Editor’s note: Melissa Orlov, LLC, is a marriage consultant who specializes in working with couples impacted by ADHD. She is the author of the award-winning book, The ADHD Effect on Marriage: Understand and Rebuild Your Marriage in Six Steps, and provides seminars for couples and therapists. Her continuing education presentation for GoodTherapy.org, The ADHD Effect on Couples, is scheduled for 9 a.m. PST on January 25. This event is available free with 1.5 CE credits for all GoodTherapy.org members. For details, please click here.

In your couples practice, you may well encounter couples in which one partner is chronically angry while the other keeps making mistakes that are hard to understand, such as regularly forgetting to do something they’ve committed to, constantly irritating their partner by being late, or never cleaning up after themselves. The angry partner tries many things to motivate his or her partner—nagging, scolding, pleading, crying—but nothing seems to work. The forgetful partner is genuinely contrite, yet continues doing the same “stupid” things.

It is possible that this couple’s relationship is being impacted by undiagnosed attention-deficit hyperactivity (ADHD).

Learning how to work with couples affected by ADHD is a relatively new and very much needed skill in couples therapy. It is only recently that we have been thinking much about ADHD in adults, and according to expert ADHD researcher Dr. Russell Barkley, as many as 90% of adults with ADHD remain undiagnosed (1). Clients often don’t know they have ADHD or that it contributes to their marital issues. Many times, neither do their therapists. Unfortunately, unrecognized ADHD can wreak havoc in a relationship—in some research studies, almost doubling rates of marital dysfunction and divorce (2).

One of the side effects of the repetitive missteps of an ADHD partner is that anger builds in the relationship. Chronic distractibility, disorganization, and difficulty remembering things are hallmark traits of adult ADHD that can severely impact one’s life. They also don’t play particularly well in a relationship or at home. A chronically distracted partner is often not particularly good at attending to his or her partner in a way that communicates love. The feelings of love are there, but the partner is simply off doing other things. It is no surprise that non-ADHD partners often report that they feel intensely lonely in their relationship (3).

As distraction, disorganization, and other ADHD symptoms continue unabated, partners of those with ADHD can lose patience and become so angry that it colors every aspect of the relationship. Minor gaffes become major blow-ups because they are symbolic of bigger issues in the relationship. For example, an ADHD partner who leaves the milk out on the counter may be reprimanded by his or her partner for “never paying attention” or being “lazy,” even though in other situations leaving milk out might be considered a “nonevent.”

With enough rebukes, an ADHD partner (who often suffers from self-esteem issues in any event) begins to avoid engaging with the non-ADHD partner. Anger that he or she is being constantly criticized builds, too. Arguments escalate more and more quickly, and the couple find themselves in a strong, negative behavioral spiral. They don’t understand their partner’s seemingly arbitrary behavior, but do understand they don’t like it.

My observation is that by the time ADHD-impacted couples make it to counseling, they are often in very significant trouble. They’ve tried everything they can think of to “fix” things, but because they don’t know about the ADHD, have not found a workable solution to their conflicts. They are suffering from great emotional pain, and are often feeling hopeless about the relationship. Many are trying to decide whether to get divorced, but are confused. They feel they ought to be able to do better and don’t understand why they can’t.

The good news for therapists is that working with these couples can literally turn their lives around. First, couples are typically greatly relieved to realize that there is a reason for their problems. Also, identifying ADHD provides a significant chance for behavioral improvement in the ADHD partner. With effort, about 70% of those with ADHD can find treatment that provides almost complete, or at least very significant, improvement in their symptoms (1).

Naming the problem not only provides renewed hope, it creates an opening for redirecting interactions between partners. Certain types of communication tactics, organizing habits, and ways to “attend” to each other simply work better than others for couples impacted by ADHD. These are often not the same tactics that couples not impacted by ADHD use (3), so therapists need new training to optimize their effectiveness.

Sometimes that training includes learning a new style of interacting with clients. I find that these couples respond well to an “activist” approach to counseling that puts the therapist in multiple roles at different points in the therapy—that of expert educator, listener, ADHD coach, sex advisor, and investigator, to name some of the most common. These couples tend not to learn through self-reflection. Rather, they need active guidance to learn a new skill set that will enable them to live together successfully and bridge their often very considerable differences.

Yes, these couples often have really significant problems. Not all of them stay together. But with the right assistance, many of them are able to turn their relationships back into something they treasure. For therapists, it can be incredibly fulfilling work.

References:

1. Barkley, R.A. (2010). Taking charge of adult ADHD. New York, NY: The Guilford Press.
2. Barkley, R. A., Murphy, K. R., Fischer, M. (2008). ADHD in adults: What the science says.New York, NY: The Guilford Press.
3. Orlov, M.C. (2010). The ADHD effect on marriage: Understand and rebuild your relationship in six steps. Plantation, FL: Specialty Press.

In an increasingly connected world, most people have an account on at least one social networking platform, and many people use social networking as their primary means of communication with friends and family. Most of us are aware that social networking poses some dicey questions in romantic relationships—whether to “friend” exes, whether to share private conversations with partners, what constitutes flirting, how much information about a relationship is acceptable to share online, and so on—but social networking is primarily an avenue for connecting with nonromantic friends.

Is social networking changing friendship as we know it? Research hints that the answer is yes.

Reduced Investment

Facebook provides bountiful opportunities for “friending”—a term we owe to social networking—and many people have hundreds or even thousands of online friends. Historically, people have had 150 to 200 people in their circle of acquaintances, on average, and only a few close friends. But Facebook, for example, allows people to “friend” others without making much investment. This could change the way people approach friendship. Where friendship previously required time, effort, and a lot of conversation, it now seemingly requires only a click of a button. This has the potential to broaden the number of people a person may consider his or her friends, while significantly reducing the number who fit the more traditional traits associated with close friendship.

