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For many, perfectionism and stress are the primary drivers of eating disorders. In some cases, a desire for thinness is not the primary motivation for an eating disorder. For many, an eating disorder is a stress management tool arising in response to chronic stress. A tendency toward perfectionism is also a risk factor for eating disorders. More than 20 percent of people with eating disorders also battle substance use disorders. Semantically, eating disorders are highly associated with body image. Clinically, this association makes complete sense as approximately one-third of people with eating disorders also experience body dysmorphic disorder,1 and many more struggle with negative body image. However, for some people body image concerns are not the primary trigger of an eating disorder, making these challenges somewhat less relevant when we consider why these individuals develop eating disorders. Studies have found that, in general, individuals with certain genetic variations and experiences of abuse and trauma are more likely to develop eating disorders at some point in their lives.2,3 Likewise, people with higher “baseline” levels of anxiety are more likely to develop disordered eating later in life.4,5 It’s also well-established, even at the cellular level, that chronic stress alters our brain and body in a way that increases our chances of developing an eating disorder.6 This appears to be particularly true for people who develop bulimia and binge eating disorder. In other words, when we try to understand the reason behind someone's eating disorder, we must consider far more than whether they are satisfied with their body or not. Purging to Be the Best Earlier this year, I had the opportunity to interview Jessica Grenzy, a 41-year-old female in recovery from bulimia nervosa. In 2018, she went into cardiac arrest. She survived to tell her story. Jessica grew up in a competitive household. At age 12, she began swimming and quickly rose to a competitive level. In parallel, she excelled in school and earned a spot on the honor roll. She was a child to be proud of—but it was not necessarily priding that Jessica experienced at home. Her father, competitive by nature, paced Jessica and her sister to excel in everything they did, applying relentless pressure to perform at the highest caliber. This home environment was a tremendous source of stress, leading Jessica to constantly wonder how she could improve both physically and mentally. Her father was shaping her into becoming a perfectionist, a mindset that is well-known to increase people’s risk of developing an eating disorder.7 Despite growing up surrounded by diet culture and the thinness ideal, Jessica did not experience disordered eating until she saw a particular movie at age 16. In the movie, two volleyball players used purging in an attempt to stay fit. Jessica was hooked. This was her ticket to not just be but also look the best. Her primary goal was to meet the high expectations instilled in her. At the time, she would have even insisted there was nothing wrong with her body. Her actions were driven primarily by her desire to excel, and perhaps please her father, rather than by the desire to be skinny. Never in my wildest dreams did I think that it would go anywhere or continue to this day. But I remember that [this movie] is what triggered my first [purging] behavior. From Eating Disorder to Substance Use Disorder and Back Again Jessica’s eating disorder was not a reflection of disliking her body; it was a means to achieve perfection. At 18, her swimming career ended, and with it, so did her eating disorder. This sort of “spontaneous” recovery is not unusual; I experienced it myself as a teenager. But it's typically not a “true” recovery, just a shift in behaviors. In Jessica's case, as she lessened her eating disorder behaviors, she started leaning into alcohol. Feeling like she had missed out on social life during her teens, she was determined to make college about having fun, which for her meant drinking. But beyond fun, alcohol became a tool to manage stress. It is estimated that 22 percent of people with eating disorders also experience a substance use disorder.8 Jessica slowly but steadily developed into what many would refer to as a “functional alcoholic.” She managed to maintain good grades, later excelled at her job, and kept up social relationships, but she was dependent on alcohol. As is common with heavy and regular alcohol intake, Jessica started gaining weight and suddenly the dormant eating disorder behaviors returned in full force. This time, body size and shape were at the center of her restriction and purging behaviors. Drinking, restricting, and purging became daily activities, and working in the food and beverage industry only perpetuated her behaviors. It is estimated that 17 percent of workers in this industry experience a substance use disorder and 63 percent report signs of disordered eating. When Cardiac Arrest Keeps You Alive In 2017, Jessica met her now-husband; inspired by his alcohol abstinence, she quit drinking too. Recovering from her alcohol use disorder was relatively easy; living with a sober partner and attending regular Alcoholics Anonymous meetings provided her with a supportive community. However, what was not easy was the sudden and unexpected exaggeration of her eating disorder behaviors. Left with only one strategy to manage stress, Jessica purged and restricted more than usual. Up until this point, no one knew about her eating disorder. On December 29, 2018, two months after quitting alcohol, Jessica went into cardiac arrest. The cardiac arrest was probably the best thing that ever happened to me. Regular vomiting can lead to severe electrolyte imbalances and, ultimately, heart failure. Jessica says that her heart attack was her real wake-up Regular vomiting can lead to severe electrolyte imbalances and, ultimately, heart failure.9,10 When assessing the physiological impacts of an eating disorder, it’s crucial to always include blood work. Failing to do so can lead to unexpected and serious consequences, such as organ failures. This complication is one of the primary reasons eating disorders remain among the top two deadliest psychiatric disorders.11 The cardiac arrest was a turning point for Jessica; for the first time, she sought treatment. For over 15 years, Jessica had been one of the approximately 27 percent of people with eating disorders who go untreated. She was ready to change that, but a lack of access to specialized providers in her area delayed her treatment by almost one year. This issue is well-documented and disproportionately affects people of color and those with public insurance.12 For Jessica, recovery is more than just stopping purging and restricting; it means redefining what it means to be a good person, a good wife, a good colleague, and a good mother. Perfectionism, along with the stress of it, was instilled in her at a young age, but managing it required substantial coping mechanics. Treatment had taken away her usual tools: alcohol and purging. Now she’s working on finding new, healthier ways to cope. I was a new mom, a new wife. I had to be the perfect mother. Now I have just learned that there is no such thing as that. Pernille Yilmam, Ph.D., - Website - References 1 - Ruffolo, J. S., Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. B. (2006). Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance. The International journal of eating disorders, 39(1), 11–19. 2 - Barakat, S., McLean, S. A., Bryant, E., Le, A., Marks, P., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2023). Risk factors for eating disorders: findings from a rapid review. Journal of eating disorders, 11(1), 8. 3 - Batista, M., Žigić Antić, L., Žaja, O., Jakovina, T., & Begovac, I. (2018). PREDICTORS OF EATING DISORDER RISK IN ANOREXIA NERVOSA ADOLESCENTS. Acta clinica Croatica, 57(3), 399–410. 4 - Frank, G. K. W., Shott, M. E., Pryor, T., Swindle, S., Nguyen, T., & Stoddard, J. (2023). Trait anxiety is associated with amygdala expectation and caloric taste receipt response across eating disorders. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 48(2), 380–390. 5 - Schaumberg, K., Zerwas, S., Goodman, E., Yilmaz, Z., Bulik, C. M., & Micali, N. (2019). Anxiety disorder symptoms at age 10 predict eating disorder symptoms and diagnoses in adolescence. Journal of child psychology and psychiatry, and allied disciplines, 60(6), 686–696. 6 - Hardaway, J. A., Crowley, N. A., Bulik, C. M., & Kash, T. L. (2015). Integrated circuits and molecular components for stress and feeding: implications for eating disorders. Genes, brain, and behavior, 14(1), 85–97. 7 - Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S., & Simonich, H. (2007). Perfectionism and eating disorders: current status and future directions. Clinical psychology review, 27(3), 384–405. 8 - Bahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A., & Hawken, E. (2019). Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis. Psychiatry research, 273, 58–66. 9 - Puckett L. (2023). Renal and electrolyte complications in eating disorders: a comprehensive review. Journal of eating disorders, 11(1), 26. 10 - Ewan, S. L., & Moynihan, P. C. (2013). Cardiac arrest: first presentation of anorexia nervosa. BMJ case reports, 2013, bcr2013200876. 11 - van Hoeken, D., & Hoek, H. W. (2020). Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Current opinion in psychiatry, 33(6), 521–527. 12 - Moreno, R., Buckelew, S. M., Accurso, E. C., & Raymond-Flesch, M. (2023). Disparities in access to eating disorders treatment for publicly-insured youth and youth of color: a retrospective cohort study. Journal of eating disorders, 11(1), 10.

