing as it was, but when I added hysterical crying to the mix, I found that I couldn’t breathe at all through my nose. I then had the sensation that my throat was closing up, and I thought, “I can’t breathe.” Those sensations and thoughts kicked my anxiety up into full gear, and the symptoms of panic began to come over me. However, because I have had experience working in the field of anxiety, I was able to recognize what was going on quickly. “I’m having a panic attack,” I said to my husband and told him I needed to stop. I went into the kitchen and got a glass of ice water, which helped alleviate the throat-closing symptom. After drinking the water, clearing my nose, and taking some deep breaths, I quickly calmed myself down and returned to the memorial. Had I catastrophized those symptoms and not recognized it as a panic attack, it could have escalated significantly. If you are someone who struggles with panic attacks, here are some tips to help you cope: 1. Make sure you are up to date with doctor’s appointments Many people who have panic attacks think there is something wrong with their bodies, which is understandable because the symptoms are so intense. It’s helpful to get medically cleared so that you know that nothing is physically wrong with you. Suppose you have a history of medical issues , like cardiac problems, as well as panic attacks. In that case, it’s essential to talk to your doctor about differentiating between the two. 2. Label the panic attack, and don’t catastrophize Because I could label the panic attack, it took the wind out of its sails. I knew that panic attacks are not dangerous and that they won’t go on indefinitely. It might be helpful to say to yourself something like: “I’m having a panic attack, and it will pass. It is not dangerous.” 3. Use physical or sensory distractions For me, the sensation of the ice water was helpful at the moment. Cold water or ice can help some people because it triggers the parasympathetic nervous system, which calms you down. You could also dunk your face in ice water or take a cold shower. For some, taking deep breaths can also calm down a panic attack, which was also helpful for me. 4. Don’t live your life in fear of panic attacks Many people who have repeated panic attacks tend to worry about having another attack and inadvertently reinforce them between attacks. For example, they might monitor their bodies by checking their pulse frequently. Or they might avoid situations associated with panic attacks. The problem with these types of behaviors is that they keep panic attacks front and center in the mind and make them more likely to occur. It’s best to work on reducing body monitoring and avoidance behaviors. When you need more help If you have challenges with coping with panic attacks or if you have made lifestyle changes to accommodate the attacks, like avoidance and frequent body monitoring, a therapist who specializes in panic and anxiety can help. Panic attacks don’t need to rule your life. Bonnie Zucker, Ph.D., - Website -

How to live well, inspired by caring for survivors of 9/11. As the first medical director and attending psychiatrist at the World Trade Center Mental Health Program at Bellevue/NYU, Sue Varma directly supported and treated civilian and first-responder survivors of the tragic 9/11 events. After years of working closely with individuals who had faced some of life's most profound challenges, she was moved to develop a philosophy of practical optimism, which happens to be the title of her new book. I spoke with her recently. GHB: What is practical optimism? And how did the book and philosophy come to be? SV: In the interactions with the 9/11 survivors, I witnessed the full spectrum of human response to stress and trauma . I saw people who were devastated and seemed to stagnate under the weight of their experiences. But I also witnessed remarkable resilience and growth in others, individuals who not only survived but thrived despite facing immense adversity. What explains the difference between those who crumble under the weight of stress and those who emerge stronger? My fascination with these experiences and the questions they raised drove me to delve deeper into the realms of psychology, psychiatry, medicine, and neuroscience. I sought answers not only in academic research but also in philosophy and personal experiences. Over time, a powerful revelation began to take shape, which coalesced over time into a coherent set of principles behind practical optimism. My work involves the fusion of two seemingly opposing ideas—optimism and practicality—that, when combined, can truly transform lives. It's about believing in the limitless positive potential within oneself and others while simultaneously mastering key behavioral skills that pave the way for healthy and rational decision-making. In creating practical optimism, my goal has been to offer a path to personal growth and success. GHB: What does it mean for you personally? SV: I wrote the book Practical Optimism because I wanted to provide a comprehensive guide and philosophy to help people