Changed Boundaries

Although some social networking sites offer options that allow people to limit the viewers on certain posts, people tend to post things to everyone on their friends list. This serves to alter the boundaries of traditional acquaintance relationships. Your boss might read about your difficult pregnancy, and an old college professor might hear about your difficulties in your marriage. Conversely, when people use only social networks to communicate with their close friends, they limit the intimacy and detail of their conversations because—despite the compromised boundaries brought about by social networking—there are still some things that most people won’t post online, even if they’d share these things with close friends.

Social networks also make it much easier to share controversial opinions with friends and acquaintances. Many of us have friends with whom we would never discuss politics or religion. But the endless political jockeying on Facebook and Twitter makes it much more likely that people will engage with their political foes. Depending on how these conversations are handled, they can increase conflict or even destroy friendships, or they can promote understanding and mutual respect.

Reaching Out

Starting a new friendship can be challenging, particularly for adults who are no longer in school or who don’t have a large pool of co-workers. For shy people and those seeking new friends, social networking provides an easy way to make the first overture of friendship. By simply clicking the “add friend” button, people can convey that they’re interested in getting to know someone, reducing a traditional barrier to friendship.

Changing Face Time

In-person communication with friends has always been an important part of friendship. Social networking might reduce the frequency of face-to-face contact. One study found that 10% of social networking friends ranked as “close” had never actually met in person. Social networking also changes how people spend face time with friends; they may spend time together perusing others’ social network profiles or discussing what they’ve seen online rather than catching up on one another’s lives.

References:

1. Novotney, A. (n.d.). R U friends 4 real? American Psychological Association. Retrieved from http://www.apa.org/monitor/2012/02/friends.aspx
2. Is social networking changing the face of friendship? (2007, September 14). ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2007/09/070912161147.htm

We all know the feeling, but few of us want to talk about it. Shame often runs our lives and undermines our relationships, but we often keep it hidden. We’re ashamed of being ashamed. I felt it today when my wife reminded me of something I had said to her that was unkind. I pride myself on being a sensitive, caring man, and when she pointed out this shortcoming, I could feel the shame rise up in me. I felt myself getting warm. My first thought was, “I didn’t do it.” My first words were, “I never said it.” I felt confused and off balance. I wanted to run away and hide. I wanted to disappear.

I was awash in my shame, but I tried to cover my discomfort. Shame is such a wretched feeling, most of us try and deny we are feeling it, hoping that if we don’t look at it, shame will magically disappear. But shame is stubborn. The more we deny it, the more it sticks to us like glue.

Recent research shows that shame is conceptualized as a multidimensional construct, manifesting in various physical and emotional ways. Shame manifests physically in a wide variety of forms. “The person may hide their eyes; lower their gaze; blush; bite their lips or tongue; present a forced smile; or fidget,” psychotherapist Marc Miller said. Other responses may include irritability, annoyance, defensiveness, exaggeration, or denial. Research indicates that the strongest correlates of shame across studies include individual differences in nonacceptance of negative emotions and expressive suppression. Because the effect of shame often interferes with our ability to think clearly, we may experience confusion, being at a loss for words, or a blank mind.

“Man is the only animal that blushes,” Mark Twain once said. “Or needs to.” He reminds us how central shame is to the human experience.

Find a Therapist

When couples come to me for counseling, they rarely mention shame as a cause for their difficulty. Yet I’ve found that shame is a major factor of relationship problems. Research shows that shame can have a severe negative impact on intimate relationships, leading to negative shame loops between partners. We know that couples often fight about money and sex. He gets angry when she spends money on things he thinks are not important. Underneath his anger we often find feelings of inadequacy. Beneath her spending patterns may be feelings of loneliness and unworthiness.

Key Insight: Nathanael Schlect, Licensed Associate Counselor “Shame often operates alongside other vulnerabilities such as fear, grief, or insecurity rather than existing in isolation.”

One partner wants more sex, and the other feels tired or withdrawn. One gets angry. The other feels hurt. Shame is rarely discussed, but is always present. One may feel like a lousy lover. The other may feel unattractive.

Recent umbrella reviews show that a relative majority of studies conceptualize shame as a multidimensional construct, representing what Helen B. Lewis, a pioneer in recognizing the importance of shame to psychotherapy, argued was an entire family of emotions. This family includes humiliation, embarrassment, feelings of low self-esteem, belittlement, and stigmatization. Shame is often experienced as a critical inner voice that judges us as “damaged goods,” inadequate, inferior, or worthless.

Shame in Men and Women

I’ve found the things that trigger shame differ in men and women. Research confirms that gender stereotypes maintain that women experience more guilt and shame than men, with meta-analyses showing small but significant gender differences (d = -0.29 for shame). Women often feel shame when they are unable to do all the things they think they should do. They must be a good mother, a sexy wife, a successful breadwinner, a caring friend, a good sister, and more. Studies show that women avoid the shame they may have if others observe that they overestimated themselves, while men do not seem to be similarly shame averse, possibly due to different societal expectations where men are expected to be overconfident.

The list is smaller for men. Shame usually manifests when we don’t feel strong. Dr. Brené Brown, an expert on shame, says, “While women are faced with a web of many layered, competing, and conflicting expectations, there seems to be one major expectation for men—do NOT appear weak.”

I’ve also found that men and women often react to shame differently. Research indicates larger gender gaps in shame with trait versus state scales, and gender differences in shame about domains such as the body, sex, and food tend to be larger than other domains. While individual responses to shame vary widely and are not strictly gender-bound, often women often blame themselves when they feel ashamed. They look embarrassed. They turn inward. Men often blame others when they feel ashamed. They often look angry. They may explode outward.

Key Insight: Nathanael Schlect, Licensed Associate Counselor “While patterns can differ across socialization, people of any gender may turn shame inward or outward depending on personality, history, and context.”