What is “adherent DBT?” And why does it matter? DBT is an evidence-based treatment for a variety of mental health diagnoses and struggles. Understanding the difference between "adherent, comprehensive DBT" and "DBT-informed therapy" is important. Most research on DBT's effectiveness for BPD (and some other disorders) is based on adherent DBT. Dialectical Behavior Therapy (DBT) is an evidence-based treatment for borderline personality disorder (BPD), post-traumatic stress disorder, substance abuse disorders, difficulties in ADHD , some eating disorders , and other mental health struggles defined by intense emotions and/or impulsive behaviors. [1-6] Because of this broad usefulness for helping many clients, more and more therapists have sought training in DBT. Sadly, many clients who believe they’re receiving DBT are only receiving “DBT-informed” therapy or learning DBT skills as a part of another therapy. Most studies on DBT’s effectiveness for treating BPD (and some other diagnoses) are based on adherent, comprehensive DBT—not just DBT skills. Furthermore, some research suggests that the more adherent to DBT a therapy session is, the more likely the client will benefit from the therapy. Adherence matters. When DBT is adherent, clinicians, clients, and client loved ones can be more confident that the therapy will be helpful and provide the powerful results demonstrated in DBT’s research. What is Adherent DBT? DBT experts say that a client's treatment is "adherent" when they are receiving comprehensive DBT as described in the original treatment manual by Marsha Linehan. Comprehensive DBT always includes four main parts: weekly individual DBT therapy, weekly DBT skills group (or some form of dedicated skills learning), as-needed phone coaching between sessions, and a weekly consultation team (for the therapist). These four parts each have specific guidelines that must be followed to be considered adherent. Below, I'll review some specific features that are most prominent and easiest for clients to know about their own treatment. Individual DBT therapy. In adherent DBT, the client meets every week for a one-on-one therapy session with a DBT therapist. While DBT explores emotions, thoughts, daily life experiences, and trauma histories, there is an emphasis on behavior. The "B" in DBT stands for behavior, after all! At the start of DBT, the therapist and client work together to collaboratively and explicitly identify the client’s goals for therapy. These goals are made into behavioral “targets” (e.g., behaviors to increase or decrease), which the client tracks using a “diary card.” The DBT diary card is a physical or digital spreadsheet that the client fills out daily between sessions, tracking their therapy targets, emotions, and other factors important to the client. DBT therapists and clients use the diary card every session to set the agenda for what to discuss. If an individual therapy session doesn't have diary cards, agendas, or behavioral targets—it’s not adherent DBT. DBT Skills Group. In comprehensive DBT, the client usually attends a weekly skills group with other DBT clients. These groups function more like a class than a typical group therapy session, as the focus is on learning skills in four main modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Typically, a weekly DBT skills group takes about six months to cover all of the skills. Based on special circumstances or learning needs, some clients in DBT will learn skills in individual sessions, rather than a group. In adherent DBT, clients will learn and practice skills every week. DBT Phone Coaching. Clients in adherent DBT have the option to contact a DBT therapist between sessions. This coaching has three primary purposes: (1) helping the client navigate emotional crises , (2) helping the client apply the DBT skills to their daily life in real-time, and (3) solving problems or repairing conflicts between the client and the therapist. Some DBT therapists have institutional rules or personal limits that impact their availability for phone coaching, but adherent DBT always has some form of between-session phone coaching. DBT Consultation Team. Therapists offering adherent DBT attend a weekly meeting with other DBT clinicians where they specifically and exclusively talk about DBT cases. This “consultation team" is designed to help the therapists provide adherent DBT. While therapists may talk about their clients during team meetings, discussion is focused on the therapists (rather than the client) and what they need to do to be the best DBT therapists they can be. Is Adherent DBT Really Necessary? Adherent DBT requires a pretty hefty commitment in time, energy, and (sometimes) money. While some clients will see the most benefit from adherent DBT, many people don't need the comprehensive treatment. There are many books, videos, and self-learning resources available for learning DBT skills in ways that are cheaper and easier to access than comprehensive DBT. Research shows that just learning DBT skills can improve mental health for a lot of people, though it’s still unclear who exactly benefits most from comprehensive DBT versus DBT skills alone. People with BPD, those who self-harm, use substances heavily, experience frequent dissociation, or have other impulsive behaviors that cause harm, are likely to benefit more from comprehensive DBT than “DBT-informed” therapy. Of course, anyone can choose to participate in comprehensive DBT if they believe that increased structure, accountability, or one-on-one guidance will help them. An individual therapist could help you decide what treatment is best for your specific needs. The Psychology Today Therapy Directory is one of the most comprehensive places to find a therapist online. There are specific questions you can ask a potential therapist to determine if they provide adherent DBT. I will write a future blog post about these questions! Kiki Fehling, Ph.D., - Website - References Panos, P. T., Jackson, J. W., Hasan, O., & Panos, A. (2014). Meta-analysis and systematic review assessing the efficacy of dialectical behavior therapy (DBT). Research on Social Work Practice, 24(2), 213-223. Haktanir, A., & Callender, K. A. (2020). Meta-analysis of dialectical behavior therapy (DBT) for treating substance use. Research on Education and Psychology, 4(Special Issue), 74-87. Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour research and therapy, 55, 7-17. Fleming, A. P., McMahon, R. J., Moran, L. R., Peterson, A. P., & Dreessen, A. (2015). Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students. Journal of attention disorders, 19(3), 260-271. Ben-Porath, D., Duthu, F., Luo, T., Gonidakis, F., Compte, E. J., & Wisniewski, L. (2020). Dialectical behavioral therapy: an update and review of the existing treatment models adapted for adults with eating disorders. Eating Disorders, 28(2), 101-121. Harned, M. S., Schmidt, S. C., Korslund, K. E., & Gaglia, A. (2023). Therapist adherence to Dialectical Behavior Therapy in routine practice: Common challenges and recommendations for improvement. Journal of Contemporary Psychotherapy. Harned, M. S., Gallop, R. J., Schmidt, S. C., & Korslund, K. E. (2022). The temporal relationships between therapist adherence and patient outcomes in dialectical behavior therapy. Journal of Consulting and Clinical Psychology, 90(3), 272. Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2015). The use of dialectical behavior therapy skills training as stand‐alone treatment: A systematic review of the treatment outcome literature. Journal of clinical psychology, 71(1), 1-20. © 2023 Dr. Kiki Fehling. The information in this post is for psychoeducational purposes, and it is not a substitute for the professional advice provided by your licensed mental health provider.