navigate life's challenges and achieve personal and professional success. Throughout my 20 years of working with individuals facing trauma and everyday difficulties, I often encountered the need for a resource that encapsulated the best practices we had developed together. Many of the people I served had asked me to recommend a book that covered topics such as stress management, resilience, fostering friendships, promoting positive thinking, dealing with challenges, and achieving success. While Practical Optimism cannot replace therapy , it is my way of sharing the valuable insights and strategies. I see myself as a co-conspirator in your pursuit of a better life, and that brings me great joy and satisfaction. As a physician, I believe that my duty extends beyond merely restoring function; it is also about guiding patients and readers from dysfunction to optimal living. The heart and joy poured into the research and writing reflect my commitment to helping individuals lead happier and more fulfilling lives. GHB: What are your key principles? SV: The book covers much more territory, but, in brief, practical optimism is a practice that we incorporate into our life, much like exercise, yoga, meditation, journaling. In the book, I provide a toolbox of strategies and insights, allowing you to tailor the practice to your specific needs and preferences. Each person will discover different aspects of practical optimism that resonate with them personally. Among the core principles, I place significant emphasis on what I refer to as the 4 Ms of Mental Health: Movement, Mastery, Meaningful Engagement, and Mindfulness. There are also 8 core principles of practical optimism (the 8 Ps of practical optimism), which don’t need to be practiced in any order but that start with setting a vision and intention (purpose), then executing upon it while recognizing that life will throw you stumbling blocks (problem solving). There are tons of tips on managing your mood and emotions, getting more out of your friendships and relationships, maximizing your physical health (practicing healthy habits), a recipe for really any goal you want to accomplish. GHB: Is there a downside to optimism? SV: Not really. But like anything in this world, the outcome largely depends on how you approach it. Optimism, when practiced in a balanced and practical manner, offers numerous benefits for mental well-being and resilience. However, it's essential to be aware of potential pitfalls. One potential pitfall is falling into the trap of toxic positivity or magical thinking. Toxic positivity involves an excessive focus on maintaining a positive outlook at all costs, often at the expense of acknowledging real challenges or negative emotions. It can lead to the suppression of valid concerns or emotions, which isn't healthy in the long run. Similarly, magical thinking involves overly optimistic beliefs without a basis in reality or concrete action. Practical optimism encourages acknowledging challenges and negative emotions while actively working towards positive outcomes. It's about finding a healthy balance that fosters genuine optimism while addressing real-life issues effectively, as you equip yourself with skills and the know-how to do so. GHB What are key tips for readers to develop practical optimism starting today? SV: There are things we can all do to start preparing ourselves to take on a practical optimism practice. Here are a few good places to start: Embrace Realistic Optimism. Start by understanding that practical optimism is not about denying challenges or negative emotions. It's about believing in positive outcomes while acknowledging the realities you face. Learn from Experience. Reflect on past experiences, both positive and challenging. Identify moments when optimism helped you navigate difficulties and draw lessons from those situations. Set Achievable Goals. Break down your goals into manageable steps and set realistic expectations. By achieving small wins, you build confidence in your ability to shape a positive future. Practice Gratitude. Regularly express gratitude for the positive aspects of your life. Shift your focus toward optimism by highlighting the good things you often take for granted. Stay Connected. Foster supportive relationships with friends and family. Social connections provide essential emotional support and encouragement. Practice Mindfulness and Self-Care. Incorporate mindfulness practices into your daily routine to build self-awareness and help manage stress effectively. Prioritize self-care to ensure you are prepared to face challenges. Seek Inspiration. Surround yourself with inspirational content, whether through books, podcasts, or inspirational figures. Sue Varma, MD, PC, DFAPA, is a psychiatrist and cognitive behavioral therapist based in New York City with over two decades of private practice experience. She served as the pioneering medical director and psychiatrist for the esteemed 9/11 mental health program at New York University (NYU). Alongside her clinical work, Varma holds the position of Clinical Assistant Professor of Psychiatry at NYU Langone Health. Her accomplishments have been recognized by the American Psychiatric Association (APA), which honored her as a Distinguished Fellow, the highest honor bestowed upon its members. Grant Hilary Brenner, M.D., - Website - Book - References Practical Optimism: The Art, Science and Practice of Exceptional Wellbeing