In fact, male violence is often an attempt to ward off shame. Recent research shows masculinity threats lead to emotions including shame, guilt, and a reduction in empathy, and these masculinity threats predict harmful behaviors such as men’s aggression, sexual violence, anxiety, shame, self-harm, and homophobic attitudes. Dr. James Gilligan has spent more than 30 years researching anger and violence in men. His research traces the role that shame plays in the etiology of murder and shows how feelings of shame cause violent and vengeful behavior. He says, “I have yet to see a serious act of violence that was not provoked by the experience of feeling shamed and humiliated, disrespected and ridiculed, and that did not represent the attempt to prevent or undo this ‘loss of face.’ ” Respect is important to all of us, but for men it is essential. Recent research on masculinity and violence shows that when men were targets of partner violence, many described feelings of weakness and shame, reflecting assumptions that men should be dominant and not victimized. Feeling disrespected or “dissed” can cause a man to strike out in rage.

Self-Disclosure and Empathy

The most difficult thing in the world to do when we are feeling down on ourselves is to admit how we feel. Yet self-disclosure is what we need to do to stop the cycle of shame and blame that so many of us get caught up with. Recent research on intimacy shows that self-disclosure, a fundamental component of intimacy, occurs only when vulnerability is met with acceptance rather than rejection. However, shame disrupts this process by inhibiting vulnerability and promoting defensive strategies. It’s harder than hell to say to my wife, “You’re right, what I said was unkind. I’m sorry.” But that’s the key to washing the shame away.

Attachment research shows that shame loops within couple relationships may not only be triggered by negative cues, such as criticism from a partner, but can also innocently be triggered by a partner seeking connection or even offering comfort. It feels counterintuitive. We’re afraid that if we admit our faults, we’ll feel even more ashamed. But the opposite is true. The more we’re able to say, “Yes, I messed up,” or, “Yes, I made a mistake,” or, “Yes, I’m sorry for what I said,” the better we feel about ourselves.

We all know the good feeling we get when we can own our mistakes and be forgiven. But that takes empathy on the part of our partner. Our partner has to be able to feel with us, not blame us or put us down. Recent clinical trials of Emotionally Focused Couple Therapy show significant improvements in intimacy and reductions in shame when couples learn to address these dynamics. For men, it often means admitting our weakness. And for women, it means accepting that we can still be strong, adequate men, even when we are weak.

Men need also to practice empathy with the women in our lives. We have to understand the things we do that shame them, the subtle ways we may put them down. And we all need to be more empathic with ourselves. We don’t have to be successful at everything, all the time. We don’t have to be strong all the time and hide our weakness. We can learn to love and accept the wonderful, flawed, human beings we all are.

References:

1. Mirzazade, Z., Molazade, J., & Hadianfard, H. (2025). The effect of emotionally focused couple therapy (EFCT) on shame and intimacy in couples: a randomized controlled trial (RCT). BMC Psychology, 13, 1111. https://doi.org/10.1186/s40359-025-03415-3
2. Frediani, M. J., et al. (2024). Seeking connection can trigger shame loops in couples: An attachment-based understanding. Family Process, 63(1), 34-47. https://doi.org/10.1111/famp.12888
3. Vescio, T. K., et al. (2025). Masculinity threats sequentially arouse public discomfort, anger, and positive attitudes toward sexual violence. Personality and Social Psychology Bulletin, 51(1), 3-20. https://doi.org/10.1177/01461672231179431
4. Stanaland, A., Gaither, S., & Gassman-Pines, A. (2023). When is masculinity “fragile”? An expectancy-discrepancy-threat model of masculine identity. Personality and Social Psychology Review, 27(4), 285-315. https://doi.org/10.1177/10888683221141176
5. Swerdlow, B. A., Sandel, D. B., & Johnson, S. L. (2023). Shame on me for needing you. Emotion, 23(3), 737-752. https://doi.org/10.1037/emo0001109
6. O’Donnell, S., et al. (2024). Masculinity and violence interconnectedness: Defining and reconciling the gender paradox among men with cumulative lifetime violence histories. SAGE Open, 14(3), 21582440241266998. https://doi.org/10.1177/21582440241266998
7. Else-Quest, N. M., Higgins, A., Allison, C., & Morton, L. C. (2012). Gender differences in self-conscious emotional experience: A meta-analysis. Psychological Bulletin, 138(5), 947-981. https://doi.org/10.1037/a0027930
8. DeSantis, A. J., Eshelman, L. R., & Messman, T. L. (2025). Emotional dysregulation, anger, and masculinity in men who have experienced lifetime sexual violence. Journal of Interpersonal Violence, 40(21-22), 5199-5222. https://doi.org/10.1177/08862605241301790
9. Deshmukh, A., Mehta, R., & Acar, Z. (2024). Perceived criticism and intimacy avoidance in couples: The mediating role of shame. Research and Practice in Couple Therapy, 2(1), 1-10. https://doi.org/10.61838/rpct.2.1.1
10. Bardi, L., et al. (2024). Conceptualization and assessment of shame experience and regulation: An umbrella review of synthesis studies. Clinical Psychology Review, 113, 102436. https://doi.org/10.1016/j.cpr.2024.102436

My friend and colleague, Linda Poelzl, has been working as a professional surrogate partner for 17 years. As a local writer commented a few weeks ago after meeting both of us, what this means is frequently misunderstood.

Sometimes I think “sex” is the most powerful and misleading word in the English language! Call Linda a sex surrogate and people start imagining her writhing in coitus.  Call me a sex therapist and local readers post, “How sicko and disgusting that we have a sex therapist here in San Luis Obispo County!” on their Facebook walls.

Our local weekly (the New Times) was particularly excited to arrange an interview with Linda and me because of the flood of positive publicity surrounding The Sessions, a new film based on actual experiences in the late 1980s when surrogate partner Cheryl Cohen Greene worked with polio-disabled journalist and poet Mark O’Brien.

In the trailer, there is one scene in which two astonished hotel workers watch a nervous and paralyzed O’Brien being loaded into an elevator on a stretcher. When one of them asks why they’re taking him upstairs, the other explains that he has an appointment with a “sex therapist,” a misnomer that has Linda and other surrogates feeling frustrated.

“The public doesn’t comprehend that you and I work together to help people heal!” she says. Where my work as a therapist is psychological, Linda’s is physical, employing exercises focused on intimacy, body image, relaxation, and the giving and receiving of touch or “sensate focus.” Sexual intercourse occasionally does occur, but it is a minor part of her work.