Considerations for a harm-reduction approach to treatment. Neurodiversity and neurodivergence are terms often used interchangeably but they have different implications. Harm reduction is practical strategies to reduce negative consequences and improve quality of life. Deficit-based narratives are problematic and should be replaced with growth-based initiatives. Neurodiversity and neurodivergence are terms people tend to use interchangeably even though they have different implications. Neurodiversity is an inclusive term meaning that, just as there are many variations in hair and eye color, there are variations between people’s brains. Neurodivergence is an exclusive term describing individuals whose minds work differently from what society has deemed the standard. Neurodivergent individuals may experience differences in how they interpret, experience, and digest the world around them. Think of it this way. Everyone can be neurodiverse, but not everyone is neurodivergent. What Is Harm Reduction? Harm reduction is a practical set of strategies and interventions aimed at reducing negative consequences and improving overall quality of life. Typically, harm reduction is a term people associate with substance abuse treatment. However, it can be applied to the treatment of various mental health disorders and physical diseases. Harm Reduction in Eating Disorder Treatment Much of the literature regarding harm reduction in eating disorder treatment centers around individuals with severe and enduring anorexia, or SEAN. The literature makes an argument for the implementation of harm-reduction approaches when a patient “will not” or “cannot” find full recovery or remission of life-threatening or life-shortening symptoms. The literature focuses on the patient’s severity and lack of ability to approach recovery, while also emphasizing that harm reduction doesn’t only offer pain and symptom management but also aims to modify the disease to ensure survival and acquire a more sustainable quality of life. The emphasis on words such as patient, symptoms, severity, harm, and cannot signal clinicians proposing harm reduction in eating disorder treatment may be doing so from a deficit-based mindset. What is a deficit-based mindset? A deficit-based mindset suggests providers are expecting less from patients due to the assumption that their circumstances prevent them from achieving more. It is important to highlight the concept of deficit-based thinking when treating any client, as there is research to suggest that deficit-based narratives are problematic and should be replaced with growth-based initiatives. Think of switching from deficit to growth like changing the perspective from “glass half-empty” to “glass half-full.” In practice, this would look like reconnecting the language used in harm-reduction treatment approaches back to the guiding principles summarized in the section below. The 6 Principles of Harm Reduction Humanism: Providers value, care for, and approach clients as individuals with dignity. Pragmatism : The knowledge that none of us will ever be able to achieve perfect health behaviors and that “perfect” health behaviors are impossible to define. Individualism: The idea that every individual is allowed to present their own needs and strengths with a spectrum of health behaviors and receptivity for intervention. Autonomy: Though one of the roles of health care providers is to improve clients’ health literacy by providing suggestions and education on treatment options, clients ultimately make their own choices regarding their treatment to the best of their abilities, beliefs, resources, and priorities. Incrementalism : The knowledge that any positive change in the client is a step toward improved health and that positive health changes take time to achieve. By acknowledging small successes and reinforcing progress, clients remain more engaged in treatment and believe they have access to trusted providers in times of crisis. Accountability without termination: Clients are responsible for their own health choices and outcomes, but providers never “fire” them from care. Deficit-Based Mindset With Neurodivergent Individuals I wanted to take a moment to also connect the deficit-based mindset back to neurodivergent individuals. There are many accounts of neurodivergent individuals going to get an assessment for an official diagnosis and feeling hurt by the overemphasis on what is “wrong” or “not working” for them in their lives. It is as if in order to be given an official diagnosis, they must lead with how their brain’s wiring has led them to a place of suffering. This can be particularly harmful when a person with neurodivergence is born with a mind that works differently from what society has deemed the standard. This is who they are. However, the symptom-focused approach attempts to take a neurodivergent brain and make it “fit” within a neurotypical world as a way to reduce their suffering. In other words, who they are is “wrong” or “not working.” Harm Reduction in Neurodivergent Individuals With Eating Disorders In the section above, I used the word harmful for a reason. I wanted to point out a potential discrepancy between harm-reduction treatment approaches and the emphasis on increasing a client’s quality of life. I mentioned how the literature surrounding harm reduction in eating disorders appears to be using deficit-based language. Now, it is one thing to discuss the potential problems for approaching neurotypical individuals with eating disorders in this way. Another layer is added when we bring in neurodivergent individuals with eating disorders and approach their treatment from a deficit-based mindset. In previous posts, I have discussed the intersection of neurodivergence and eating disorders. I have written about how experiences, such as intense sensory processing and executive functioning differences, can lead to the development of disordered eating patterns. There is a strong overlap between unique experiences with food, eating, and hunger, and neurodivergent minds—meaning that symptoms seen in neurodivergent individuals with eating disorders that are reducing their quality of life may also be entangled in the way they experience and interpret the world. Therefore, a harm-reduction approach to eating disorders with neurodivergent individuals may need to propose two more principles: Provider reflection: The provider should first reflect on how their own narrative around what is a “symptom” may be informed by a neurotypical definition of recovery and could be failing to consider how their client's experience of recovery may vary from their previous education or assumptions. Client collaboration: After a personal reflection regarding potential assumptions being brought into the treatment plan, it is important for both the clinician and the client to collaboratively form a harm-reduction plan and definitions of quality of life. Collaboration efforts are crucial because they suggest that the harm-reduction approach to treatment applies not only to the neurodivergent individual but also to the clinician in their way of showing up during the treatment process. This means that the clinician is committed to reducing the harm they may bring into the treatment process, and the client is committed to making recovery-focused changes that align with their experience of the world. Conclusion Please know that there is an abundance of considerations attached to this topic, and this article only begins to scratch the surface. But you can keep an eye out for more content and elaboration on these topics in my future posts. Morgan Blair, M.A., LPCC - Website References Hawk, M., Coulter, R.W.S., Egan, J.E. et al. Harm reduction principles for healthcare settings. Harm Reduct J 14, 70 (2017). https://doi.org/10.1186/s12954-017-0196-4 Joel Yager (2021) Why Defend Harm Reduction for Severe and Enduring Eating Disorders? Who Wouldn’t Want to Reduce Harms? The American Journal of Bioethics, 21:7, 57–59, DOI: 10.1080/15265161.2021.1926160 Peter Beresford (2002) Thinking about 'mental health': Towards a social model, Journal of Mental Health, 11:6, 581–584, DOI: 10.1080/09638230020023921

Intrusive thoughts are unwanted and involuntary. They are disturbing, stressful and distressing. Everyone experiences intrusive thoughts from time to time. What you can do to reduce them and when to get help. Do you ever find yourself daydreaming or distracted and your thoughts turn negative? You try to push away the upsetting thoughts, but it’s difficult, or even impossible. Those are intrusive thoughts. They are unwanted and involuntary thoughts or images that pop into our minds and become disturbing, stressful, or distressing. They come in a wide variety of unpleasant topics, commonly self-doubt, or some catastrophic outcome, health or financial. Intrusive thoughts can happen to anyone and everyone from time to time. It can be a random thought of losing your job or swerving your car off a cliff, with no intention to act. It’s almost like a combination of imagination and an inability to stop one’s thinking. More severe intrusive thoughts are experienced by people with obsessive-compulsive disorde r , Tourette's syndrome, depression , body dysmorphic disorder, post-traumatic stress disorder , anxiety disorders , eating disorders , and psychosis. A person with severe intrusive thoughts will have challenges with relationships and work that affect daily life. The thoughts carry a heavy emotional toll, and the resulting anxiety can be hard to manage. However, having an occasional intrusive thought does not necessarily mean you have any of the above conditions. Recognizing intrusive thoughts People daydream all the time, but when the thoughts turn negative, they can feel alarmingly real. The result of these intrusive imaginations can leave you feeling scared, anxious, worried, or even afraid of yourself and worried about your future behavior. In extreme cases of despair or fear, people need to seek out help from a doctor or other trusted person to help relieve their burden of anxiety. As a psychiatrist, I have been privileged to hear about people's inner dialogue all the time. Over the years I’ve noticed patterns from people with intrusive thoughts and identified solutions that can be helpful. For example, one pattern I see often in people who are either anxious, depressed, or have attention deficit, is the inclination to go down negative thought spirals. These can be based on reality, feel real, and incite fear. In my practice, we call these “daymares,” or the waking version of nightmares. Some nervous or anxious thoughts are useful, and others are not. The quickest solution that has helped so many of my patients is asking one fundamental question: "What is the utility of this thought?" Sometimes patients share that their nervous thoughts are useful. For example, the thought that you might be late on a work deadline or unprepared for an exam can compel you to do something about it. In these cases, the anxious thoughts have a function. They remind us to prepare or to get something done. These thoughts are more easily managed because they are rooted in reality and have tangible steps for actions that will help to relieve the anxiety. Other times patients share what we call, “stabbing thoughts.” These are automatic and negative or catastrophic thoughts that occur over and over again. When asked, "What is the utility of this thought," the patients can’t answer leaving them feeling powerless with no agency over their thoughts. These thoughts are like eating junk food or rubbernecking at a car accident – you know the outcome will not be good, but you cannot stop. It’s almost like an addiction to feeling unpleasant and finding ways to achieve that – doom scrolling included. Some people live in a constant state of stress where self-oppression becomes the norm. I’ve had patients over the years who tell me they wake up in the morning and scan the news to find something to worry about. I’ve called this “ bingeing on negativity .” What to do about intrusive thoughts? How do you stop or minimize intrusive thoughts? First, understand the common causes and triggers. In my practice, we see patients with stress, lack of sleep, anxiety, and other major life changes experiencing intrusive thoughts. Being sad, hungry, or tired can make it harder to resist the temptation to go down these dark thought spirals. Ironically, we know that trying to directly suppress these thoughts can make them occur more often. Learning coping mechanisms can be a big key to stopping or minimizing intrusive thoughts. Common techniques that can be helpful include mindfulness, acceptance of the thought, and de-stigmatization. The more you let these thoughts disturb you, the more they return. Conversely, if you accept them, and know that they are just trying to get your attention – you are better equipped to move past them. Talking to someone or writing down intrusive thoughts can also help minimize their power. In addition to self-care, there are medical treatment options for more severe cases. Treatment options can include cognitive behavioral therapy or medications that may be prescribed. Keep in mind that in severely distressing cases, it is important to seek professional help. Alex Dimitriu M.D. - Website - References Effects of rumination on unwanted intrusive thoughts: A replication and extension. Journal of Experimental Psychopathology. 2020. M. Kollárik, et al.