Personal Perspective: Life events can often bring past issues into the present. When a major life event occurs, adult survivors of child abuse must often run interference for their abusers. There's no shame in trying to explain an extended family's dysfunction to others who have no concept of such. By not hiding or being ashamed of past abuse, survivors make it OK for other survivors to do the same. Being confronted by the past can leave one more resilient and even more committed to living one's best life. As an adult survivor of child abuse, I’m not sure I’ll ever be fully healed of the horrific experiences I was raised in. Even as someone who lives life with a grateful heart for friends, relationships, and business-related successes, there are times I come face-to-face with circumstances that instantly put me in touch with the inner child who was neglected, beaten, and left alone at a very young age for days on end—not sure if my sister and I could endure the circumstances; at one point even calling the police for help and having them refuse to investigate. Like me, many survivors of abuse react to things differently, live a little differently, and must handle life’s watershed moments differently. Recently, I was informed that my father had passed away. Due to dementia issues and his residing in an assisted living facility overseas (where he had been married to his third wife), he and I didn’t have much of a relationship. This wasn’t by choice. I decided long ago that I would entertain polite, if curt, exchanges with my birth parents for my own mental well-being. Not for their sake. Unlike some abusers, my parents never admitted to or even saw the error of their ways. My mother went to her deathbed claiming my sister and I were both adopted. Even her obituary stated as much—and as a matter of record, we were not. In hindsight, I surmise that my mother was very mentally ill. This calls into question why our dad and other relatives would leave my sister and me alone in her care. So, my father’s passing is bittersweet. It’s not something I celebrate. I do mourn for him. I tell myself he was doing his best, even at his worst. And yet, his passing brings up all kinds of issues. His will. His burial. His obituary. In most cases, there’s a methodology for handling life’s milestones. But in broken families, there is not. And when you insert other characters (second husbands, second and third wives) into the mix, things get even more complicated. Suddenly, the discarded child wonders if they’ll even be invited to the funeral, much less consulted regarding the last will and testament. Explaining this dysfunction even to people who know and love me and my sister is a chore. We can see their facial expressions change from consolation to confusion. Why aren’t we more sad? Why wouldn’t we know if our dad had a will? Or what his wishes were regarding how he’d like to be laid to rest? And why haven’t we spoken to our parents in years? The looks from others then usually turn suspicious in nature—as if my sister and I are somehow the culprits or, at the very least, coconspirators in our family’s web of dysfunction. And so, when a parent passes, or another major life event occurs (whether it’s an occasion that inspires happiness or grief ), adult children of dysfunctional families must not only run interference for themselves but also their abusers. It’s a tragic hangover from a life that, for many, would be too terrifying even to hear the details of. But I’ve learned that by not hiding these issues in the shadows—even if we sometimes confuse the curious—we make it OK for others who’ve lived through similar hardships. It turns out the “normal” can also be abnormal. And for those of us doing the best we can to stop the legacy of abuse in our family trees, being true to ourselves—mental and/or physical scars from the past and all—is the best gift we can give ourselves and the best kind of behavior we can model for others. There’s no shame in surviving. No matter how that’s defined for anyone reading this. Sometimes, waking up, getting dressed, and showing up for the new day takes a monumental effort for the adult survivor of child abuse. Much less dealing with major life events like the death of a family member. Even when it’s the passing of one of the perpetrators who never allowed us the joy and safe feeling of being a child. Not to mention the feeling of being loved—or even wanted. We all deserve to rest in or be at peace—even those of us who have survived and are still among the living. Being confronted by our past, while often jolting, can help us to be more resilient and even more committed to living our best lives. Gregg McBride - Website -

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.