Common presenting issues for men include rapid ejaculation, delayed ejaculation, and very often, simple inexperience—one of Linda’s current clients is a 32-year-old virgin. “He’s never, until recently, held hands, kissed a girl, had sex,” Linda says. “He’s a gorgeous guy! There are a lot of people around who are silently suffering.”

Some people refuse to differentiate what Linda does from prostitution, she explains. What they don’t comprehend is that she never works alone. After each session, she relates her impressions to me, which enables me to better assist clients through many challenges toward sexual healing.

I, in turn, communicate with Linda after each talk session in my office, and the three of us usually meet together to conclude the surrogate’s involvement. Legitimate surrogate partners always work in tandem with therapists who have an ongoing established relationship with the client they refer.

I was introduced to Linda by Cohen Greene herself, and we’ve worked together for much of this year. Her approach is gradual, with the first sessions devoted to getting acquainted, discussing issues, and building rapport. “I’m going to touch you, and you’re just going to relax and feel and enjoy it, and then we’ll check in at the end …”

“And that’s usually like hands and face and maybe a foot rub—the first couple sessions are with clothes on, usually,” Linda says. “And sometimes if the client is ready and I’m ready, we might take clothes off in the third session … to do an exercise called ‘Body Image’ … it’s more about being comfortable with each other nude before we get into being sexual …

“We answer questions. I talk about condoms and safe sex. Then we usually get into bed … and I ask them about their bodies, and how they like to be pleasured. After that, it pretty much gets into whatever their problem is. If they have rapid ejaculation, we do exercises to work on control and awareness. A lot of times people think it’s all about intercourse, and it’s not. That’s a small part. Usually by the time they’re ready to do a lot of that, they don’t really need me anymore.”

If the client is able to form a bond with the surrogate, this means the person is capable of falling in love with future partners “out in the real world.” After finishing work with the surrogate partner, the client generally continues ongoing intimacy work with me as “talk therapy.”

It’s natural intimacy work, pure and simple. Many people yearn for the physical experience, the orgasm, without the relationship, without the intimacy. One without the other never satisfies in the end. So the work that Linda does, in conjunction with the work that I do, is invaluable.

Family therapy can help families and couples overcome challenges with interpersonal relationships. Many issues that families and couples face become volatile and hostile without the help of learning how to constructively communicate and problem-solve. Relationship issues do not discriminate, and people of all cultures and races are vulnerable to family conflicts. This does not mean that people of every ethnicity embrace family therapy equally. In fact, African-Americans are far less likely than white people to seek out therapy for family problems. The reasons for this are many, and could include limited access to care, financial restrictions, mistrust of mental health professionals, and fear of stigma associated with counseling.

Cadmona A. Hall of the Marriage and Family Counseling Center at the Adler School of Professional Psychology in Illinois wanted to examine the specific barriers preventing African-Americans from seeking treatment. In a recent study, Hall interviewed nine participants and found that stigma presented the biggest obstacle to treatment. Resilience was the most common personality trait that helped the participants overcome the stigma. Hall believes that African-Americans are more likely to be resilient, having had to surmount the atrocities of slavery and the injustices of discrimination. This ability to overcome could have been an underlying force that led the participants to seek out help despite the barriers.

Hall also noted that eight of the nine individuals in her study were affiliated with the college where the counseling clinic was located. Having knowledge of and access to the services could have increased the willingness in this sample of participants. Another appealing aspect of the university clinic was the sliding fee scale, which was cited as a very beneficial aspect. Mistrust, which was listed as a barrier to treatment seeking, was addressed when the participants realized that their sessions were confidential and they felt comfortable enough to build rapport with their therapists. This was critical in setting them at ease and ensuring they would return to complete therapy. Although the sample size used here was small and lacking diversity, it was able to provide insight into the factors that prevent African-Americans from seeking out therapy. “As clinicians increase sensitivity and understanding of the unique features of African-Americans, they will have an increased ability to engage that population in therapy and increase quality of care,” Hall said.

Reference:
Hall, Cadmona A., and Jonathan G. Sandberg. “We shall overcome”: A qualitative exploratory study of the experiences of African-Americans who overcame barriers to engage in family therapy. American Journal of Family Therapy 40.5 (2012): 445-58. Print.

Depression makes it difficult to function in daily life, but adding discrimination to the equation makes it even more troublesome.

A new study in the journal The Lancet stated that out of the 1,082 adult participants with major depressive disorder, 79% reported that they have experienced discrimination. People who experienced discrimination while depressed had more depressive episodes, social difficulties, and issues finding and keeping a job. They also were less likely to reveal a diagnosis of depression.

These results suggest that more works needs to be done in the area of preventing discrimination and eliminating stigma. Discrimination can prevent people with depression, who may be worried about disclosing their diagnosis, from getting the help they need. While getting a job and growing social networks can help fight depression symptoms, those pursuits become more challenging in the face of discrimination.

How, specifically, does discrimination affect people with depression? How can the general public be more understanding? And what options do people with depression have? Mental health experts and other professionals have some answers.

Dr. David Sack, CEO of Elements Behavioral Health and Promises Treatment Centers, said by email that sensitivity toward people with depression often is lacking.

“The most common example has to do with intolerance toward peers/friends/relatives that comes from not understanding that depression is a disease that the individual cannot simply will themselves out of,” he said.

Sack said a supervisor might question an employee’s motivation and commitment due to symptoms of depression, even if those symptoms don’t reflect how the employee really is.

“How often have we heard that this or that person claims that they are depressed just so they can get time off from work or won’t have to take responsibility for mistakes they’ve made?” Sack said.

Although many people know the basics of depression thanks to widespread awareness initiatives, prejudice, bias, and stigma still are rampant.

Viola Drancoli, a clinical psychologist, said in an email that friends and family members of people with depression might exhibit discriminatory behavior with them because they may feel drained from being around someone who expresses sadness, pessimism, irritability, and a lack of motivation.