New research shows how trauma therapy helps recovery from an eating disorder. Up to 50 percent of people with eating disorders also have PTSD . PTSD complicates ED treatment, yet trauma therapy is not included in most eating disorder recovery programs. A real-world study shows how trauma therapy improves recovery for patients with PTSD and eating disorders. Traumatic experiences , such as sexual or physical abuse , severe bullying, psychological abuse, unhealthy pacing, or accidents, are common among people with eating disorders (EDs). In fact, up to 50 percent of people with EDs also meet the diagnostic criteria for post-traumatic stress disorder (PTSD)1, and researchers think that ED behavior may, in some cases, be a maladaptive way of responding to the long-lasting effects of a traumatic experience2. Somehow, trauma changes the way we relate to our bodies, and our bodies become a tool for dealing with our trauma. This means that in order to treat EDs effectively, we may also need to address an underlying trauma. Surprising to many, residential treatment for EDs typically does not include targeted trauma therapy. I recently interviewed Dr. Molly Perlman, a psychiatrist and chief medical officer at a leading eating disorder treatment center, about her team's recent study testing how one type of trauma therapy influenced ED recovery in a residential treatment setting3. What is PTSD-ED, and why should we pay more attention to trauma in EDs? PTSD-ED refers to people that meet the diagnostic criteria for both PTSD and one or more EDs. Compared to people with ED that now have PTSD, PTSD-ED patients tend to have an earlier onset of ED behaviors, more severe ED symptoms and are more likely to drop out of treatment1. If they do complete treatment, they are more likely to relapse after discharge1. Even if patients do not meet the full criteria for PTSD, previous trauma is a risk factor for developing EDs and worsens ED symptoms and treatment outlook. Dr. Perlman and her team at MNA found that around 50% of their adult clients with EDs also had PTSD, and this was also the case for 38% of the adolescents . Similar to other studies, Dr. Perlman and her team found that around 50 percent of their adult clients with EDs also had PTSD, and this was also the case for 38 percent of the adolescents. Shockingly, almost no research is testing what we can do to improve treatment outcomes for this large population of ED patients. To Dr. Perlman, it is clear that we need to address the trauma in order to successfully treat the ED. So that’s what her and her team did. Why is trauma therapy not a standard part of ED treatment? I first wanted to understand why trauma therapy is not already a standard part of ED treatment. Apparently, many professionals, including Dr. Perlman, were trained to avoid addressing previous traumas during ED treatment. “I was trained not to open “the trauma box.” They told us not to touch a patient’s trauma during therapy because it would only worsen the ED symptoms or lead to relapse after discharge… but research, including ours, is now starting to show that this assumption is wrong and that we have to address the trauma concurrently with the ED.” "From our internal data, we could see that PTSD-ED clients maintained their recovery more successfully when ED treatment included trauma therapy”. Dr. Molly Perlman, MD and chief medical officer Source: Vlada Karpovich/Pexels Dr. Perlman points out that one of the major challenges with ED patients is that they tend to drop out of treatment programs, and a common concern is that they may drop out in response to a reactivated and unprocessed trauma that triggers relapse into disordered eating or self-harm. This concern has served as one of the major reasons for excluding trauma therapy during ED treatment. However, when clients dropped out of the combined trauma and ED residential treatment program prematurely, they still showed improvements in several ways. Said differently, we might not need to worry about PTSD-ED clients receiving incomplete trauma therapy. How does trauma therapy improve ED treatment? Dr. Perlman’s team implemented a well-known type of trauma therapy, called Cognitive Processing Therapy (CPT), into their eating disorder treatment regimen. CPT is very similar to Cognitive Behavioral Therapy (CBT), and one of its major advantages is that it is a highly standardized method, meaning that different therapists can follow the same guidelines to achieve the same results. For a large organization, standardized procedures are critical to ensure that all clients receive the same level of care. Scientists have reported that CPT improves outpatient treatment for EDs, but Dr. Perlman’s team has demonstrated that CPT also improves ED outcomes during residential treatment. Typically, PTSD-ED patients relapse faster after treatment discharge, but with CPT treatment they maintained their reduced ED symptoms as well as ED patients without PTSD. Although PTSD-ED patients still had higher symptom severity, these results encourage the idea that addressing preexisting trauma may improve their long-term treatment outcomes. CPT helps people understand why and how trauma contributes to their ED, and it instills the hope that recovery is possible. When people understand that their ED is tied to their trauma, it becomes easier to let go of the ED as they work through their trauma. In other words, CPT endows people with new coping skills and helps them reconnect with their bodies in a healthy way. It is commonly said that no one recovers from EDs; you only learn to live with them. I know personally that this is not true. We can recover. Dr. Perlman agrees: “Our clients are so resilient, yet these [EDs] are so tenacious. [Our clients] need treatment to be armed with the tools to combat these negative [ED] thoughts. It is a battle, but we know recovery is possible. With the right treatment, recovery is possible.” Pernille Bulow, PhD - June 17, 2023 - Website References 1. Day S, Hay P, Tannous WK, Fatt SJ, Mitchison D. A Systematic Review of the Effect of PTSD and Trauma on Treatment Outcomes for Eating Disorders. Trauma Violence Abuse. 2023 Apr 26:15248380231167399. doi: 10.1177/15248380231167399. Epub ahead of print. PMID: 37125723. 2. Trottier K, MacDonald DE. Update on Psychological Trauma, Other Severe Adverse Experiences and Eating Disorders: State of the Research and Future Research Directions. Curr Psychiatry Rep. 2017 Aug;19(8):45. doi: 10.1007/s11920-017-0806-6. PMID: 28624866. 3. Brewerton TD, Gavidia I, Suro G, Perlman MM. Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results. J Eat Disord. 2023 Mar 27;11(1):48. doi: 10.1186/s40337-023-00773-4. PMID: 36973828; PMCID: PMC10044735.