This could push someone with depression into isolation. A person with depression might prefer being alone so he or she doesn’t have to attempt to hide feelings from others.

“The social isolation often starts a vicious cycle in which the (client’s) negative outlook on life is reaffirmed, they feel let down by family and friends, and symptoms may worsen,” Drancoli said. “This is especially dangerous for individuals who have suicidal ideations and need support and monitoring.”

Drancoli said it’s important for family and friends to be supportive. She suggests volunteering to help out with chores that might be difficult for someone with depression to complete when he or she is struggling to function, as well as patiently listening without judgment. Loved ones can gently encourage a person with depression to exercise as well, as this has been shown to boost mood.

People with depression who believe they have been discriminated against have the law on their side. Sack said that discrimination against people with any disabilities, including mental issues such as depression, is forbidden by the Americans with Disabilities Act. The civil rights law, enacted in 1990, defines disability as “a physical or mental impairment that substantially limits a major life activity.” Some states have additional laws against discriminatory behavior.

“An individual who is concerned about discrimination at work will want to speak with their supervisor or the director of human resources first,” Sack said. “Most companies have strong policies to promote fairness and nondiscrimination.”

Justine Lisser, a senior attorney advisor in the Office of Communications & Legislative Affairs at the U.S. Equal Employment Opportunity Commission, said by email that if an employer has at least 15 employees, it must abide by the ADA. Employers need to provide “reasonable accommodations” for people with disabilities, as long as the employer isn’t deeply burdened as a result.

“For example, if a person with depression is hired for a position that requires an 8 a.m. start time, but due to the effects of (antidepressant) medication the person could not start until 10 a.m., it would be a reasonable accommodation to permit the employee with depression to start at 10 a.m., assuming that it would not cause an undue hardship for the employer,” Lisser said.

The EEOC has successfully enforced employee discrimination laws in a few cases involving people with mental health issues. In one case, a sales associate at a video retailer experienced harassment because of his social anxiety disorder and depression. His employer was ordered to pay $70,000 to settle the discrimination suit, according to an EEOC press release from March 2012.

One of the reasons many children do not tell anyone about being sexually abused is because they fear that their loved ones will not believe them. Often, their abuser is a friend or family member, and although children may know that what occurred is wrong, they may be confused and worried that their caregivers will think they have misconstrued the behavior. Children who feel neglected or maltreated by caregivers may feel reluctant to disclose abuse, and many abusers threaten children, creating more reasons for nondisclosure. However, when children do reveal abuse, getting them to explain the abuse in a way sufficient to lead to prosecution can be challenging.

Various methods of interrogation are used on child-abuse victims, including open-ended questions, yes/no questions, “What happened?” questions, and “How did that make you feel?” questions. For the most part, open-ended questions and “what” questions tend to provide the least amount of detail. Children often are unable to articulate the details of their abuse. And while “how” questions that prompt children to reveal their physical reactions and feelings allow them to detail their personal experience in great detail, this is the most rarely used form of interrogation. To explore which method would provide the most accurate recollection of abuse and elicit emotional responses that could demonstrate credibility to jurors, judges, and therapists, Thomas D. Lyon of the Department of Psychology at the University of Southern California recently examined transcripts from more than 100 child-abuse cases.

Lyon discovered that when children were asked closed-ended questions such as yes/no, their responses were narrow and they exhibited little emotion. Similarly, when they were asked “What happened?” they were hesitant to reveal details and appeared emotionally undisturbed. But when children were asked how the abuse made them feel and what their physical reactions were, the responses were extremely vivid and consistent. They demonstrated emotional responses and used words such as angry, sad, afraid, confused, “sick to my stomach,” and dirty. They manifested facial and physical reactions that allowed those interviewing them to see the damage of the abuse in ways that the children could not articulate when prompted with direct questioning. “Children can be surprisingly articulate about their reactions to sexual abuse, despite their apparent lack of affect in describing the abuse itself,” Lyon said. He hopes that these findings will motivate interviewers, prosecutors, and mental health professionals to evaluate physical and emotional reactions of abuse as a means to gather details from child sexual abuse victims.

Reference:
Lyon, Thomas D., Nicholas Scurich, Karen Choi, Sally Handmaker, and Rebecca Blank. ‘How did you feel?’: Increasing child sexual abuse witnesses’ production of evaluative information. Law and Human Behavior 36.5 (2012): 448-57. Print.

One of the basic ingredients of good psychotherapy is being understood. People often do not consider what it means for a therapist to understand. Ideas vary from one school of therapy to another—even from one therapist to another.

Some look for understanding through causes. How did you get to be the person you are? What early experiences may have taken part in forming your personality?

Some therapists focus on understanding in a manner rooted in biology. Do you have a shortage of neurotransmitters that are designed to make you feel happy—to give you a sense of well-being?

Others are more interested in understanding what you experience as you go through the world. What does it feel like to be in your shoes—to have your anxieties, loves, fears, and hopes?

Most therapists use a combination of these modes, as well as many others I haven’t mentioned. In my view, there is a critical part of understanding that provides a profound respect for your humanity—a sort of understanding that is familiar to all of us, but is not an ordinary part of the therapeutic literature.

I’m referring to the process of understanding a person precisely how that person understands himself or herself. I believe the modes of understanding that I have mentioned are critical, but having someone see you in the way you see yourself is foremost. There is subtle disrespect in a therapist’s bypassing your self-understanding toward an investigation that lies beneath—whether it be unconscious phenomena, biochemistry, or even felt experience—as your experience in the world is not quite the same as your evaluation of it.

[fat_widget_right]It’s true that we all have blind spots, and therapists are in a position to notice things we may not. We collaborate with our therapists to investigate the mysteries of the unconscious, the unknown, and what we don’t understand about ourselves. That quest has been a part of therapy since its inception. But wouldn’t it make sense for therapist and person in therapy to have dialogue about that first?