Enhanced CBT is a promising alternative for adolescents with eating disorders. CBT-E actively involves the young people in the treatment, and it is well accepted by patients and parents. The collaborative nature of CBT-E is particularly beneficial for ambivalent young patients. CBT-E accommodates parents who may not be able to participate in all treatment sessions. Eating disorders can profoundly impact the psychosocial functioning and physical health of adolescents . Early and effective treatment is essential to prevent long-term adverse and devastating effects. The National Institute for Health and Care Excellence (NICE) recommends cognitive behavior therapy (CBT) for adolescent eating disorders when family therapy is unacceptable, contraindicated, or ineffective. This recommendation is based on promising results from an enhanced version of CBT (CBT-E), adapted for adolescents aged 12 to 19 with eating disorders. Origin of CBT-E for Adolescents CBT-E was initially developed for adults with eating disorders at the Centre for Research on Eating Disorders at Oxford (CREDO). The idea to adapt CBT-E for adolescents originated a decade ago at the Department of Eating and Weight Disorders of Villa Garda Hospital in Italy during periodic supervision by Professor Christopher Fairburn. Two main clinical observations prompted this project: Adolescents with eating disorders share the same specific psychopathology (e.g., overvaluation of weight and body shape, rigid dieting, excessive exercise, binge eating, and purging behaviors) as adults. They could benefit from CBT-E, a treatment designed to address this specific psychopathology. Adolescents, despite often being in a strongly ego syntonic phase of their eating disorder, can actively engage in individual psychological treatment. Key Adaptations of CBT-E for Adolescents CBT-E for adolescents incorporates three distinctive characteristics to accommodate young patients with eating disorders: Periodic medical evaluations and a lower threshold for hospitalization are integral, given the severe medical complications (e.g., osteopenia and osteoporosis) associated with eating disorders in this age group. Special efforts are made to engage adolescents in treatment and change, as they often do not recognize they have a problem. Parents are usually involved in treatment due to the age and circumstances of the patients. Description of CBT-E for Adolescents CBT-E for adolescents involves two assessment/preparation sessions, followed by three main steps, one or more review sessions, and three post-treatment review sessions (Figure). The treatment lasts about 20 weeks for non-underweight patients and about 30-40 weeks for underweight adolescents. Parents participate in a 90-minute interview during the first week of treatment and in six to eight brief sessions (15-20 minutes) following the individual sessions with the patient. General Treatment Strategy After assessment, patients are educated on the disease model and the CBT-E psychological model for understanding eating disorders and the therapeutic approaches based on them (see Table). Contrary to the disease model, the psychological model adopted in CBT-E never requires patients to do anything against their will. During the two assessment/preparation sessions, patients are asked to consider the pros and cons of starting Step One—not necessarily to change—providing them with an opportunity to better understand the psychological function and maintenance mechanisms of their eating disorder. This helps them to be in a better position to evaluate the implications of changes. Moreover, the goal of Step One in CBT-E for underweight patients is not weight restoration but rather understanding the psychological nature of their eating disorder and actively deciding whether to address changes, including weight recovery. In other words, the objective of CBT-E is for the patient to decide to recover weight rather than having this decision imposed by the therapist. This strategy is also applied to other ego-syntonic characteristics of eating disorder psychopathology, such as dietary restriction and restraint and excessive exercise. A key strategy in CBT-E is to collaboratively create a personalized formulation of the main processes maintaining the patient's eating problem, which becomes the treatment target. The patient is educated about these processes and actively involved in deciding to address them. If the patient does not conclude that there is a problem to address, treatment cannot begin or must be postponed, although this is a rare occurrence. The patient is instructed to observe how the maintenance processes of their eating problem operate in daily life. They are asked to monitor their eating in real time and the events, thoughts, and emotions influencing it. Subsequently, the patient is encouraged to make gradual behavioral changes within the context of their formulation and analyze the effects and implications on their thinking. In the later stages of treatment, when the main maintenance processes of the eating disorder have been interrupted and the patient reports periods free from concerns about weight, body shape, and eating control, the treatment helps them recognize early signs of the eating disorder mindset and quickly detach from it, thus avoiding relapse. Parents, also with the help of specific educational videos, are actively involved in creating an optimal family environment to facilitate the adolescent's change and, with the adolescent's agreement, support them in implementing some CBT-E procedures. Effectiveness of CBT-E for Adolescents Several studies have evaluated CBT-E's effectiveness for adolescents aged 11 to 19. Seventy-two percent of patients with anorexia nervosa completed outpatient CBT-E, with 62 percent achieving complete remission at follow-up. A non-randomized efficacy study at Children's Hospital of Minneapolis found CBT-E's outcomes similar to FBT at 6 and 12 months post-therapy. The CogFam Norwegian Trial In 2024, the Cog Fam trial, a non-inferiority randomized control study, commenced patient recruitment to evaluate the efficacy of CBT-E versus FBT for adolescents aged 12 to 18 with eating disorders. The study spans eight outpatient clinics across four regions in Norway: Oslo, Bergen, Trondheim, and Tromsø. By comparing these treatments, the Cog Fam trial hopes to shed light on which approach might be more effective for specific subgroups of patients, thereby enhancing treatment personalization in the management of eating disorders. Conclusions CBT-E is a promising treatment for adolescents with eating disorders and offers several clinical advantages. It is well-accepted by both young people and their parents. The collaborative nature of CBT-E is particularly beneficial for ambivalent young patients who may be especially concerned about issues of control. Additionally, it accommodates parents who may not be able to participate in all treatment sessions. Riccardo Dalle Grave, M.D., - Website - References Dalle Grave, R., & Calugi, S. (2020). Cognitive Behavior Therapy for Adolescents with Eating Disorders. New York: Guilford Press Dalle Grave, R., & el Khazen, C. (2022). Cognitive Behaviour Therapy for Eating Disorders in Young People: A Parent’s Guide. London: Routledge. Dalle Grave, R., & Calugi, S. (2024). A Young Person’s Guide to Cognitive Behaviour Therapy for Eating Disorders. London: Routledge.

Differentiate between physical and emotional pain. Apply the dichotomy of control. Don't demand a perfect solution. Apply the problem-separation technique. An unpleasant and often difficult aspect of life consists of experiencing temporary, extended, or permanent physical pain. As we go through life, no matter how careful we are or what precautions we take, we may have physical pain many times within the course of a month, week, or even day. Unfortunate, yet a fact of being human. The challenge this presents involves learning, at times through difficult experience, the most effective ways to cope. To address this problem, first apply the problem-separation technique. Differentiate between your practical problem and your emotional problem about your practical problem. Practical Problem What is a practical problem? It consists of your challenge, goal, or objective. It may be a short-term or long-term goal. How to avoid entirely, ease, or overcome pain constitutes a practical problem. Surgery, physical therapy, or taking pain meds can be effective approaches. Fine! Emotional Problem Do you feel anxious , depressed , guilty, or resentful about having the pain? Many of my clients have made themselves depressed about this condition. If this is true for you, then you have an emotional problem. Let's take an example of how this may come about. Suppose you've had an injury that continues to cause pain. Clearly your practical problem consists of how to limit, stop, or distract yourself from your pain. Making yourself depressed about that is your emotional problem. To overcome your depression about your pain apply the Three Minute Exercise: A. Adversity: I have much pain after my surgery. It makes it difficult to sleep and interferes with my daily functioning. B. Irrational belief: I can't stand all this pain. C. Undesirable emotional consequences: Depression. D. Disputing or questioning your irrational belief: What is the evidence that proves I can't stand the pain? E. Effective new thinking: There is no evidence, logic, or pragmatics that proves I can't stand the pain. I am standing it. The proof is it hasn't killed me, although I am standing it poorly by unnecessarily disturbing myself about it. I strongly desire to live pain free, but there's no reason I absolutely must. Demanding the pain disappear doesn't help and only makes me feel worse. Even if the pain never leaves me, that would be extremely regretful, but not awful, terrible, or horrible. F. New feeling: Great discomfort from the pain rather than feeling depressed about it. Write this exercise one to three times daily to change your thinking from an irrational demand perspective to one of strong preferences and desires. You will see, as you change your thinking, your emotions change. Michael R. Edelstein, Ph.D., - Website - Blog - References Edelstein, M.R. & Steele, D.R. (2019). Three Minute Therapy. San Francisco, CA: Gallatin House Publishing.