For example, does your understanding of self-discovery differ from that of your therapist? Presumably, nobody is the expert when it comes the most important human questions—those that matter most to us. Therapists in their craft have something to teach: Sigmund Freud’s technique ignited a passion for self-inquiry lasting more than 100 years and still burning. However, the extent to which you may have something to teach often is overlooked.

Following one of Freud’s favorite metaphors, as the archaeologist penetrates beneath the earth’s surface, the psychoanalyst does the same with the mind. In a descending excavation, the height of great aspirations—the astronomer’s sky—may be inappropriately understood.

Therapists can become preoccupied with your biases and misconceptions. They may lose sight of the independent dignity of what you see. What are the things you love and hold dear? Why do you love them? What are the things that guide your life? Love? Family? Truth? Beauty? Security? What are your highest aspirations? Your virtues? Strengths? What are your opinions about the most important things? The universe? And how do you understand your place in it?

Many therapists develop understandings of people in therapy in relation to these questions. However, it might be a mistake to believe these investigations lead only to an illusory superstructure under which your real truth lies. These questions are integral to being human and hold an independent dignity. They cannot be reduced to something else. It is a terrific advantage if your therapist welcomes the things that are most dear to you and understands them on your terms with the utmost seriousness.

This is the third in a series of articles designed to explore some of the issues and concerns that arise around what is currently called Asperger’s syndrome, which will soon be incorporated into the broader spectrum of autism disorder when the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is published in 2013.

I had a client we’ll call Brian, a man in his mid-thirties with a diagnosis of Asperger’s syndrome who came to me to discuss what he referred to as “issues he was having with people at work.”

It is not an unusual request for a person with Asperger’s to want to work on the confusion that surrounds social interactions in general. Interactions at work often are more challenging because in the office, not only do the normal social protocols apply, but there often is an additional layer of a particular corporate culture overlaid upon this basic structure, invisibly directing everything.

Bryan was a pleasant and engaging man. He held good eye contact, spoke with precision, and demonstrated a light touch with humor. His demeanor changed, though, when I asked him about his colleagues in the office where he worked as a certified public accountant.

A quiet earnestness overcame him. He spoke clearly and without breaking to collect his thoughts or in expectation of response. He discussed one individual after another in great detail, including information about the kind of work they did, their areas of responsibility, and where they stood in the hierarchy. This was precisely the sort of information I expected to get from Brian on the topic of work relationships.

Then, however, he began to speak of his colleagues in more personal terms. He knew who was married and who was single. He knew who had children, their names and ages, and the schools they attended. Brian told me who had recently vacationed and where they had gone; who golfed and who played tennis; who had iPhones and who used Androids. He knew the makes and models of everyone’s cars. He knew the names of spouses. He knew which neighborhoods his coworkers called home. He even knew who had housekeepers and who did not.

It might appear surprising on first glance to read that I was given such detailed and personal information about others from a man with Asperger’s who came into my office with self-identified problems related to interpersonal relationships. But I have seen this before. Once you look at this apparent contradiction in another light, you may recognize it, too.

I’m talking about the illusion of friendship.

Further discussion with Brian demonstrated to me that he had gleaned all this information about his coworkers not from interactions with them over time, the way you or I might imagine getting to know the people we work with. Instead, Brian had developed his extensive knowledge of everyone around him by listening and even eavesdropping on conversations others were having around him, but in which he had not once been involved personally.

And he was having problems with his coworkers when he would make a statement revealing his knowledge about a person, info he had no apparently legitimate way of knowing. People became uncomfortable around him because of this and withdrew from him, which left him utterly confused.

Of course, this became the starting point for our work together. Brian had to learn about the ways that acquaintanceships and friendships develop over time. Importantly, he also had to learn the concept of reciprocity: It is not enough to know things about another person, but one must also share personal information about oneself as well in the give-and-take manner of casual conversation. This is how trust develops between people. This is the foundation from which we can make a statement such as, “Oh, yes, I know Brian,” with legitimacy.

Brian had to learn that knowing confidential or intimate facts about another person without that reciprocity was considered socially gauche, and that it had the potential even to be frightening to some individuals. Brian had to learn the difference between having friends and having the illusion that he had friends.

Once we began to tease this distinction apart, Brian began making progress in his social interactions. We used role-playing techniques and many “what-if” exercises, and Brian’s distress around the topic of his work environment noticeably decreased over time.

What was once considered a rarity—step-siblings, step-parents, and step-in-laws—has become more common than not. When couples marry, there is a very good chance that one of them brings an extended family that branches by halves and steps. And if that couple winds up divorcing, the tree splinters even further. Because there is no biological bond that obligates a step-family member to stay in contact with other steps, the rules of engagement can be confusing and tense. In a recent article, marriage experts explain how to navigate the rocky road of step-relationships after divorce.

Take, for example, the case of an ex-wife who spent decades raising her step-children. Should she continue the relationship with these nonbiological children, even though she has no legal claim to them? Mary T. Kelly, a marriage therapist from Colorado, notes that often step-children can be a contributing factor to divorce. Many blended-family parents disagree over how to raise his, hers, and their children. Tension that exists between step-children and step-parents seems like normal childhood rebellion, but in many cases may actually run deeper.

Paul Hokemeyer, a New York therapist, says couples and children need to determine if they want those relationships to continue after divorce. Many children may not be permitted to make contact with their ex-step-parents while they are minors, but can make the choice whether to have a relationship with that significant person when they reach adulthood. Even step-grandparents get caught in the mix when step-families divorce. Grandparents who become attached to step-grandchildren, only to have them taken away, may not be willing to invest as much into future step-family members.

One Massachusetts psychologist, Patricia Papemow, recommends that clients try to initiate contact through letters rather than personal visits or phone calls. It is important for step-children to be allowed to have time to process the shift in the relationship on their own terms. Letting them know a step-parent is there through cards and letters is a noninvasive and subtle way to continue contact and keep the door open for future communication. Regardless of how an individual chooses to stay in contact with their step-children, Hokemeyer insists that they review their motives so that all parties will be receptive. “Make sure that you are acting out of genuine love and concern for the other person, and not out of anger and attempts to manipulate,” Hokemeyer says. Following these tips could help step-exes maintain important family ties in a world of ever-changing family dynamics.