Making sense of differing descriptions of C-PTSD. Complex PTSD refers to different things for different people. Among clinicians, C-PTSD is often used to refer to someone with both Axis I and Axis II disorders. For trauma sufferers, C-PTSD validates their experience of multiple layers of trauma. The two perspectives can be unified by adopting a larger, more compassionate view of trauma's impact. Complex PTSD , or C-PTSD, refers to different things for different people. Among clinicians, C-PTSD is often used as a polite way to refer to someone with both Axis I and Axis II disorders—that is, someone who not only has an anxiety disorder but whose personality also has diagnostic significance. Among some clinicians, C-PTSD is used interchangeably with borderline personality disorder ; they are expressing that effective treatment often involves addressing difficulties with emotional dysregulation, self-perception, and maladaptive behaviors in close relationships. C-PTSD is used in quite a different way among those who suffer from trauma—as a better term to describe the challenges they face relative to the conventional understanding of PTSD. For many of my patients, C-PTSD is a term that validates their experience of multiple layers of trauma . What they're expressing is that they've had early-life trauma in addition to subsequent trauma exposure in adulthood. My patients often contrast this set of experiences with the conventional understanding of PTSD, which is diagnosed after someone is exposed to an event that causes a feeling of helplessness or horror. In such classical descriptions, there is often a major focal trauma that changes the life course of an individual. For example, suppose that an individual has had a catastrophic car crash and develops PTSD as a result. It’s important to note that the very term “PTSD” has actually been evolving into “post-traumatic stress injury.” Other classical focal traumas might be an assault, or a trauma sustained during combat operations. In such cases, the clinical treatment plan often involves identifying the central trauma, what psychologists call an “index” trauma, and doing work to process and resolve that trauma. But with complex PTSD, there is often no clear index trauma. Individuals with complex PTSD often have a high ACEs score. ACE refers to adverse childhood experiences and is a measure of adverse childhood events such as physical or emotional abuse, neglect, caregiver separation or divorce, exposure to family member addiction, or witnessing violence. Identifying the presence of childhood trauma is often critical to patient outcomes. Research is now reshaping understanding of the landscape of trauma. For example, research is confirming that for many veterans, the trauma of warfare is not the trauma that causes the greatest damage. Studies show that military service members often enter the military with significant childhood trauma. It is often the trauma from their childhood that was never addressed before they entered the military that causes the greatest negative impact. In addition, cultural influencers like Oprah Winfrey and Dr. Bruce Perry are changing the way that society views trauma and trauma sufferers, refocusing through a more compassionate lens—not a “What’s wrong with you?” but rather a “What happened to you?” approach. It’s interesting that C-PTSD is often used in such different ways by clinicians and trauma sufferers. Could these two very different perspectives potentially merge? I believe they can. The alignment would come from shifting understanding: When people suffer continual trauma in early childhood, their personalities form in the crucible of the trauma exposures. Trauma shapes and changes them in ways that are both biological and psychological. Attachment research offers a valuable perspective on how default trust (or lack thereof) is developed in early-childhood relationship contexts. From my perspective as a trauma psychologist, it should not be surprising, or an exception to the rule, that people who have suffered early childhood trauma may develop personality features that are shaped by that trauma. This does not mean that everybody with early trauma has borderline personality features or meets the criteria for such a diagnosis. It’s just the inverse. Those with borderline personality features or other relationship-altering personality features may be explained in large part because of early childhood trauma experiences. This is the compassionate frame we can adopt to destigmatize mental wellness and help those who suffer from trauma begin to heal. Shauna Springer, Ph.D., - Website - Blog - References Blosnich, J. R., Dichter, M. E., Cerulli, C., Batten, S. V., & Bossarte, R. M. (2014). Disparities in adverse childhood experiences among individuals with a history of military service. JAMA psychiatry, 71(9), 1041–1048. Kang, H. K., Bullman, T. A., Smolenski, D. J., Skopp, N. A., Gahm, G. A., & Reger, M. A. (2015). Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars. Annals of Epidemiology, Volume 25(2), 96-100.

Personal Perspective: Start prioritizing your well-being by learning how to say "no." Many moms don't prioritize their mental health, and that needs to change. Moms of children with neurodivergence often experience chronic stress. You can't pour from an empty cup. Put a stop to people pleasing and take care of yourself first. May is Mental Health Awareness Month. It's also the month we celebrate Mother's Day. The combination of the two moments inspired me to write this article. Over the years, I’ve noticed that many moms don't take care of their mental health. We sacrifice ourselves for our children , spouses, jobs, and extended families. A recent Gallup poll of 60,000 mothers revealed a wide spectrum of emotions: Half reported feeling stressed, 41 percent experienced worry, 28 percent felt depressed , 26 percent reported sadness, and 19 percent expressed anger . Moms of children with disabilities or illnesses face even more unique challenges that often lead to stress and burnout. For example, several studies show that moms of adolescents and adults with autism experience chronic stress, resulting, at least one study found, in cortisol patterns similar to those seen in combat soldiers.* I can confirm that I see their stress in my line of work all the time. My husband often tells me not to be a martyr, but that's who I am! And it doesn't stop with my children. I'll give up that last cookie if someone else wants it. I'll drive someone somewhere, even if it's an inconvenience. When someone asks for a favor, I say "sure," even when I'm crying inside. I may be exhausted and overwhelmed, but I never want to disappoint anyone. A colleague of mine always reminds me of the airplane analogy. During the safety check, the crew says, should the oxygen masks come down, cover your face first and then cover the faces of the small children. If you don't care for yourself, you can't take care of others. It makes so much sense—you cannot pour from an empty cup. Think about it: How many of us take the time to recharge our batteries? The problem is that many people, especially moms, are not great at saying no. I imagine many of you are like me—give, give, give, until nothing is left. And then, I admit, I melt down like a toddler in overload mode. I overreact to the dumbest thing because everything just piled on, and I can't take it anymore. I take responsibility for my lack of communication; I don't always express my wants and needs. Realistically, I know that my husband and children aren't mind readers. And yet, I get frustrated when they don't know I'm tired or have too much on my plate, and I need a break to center myself. If you're a people-pleasing mom like me, here are some helpful tips to preserve your mental health and sanity: Communicate what you're feeling. No one knows what you want and need except you. Your family wants a happy mom; they want you to smile and not freak out. Help them help you. If your child is young, they don't need the ins and outs. However, if your child is older, it's a great lesson in mental health to say, "I'm so tired. Could you help me with X, and then we can grab your favorite pizza for dinner?" Take a break. Give yourself a mommy time-out. They work for our children, and they will work for us, too. Take a deep breath when you need it and walk away from whatever disaster is happening around you. Whether you nap, read a book for 20 minutes, take a walk, or enjoy some chocolate or coffee, take time for yourself, and do something relaxing. Learn the word "no" and use it! It’s OK to say no—it's a complete sentence. Often, we feel guilty for not answering a call we’re too tired to take or for not helping a neighbor out. But we also need to put ourselves first. A mom’s mental health shouldn't be at the bottom of her to-do list! Knowing we need a break shouldn’t provoke guilt (or shame). This month, I challenge all moms to prioritize their well-being and learn the word "no." It's time to reclaim moments to lower stress levels and become better women, spouses, and parents all the time. We deserve it. Lisa Sheinhouse, M.A., - Website - Blog - References *Seltzer MM, Greenberg JS, Hong J, Smith LE, Almeida DM, Coe C, Stawski RS. Maternal cortisol levels and behavior problems in adolescents and adults with ASD. J Autism Dev Disord. 2010 Apr;40(4):457–469. doi: 10.1007/s10803-009-0887-0.