Reference:
Gootman, Elissa. When branches tangle in a stepfamily tree. (n.d.): n. pag. The New York Times. 3 Oct. 2012. Web. 8 Oct. 2012. http://www.nytimes.com/2012/10/04/fashion/-step-family-trees-with-tangled-branches.html?pagewanted=all&_r=0

A client recently described how thrilling it was to take her daughter to see the Broadway musical Annie.  She recalled that her mother took her to see it when she was a child, and it had been an indelibly wonderful experience. Now she had the pleasure of providing the same thrill for her daughter. I thought how special it was for my client to share this with her daughter and how lucky my client was that her daughter had the same feelings about the experience. It also reminded me that so many parents who want to provide what they believe to be all the right things for their children are not always met with such good feelings.

I recalled another client whose desire to recreate his delight for his son was dashed when he took him to the rodeo and was met with the response, “This is stupid.” In spite of their most nurturing and positive intentions, parents may find that their wishes and rules for their children are met with rejection. This can create painful feelings, including insult, hurt, anger, and disappointment. “Drew,” a 42-year-old client, was in a prolonged struggle with his 8-year-old daughter about piano lessons she adamantly refused to take. He told me, “When I was a kid, I refused to continue piano lessons after a few months. My parents never insisted I continue. I’m not going to let that happen to my daughter. She isn’t old enough to know what she wants or what the consequences of her actions will be.”

As Drew and I explored his feelings, it became clear that he not only felt disappointed, he felt rejected by his daughter. “It feels like she is telling me, ‘Get out of here, you don’t know what’s good for me,’ ” he said. I responded: “I can see how upset you are about this, but I wonder what it is that makes you feel so personally rejected. Is it possible that your daughter is different from you?” Drew’s first response was, “She’s my daughter and she is like me. I just know this is very important for her to do. When I was a child, I didn’t know I was making a terrible mistake. My parents should have known and pushed me to continue.”

It took a lot of talking for Drew to become aware of his many disappointments about the ways his parents had been involved in his life when he was a child. He began to consider that he might not need to protect his daughter from this disappointment. He recognized that his daughter might, like him, regret not learning the piano, but forcing her to take lessons could easily turn her away from the piano. He realized that her experience and development was and will be different from his and she is a different person with her own thoughts and feelings. After all, she has different parents than he did. The more Drew could understand his daughter’s need to differentiate from him, the easier it was not to feel so rejected and hurt.

When parents assert their desires for their children, it is not unusual for them to be met with expressions of different or opposing wants and needs. Pushing back against what parents want is a necessary part of a child’s development. For a healthy sense of self to grow, children need to differentiate from their parents and become unique, separate, individual selves. This doesn’t mean children are totally different from or always in opposition to their parents. It does mean children need to develop minds of their own. Having one’s own mind is about being able to think about your needs and wants without being overly influenced by others. Ideally, the wishes of others are considered, but ultimately one makes his or her own life choices. Obviously, the degree of autonomy for a 4-year-old differs from that of a 13-year-old and again for a 20-year-old. When children are not given the space to differentiate from their parents and don’t develop a self that is confident and strong, they will not have developed the autonomy to make life choices and get what they want as they enter full adulthood.

At age 53, “Anne” was struggling with her teenage son, “Noah.” She came to therapy expressing feelings of anger and insult from their encounters. She explained that he fought her at every turn about anything she asked of him: cleaning his room, doing household chores, getting his college applications completed.  “I don’t believe how he treats me,” she said. “He says things like, ‘Leave me alone and mind your own business.’ Is that any way to speak to your mother? I feel so hurt and insulted. Doesn’t he know I only want what’s best for him?” In great distress, Anne added, “He has become a terrible person. He is so mean and inconsiderate. He seems like a completely different person than the son I felt loved me a year ago.”

As we talked, Anne described how when she was growing up she never went against her parents. When we explored her past and present relationships, Anne began to wonder if her early experiences being compliant are related to her difficulty asserting herself as an adult. She described how difficult it is for her to disagree with her husband and how she doesn’t always feel so good about herself. She realized that it wasn’t just with her son that she felt so badly treated. “I guess I don’t feel very powerful,” she said. “I have a lot of trouble believing that what I think and feel is OK. I always followed the rules with my parents. Maybe I didn’t develop what Noah needs to do—be someone who feels OK asserting himself when there is opposition.” Many parents with teenagers experience difficult feelings in their parent-teenager relationships. For Anne, the feelings of insult and rejection were intolerable. Even worse for her was the terrible shame she felt about her negative feelings toward her son: “I’m the terrible person. Mothers shouldn’t feel this way.”

How to handle this kind of situation with teenagers is controversial. Furthermore, how any parent hears what a child says is open to interpretation and may be related to how the parent differentiated from his or her own parents. While Anne felt insulted and hurt, another parent in these circumstances might shrug and think, “When will these awful teenage years pass?” On one end of the continuum of parental response, parents might believe that a child of any age should never be permitted to say anything that is hurtful, disrespectful, or angry to a parent. At the other end of the response continuum, parents might accept any expression their child makes without intervening. An extreme example might be if a teenager said, “You’re an awful parent, you have no business having children,” and a parent made no protest about being treated that way. On this far end of the continuum, the lack of a parental response to push against doesn’t provide the child with the feeling that there is a strong parental self to separate from. If there is no other out there to individuate from, it becomes difficult for a child to develop a sense of who he or she is and the ability to be autonomous. The child is left wondering, “Who am I?” Potentially more problematic, the child may be left with a feeling of powerlessness. He or she has not been given the experience of successfully asserting his or her developing self in the world.

There is a lot of room along this continuum for parents to develop responses that feel comfortable to them while allowing some room for their children to develop their unique selves. It helps if parents let their children know what behaviors are acceptable. For instance, telling a child, “You can’t talk to me that way” is not the same as saying, “You can’t be angry at me,” or “You are hurting my feelings.”