Knowing what grief surprises are helps you and your child. There is no one right way to grieve—we all do it our own way, but some experiences happen to everyone. Landmark dates such as birthdays often activate intense grief. These can be planned for. Grief surprises are those unexpected times you confront reminders of your loss that are extra challenging. Naming those times gives you and your child a sense of steadiness and a way through the intensified pain. When someone you love dies, you grieve deeply whether overtly or not. We each do that in our own way and on our own timeline. There is no one way to grieve and certainly no one right way to do so. One thing that is universal, though, is that landmark days – birthdays, important holidays, graduations, etc., tend to activate intensified feelings about the loss. This is talked about enough that most people expect that it is a possibility. So, we wanted to reflect on those moments during grieving that can take your breath away as they come unexpectedly with no chance for preparation. We propose a new term for them: “ grief surprises”. Jack is a teacher in his late 40s with 2 children, Lisa, age 6, and Mark, age 10. He began therapy with one of us when his wife Leah died a year and a half ago after a year-long struggle with an aggressive cancer . All 3 of them responded to her death differently. Jack felt numb for weeks, and only after the kids seemed to be more settled back in school did he begin to sob. Lisa cried a lot and would not sleep alone for months. Mark stomped around the house and acted up mildly at school. At the one-year anniversary of Leah’s death, each of them re-experienced these reactions in an intensified way. Jack had learned in therapy that this might happen and was able to talk with his children about it and respond with compassion for all three of them. He had also learned with us about the “grief surprises” and came in one day to tell us about one. He was on the phone making a routine appointment with a doctor when the receptionist asked to review his profile and went over his emergency contacts. Without any recognition of his loss, she read aloud his list, which had Leah at the top. On some level, of course, Jack had known she was his first contact if there was an emergency, but he thought he had taken care of changing that for all of his doctors. He felt that “grief surprise” as a punch in the stomach, an inability to think clearly for a minute, and the beginning of tears. He apologized and went on to give her a replacement name. Why we feel the need to apologize for showing natural human emotion is a whole other issue we will write about in the future. It overshadowed the rest of his day as he felt plunged into overwhelming sadness. It took him until sometime late the next day to re-equilibrate. It helped to know what it was, why it had happened, and that he needed to seek the things that comforted him in tough moments. One way to understand why “grief surprises” occur is that grief is a learning process. You do know the person you love died, and you experience that loss throughout the day and sometimes the night. But the way our minds work is that, with very difficult things, we know them and also don’t know them. In order to function, we don’t let ourselves know it for a minute or an hour or a day. And then along comes something that pushes its reality unavoidably in front of us, and we have to learn it all over again. While deeply painful, this process is also part of healing. In that re-learning is adaptation, allowing us to let it sink in in smaller bits til eventually we can tolerate it in all of its fullness. As we had talked about with Jack, when those grief surprises inevitably occur, we recommend naming them as such. This helps us to feel a sense of agency about them, and then do the things that give the comfort we need — whether it's getting outside for a walk, putting on music, calling someone, or writing in a journal. Note what works best in a “tough moments list” to help you remember what you can do when you are most immersed in it. We recommend you do this with your children as well. Grieving is never easy. And we believe that, after you lose someone that you loved dearly, you will carry that grief in evolving form as it becomes part of the fabric of who you are. While we cannot take away the pain of your losses, we hope that understanding some of the process can make it less overwhelming for you. You can support your children by helping them to understand it too. Elena Lister, MD, - Website - Blog -

The troubling realities and research on habitual cannabis and alcohol use. New research links cannabis usage to numerous serious physical and mental health outcomes. US Surgeon General called for warning labels on alcohol as a result of research linking it to several cancers. With these new findings, consumers can understand their risks and make choices that support their health. Today, alcohol and cannabis usage are ubiquitous in the daily lives of many North Americans. Habitual — even daily — consumption of cannabis is accepted as normal, relatively harmless, risk-free, legal, and easily available in an increasing number of jurisdictions. People turn to alcohol and/or cannabis for a variety of reasons, including to relax, de-stress, bond with a group, self-soothe, numb uncomfortable feelings, or take the edge off at the end of a challenging encounter or rough day. Even those who do not use either substance have friends, colleagues, and family members who regularly consume one or both. As a result of this widespread usage, and despite increasing awareness of the harms of both substances, few of us are willing to look too closely at the mounting research on the negative impacts of alcohol and cannabis. Uncomfortable common knowledge Both alcohol and cannabis are associated with serious side effects and symptoms and can leave users vulnerable to dependence. Alcohol has long been acknowledged as harmful in many ways. It is linked to heart disease, stroke, liver disease, numerous cancers , and mental health issues, including depression and anxiety . It is also linked to numerous social, legal, and interpersonal issues. Cannabis usage has undergone a shift in both legal status and perception in recent years. Vilified and propagandized for generations as the demon weed in films like Refer Madness, with strict penalties for possession and usage, it has undergone a significant image make-over, in part due to its medical use in the treatment of nausea, anxiety, sleep disorders, and other conditions, as well as its growing legalization. On the downside, cannabis is widely known to negatively impact mental health, damage the lungs, lower the immune response in some users, and — after chronic, long-term use — result in cyclic vomiting syndrome, also known as cannabinoid hyperemesis syndrome. Disconcerting new cannabis research Recent research has established a link between an increased risk of heart attack and stroke in younger people and other groups diagnosed with cannabis use disorder (CUD). A January 2025 study published in JAMA Network Open determined that cannabis usage had a negative impact on brain functioning and that “cannabis use is associated with short- and long-term brain function outcomes, especially during working memory tasks.” What’s more, a 2024 study links individuals with CUD to an increased risk of head and neck cancers. Furthermore, a McGill University study linked cannabis as a contributing factor to reduced brain connectivity for young users at risk of developing psychosis. More bad news for consumers of alcohol An incendiary 2023 Canadian study on alcohol usage determined that even small levels of alcohol consumption are unsafe. In January of 2025, US Surgeon General Dr. Vivek Murthy called for warning labels on alcoholic beverages as a result of research linking alcohol to several cancers. What’s more, a January 2025 draft report from the US Department of Health and Human Services on the Scientific Findings of the Alcohol Intake & Health Study suggests that alcohol consumption, even in moderation, increases the health risks of cancers and other serious health impacts. A 2022 study suggests that alcohol consumption in middle age increases the risk of cognitive impairment later in life. The risks of combined alcohol and cannabis usage A new study links the combined use of cannabis and alcohol with increased stimulation and intoxication. While both cannabis and alcohol lead to impaired driving, a 2023 study concludes that combined alcohol and cannabis usage “is associated with more severe driving-related outcomes than either substance alone.” A 2024 study of the co-use of cannabis and alcohol among college students established a link between co-usage and a heightened risk of “substance-related harms.” Knowledge is power Research findings reveal mounting evidence of the risks of cannabis and alcohol for our physical and mental health. Armed with this knowledge and awareness, we can examine our habits, patterns, and levels of consumption and make choices that support our physical and mental health and well-being. What now? We are here to live our best lives and make healthy choices. By reflecting on our cannabis and alcohol usage and recognizing and addressing our problematic patterns and habits today, we can have a positive life-long impact on our health and happiness. What to do if you are concerned about your alcohol or cannabis usage Acknowledge your concerns. Acknowledging your concern is the first step to creating positive changes in your life. Take stock of your habits and patterns. Resist the urge to minimize or normalize your concerns. Consider the potential and very real risks to your long-term health and happiness. Try to decrease your usage. You may find that if you make the effort, you can decrease your usage on your own. Seek help if you find you are struggling to manage your alcohol or cannabis consumption. A family doctor (GP), or a mental health clinician will be able to connect you with the resources you need. Monica Vermani, C. Psych., - Website - Blog -

Why are a partner’s death, the loss of a pet, or the ability to knit similar? Losses can create holes in our identity. We don't grieve the loss of a person, ability, or object, but rather the emotion it engendered in us. Try different activities. Find something that arises an emotion similar to the one you no longer experience. We mistakenly believe there is a grief hierarchy, with the intensity of loss more legitimate for some events than others. The criteria are usually based on social norms. We don’t question a person’s all-consuming grief over the loss of a life-long partner. But we may find excessively mourning the death of a Golden Retriever questionable and endlessly grieving a broken vase unfathomable. Are we missing something in our moralizing that prevents us from seeing that these examples and thousands of others are more similar than dissimilar? Absolutely. Scratch the surface of any significant loss, and you’ll find two unifying features: their importance to one’s identity and the absence of a missing emotion. Identity How we view ourselves—our identity—is based on an amalgam of experiences, values, abilities, and expectations. When a meaningful part of your life is lost, self-perceptions and your place in the world may change. It’s irrelevant if the loss was a life-long partner, the daily jog for someone who has run for 40 years now shuffling because of deteriorating joints, encroaching deafness for someone who played the cello her entire life, the gradual memory loss of a writer who spent his days in front on a computer crafting short stories, or the avid knitter whose fingers are crippled by arthritis. Significant losses produce holes in a person’s identity. For example, when I could no longer fly fish alone in the wilderness, my family and friends didn’t understand why I became despondent. “After all,” the consoling began, “look at everything you still can do.” Statements that start with “but look” rarely comfort anyone who loses something significant in defining their life. Yes, I was still a husband, a father, a university professor, and a writer, but the overriding identity umbrella of “Stan Goldberg, wilderness flyfisher,” was gone. I became “Stan Goldberg, an ex-wilderness flyfisher.” Losses such as these—ones that change identity—are rarely confined to changes in self-perception. Instead, they also affect behavior .[6] Some of these may be “unintended consequences” of the loss. For example, I love taking my granddaughter to fish in a peaceful lake using worms. Although I try to be encouraging when she attempts to get her line into the water, my enthusiasm would be different if I anticipated introducing her to my favorite spot. Loss of Emotion When my father died, well-meaning, compassionate friends said to my mother that with enough time, she would get over the loss of my father, someone with whom she had spent almost every day since they were married. It was advice commonly given and found in many counseling approaches, where the “time heals” mantra is repeated. My mother’s response was prophetic: “There isn’t enough time in the universe for me to get over his death.” We think loss is tied to something tangible: a husband, a skill, an object, etc. Yes, the loss of these can result in grief—but not always. A wife most likely won’t miss an abusive husband. A factory worker who hated his repetitive job might be joyful that a stroke removed him from a despicable job. And the farmer who hated tending her cows won’t miss the responsibility of milking them at 4 a.m. if the herd met fatal consequences from foot-and-mouth disease. So, what creates grief associated with a change in identity? What ties the loss so intensely to us that we are immobilized when we think about its absence? The loss of the emotion it generated. We get enjoyment and fulfillment not from the thing, activity, or person itself but from the emotions it once stirred in us. Let’s take my fly-fishing example. It was the most enjoyable activity I ever did. When my cancer treatments and a chronic sleep disorder prevented me from continuing that pursuit, I mourned the activity’s loss as if it were a loved one who died. My head knew that I was fortunate that one group of medications was containing the cancer, and another was allowing me to sleep. But my heart still longed to be in the remotest ripples of the McCloud River, spending hours alone, just waiting for a fish to rise. I eventually realized it wasn’t the act of fishing in the middle of a pristine river that I missed; it was the serenity I felt being there. I sought other activities that could engender “serenity” or something similar when I realized that. I found it in crafting and playing with wooden flutes. Was it the same? Not quite, but close enough to partially fill that pothole. Remedies for Grief If you regret the loss of something important, seek counseling if you believe talk therapy is appropriate for you.[8] But there is an alternative method: Experiment as a scientist would do by engaging in activities that can generate an emotion similar to the one you no longer experience because of the loss. Once you have identified the emotion, try activities that may cause similar emotional responses. You might be surprised that pleasure can be found in very different activities since the brain’s physiology can produce the emotion—stability, for example—whether it comes from an unchanging social environment, an orderly home, or the interaction of supportive people. Takeaway There shouldn’t be any place for righteous indignation when assessing grief and loss, whether it comes from or is directed against you. Loss is loss is loss. Mourn what you lost, understand its place in your identity and emotional fulfillment, and start a search to fill the hole. If you are open to experimentation, you may be surprised that the feeling your partner engendered in you returns by weeding the garden. Stan Goldberg, Ph.D., - Website - References [1] Robson P, Walter T. Hierarchies of loss: a critique of disenfranchised grief. Omega (Westport). 2012-2013;66(2):97-119. doi: 10.2190/om.66.2.a. PMID: 23472320. [2] Fearon, J. D. (1999). What Is Identity (As We Now Use the Word)? California: Stanford University. [3] Peter J. Burke, “Identity Change,” Social Psychology QuarterlyVol. 69, No. 1 (Mar., 2006), pp. 81-96, American Sociological Association [4] Stan Goldberg, “Welcome to Kauai. What’s that Strange Stick in Your Hand? Saltwater Fly Fishing, December, 1999 [5] Stan Goldberg, Preventing Senior Moments: How to Stay Alert Into Your 90s and Beyond (Lanham, MA: Roman & Littlefied, 2023) [6] Jack D. Simons, “From Identity to Enaction: Identity Behavior Theory,” Front. Psychol., 24 August 2021 [7] Titlestad KB, Dyregrov K. Does 'Time Heal all Wounds?' The Prevalence and Predictors of Prolonged Grief Among Drug-Death Bereaved Family Members: A Cross-Sectional Study. Omega (Westport). 2022 Apr 28:302228221098584. doi: 10.1177/00302228221098584. Epub ahead of print. PMID: 35482973. [8] Newsom C, Schut H, Stroebe MS, Wilson S, Birrell J, Moerbeek M, Eisma MC. Effectiveness of bereavement counselling through a community-based organization: A naturalistic, controlled trial. Clin Psychol Psychother. 2017 Nov;24(6):O1512-O1523. doi: 10.1002/cpp.2113. Epub 2017 Aug 29. PMID: 28850762; PMCID: PMC5763344. [9] Šimić G, Tkalčić M, Vukić V, Mulc D, Španić E, Šagud M, Olucha-Bordonau FE, Vukšić M, R Hof P. Understanding Emotions: Origins and Roles of the Amygdala. Biomolecules. 2021 May 31;11(6):823. doi: 10.3390/biom11060823. PMID: 34072960; PMCID: PMC8228195.