When children respond to parents in disappointing or unacceptable ways, it is important that parents stop and consider how they will meet that response. Each situation requires thought. Sometimes, interfering with the child’s wishes or experiences provides an opportunity for the child to push back against the parent and feel a sense of his or her developing self. At other times, supporting the child’s differentiation provides the child with a sense of confidence and recognition of his or her developing self. No matter the age of the child, parents who are curious and interested in why there is disparity or opposition are communicating their openness to more than one way of behaving and/or feeling. This openness to difference helps children develop into self-confident, autonomous adults. Moreover, parents are less likely to repeat the dynamics of their own childhoods if they consider their children’s behavior from a developmental perspective. They will be in a better position to not take things so personally and will feel less hurt, insulted, or disrespected by their children.

Many mental health professionals consider the three “A’s”—addiction, affairs, and abuse—sufficient reason to leave a partner. This blog addresses lower-level offenses related to the first two. While most couples can overcome low-level indiscretions in any area of the three “A’s,” when multiple indiscretions occur or the degree of severity is greater, it may be time to throw in the proverbial towel. As couples grapple with why one partner cheated or entered the depths of alcoholism or drug addiction, they need to evaluate the patterns of relating they have become used to, the interpersonal dynamics they engage in, the dances they dance, and the issues they may have brought into the relationship. One theme that consistently emerges is the degree to which couples are honest with each other. How much do they divulge? How important is it to tell the truth? Do you really need to tell your partner everything?

In Alcoholics Anonymous, we hear people say, “We are as sick as our secrets.” Family addiction therapists are fond of saying that there are no family secrets. By this, they mean that even when we believe that other family members don’t know a certain secret, that secret still has an impact on everyone in the family. If individual members don’t know the specifics of the secret, they are still impacted by it and sense or experience it unconsciously—and that can affect the whole family. I work with patients who learned in their twenties or later in life that they were adopted, that their parents were once married to an abusive spouse, or that they have a sibling they never knew, among other revelations.

I’ve also become aware of the extent to which sober and recovering clients keep things from their partners. Even in relatively healthy relationships, there appears to be a fair amount of small-scale concealment and deception, though the extent of the infractions often is debatable. Several clients I see—coincidentally or not, all men—have reported engaging in exercise cheating. What’s that, you ask? Exercise cheating, essentially, is exercising and not telling your partner, or not revealing how much or what type of exercise one engages in.

Even I have been guilty of cheating on my wife. A few years back, as I was setting up my new Philadelphia office, I decided to buy a painting by an artist that my wife and I liked. My wife studies art history, and I thought she would appreciate that I was acquiring a painting by a Temple University master’s graduate. And while $650 is no small chunk of change for this sort of thing, I thought it was a great investment for my new office. I thought I would surprise her with the purchase. Instead, she was angry. “You art cheated!” she cried as soon as she saw it. She was genuinely annoyed that I had not consulted with her on a purchase of this magnitude. Whether I was right or wrong in purchasing something of that cost for my office was not the issue. What is important is my partner’s perceived betrayal and need for dialogue, negotiation, and consultation.

Many hypothesize that cheating behavior is related to vestiges of evolutionary differences among men and women. While this theory would be a gross generalization in today’s society, it suggests that it was more adaptive in an evolutionary way for men to cheat than for women to cheat. Assuming evolution prioritizes any behavior designed to propagate one’s genes, men may benefit from spreading their genes in a quantity-focused way. Women, meanwhile, have long gestation and nursing periods which may temporarily move them to be more devoted and committed to their offspring. Thus, they benefit from finding a better quality mate. In other words, women are biologically, or at least evolutionarily, better at taking care of their young, especially in early developmental stages. Most people agree, and research appears to back this up, that most men think about sex more frequently than women do. While both men and women want to find a quality mate, men may be more inclined to seek quantity than women are.

According to this evolutionary perspective, neither men nor women want their mates to cheat because a mate who cheats may have more offspring, which in turn means that mate is less likely to care for the original partner’s offspring and more likely to leave and care for his or her new offspring. It is in a man’s evolutionarily best interest not to alert his partner to the fact he is cheating. Any behavior—sexual or not—that results in producing healthy offspring is powerfully reinforced to the extent that it aids in propagating an individual’s genes. So, infidelity and hiding that infidelity through the processes of natural selection and evolution can become more prevalent over time.

A fair question would be whether cheating sexually is related at all to other types of cheating. Just because a partner doesn’t tell a mate where he or she is going and what he or she is doing doesn’t mean that an affair is happening, and it doesn’t mean that a tendency toward nonmonogamous behavior is the cause of disingenuous behavior in the context of the couple. In fact, the point of this article is to lessen the impact of minor violations of the honesty contract. Putting small indiscretions of dishonesty in an evolutionary context may allow couples to see this behavior as resulting from the natural instincts of the animals we are. What is important, though, is that as humans we have the capacity to dialogue. This is precisely what can keep our natural tendencies in check. Speaking honestly to our partners about our needs and wants, while often challenging, is the hallmark of a healthy relationship.

Smoking gun example: A client once described an interaction he had with his wife after she busted him for smoking pot in the garage. She smelled the smoke even as he vehemently denied he had been smoking marijuana. When she found his metal pipe, still warm, he stuck to his story. “The lie just came out,” he explained later. “I was so used to it.” He eventually was able to talk about why he lied and why he has often felt the need to cover things up. It had nothing to do with infidelity, but was instead linked to his history of struggling to feel good about himself, to be able to ask for help with his emotions feelings and thoughts and to find purpose and meaning in his life. Beginning to discuss these issues with his wife and therapist helped him think more carefully about his tendency to lie and cover his tracks. He became better at advocating for himself and negotiating with his partner in a more healthy way.

Honesty is important in recovery from any mental health issue, whether it be depression, anxiety, or stress, but it is especially important in recovery from addiction and substance use because of the strong tendencies to hide, deny, and minimize one’s behaviors. Seeing an addiction psychologist or other specialist is an important first step in understanding one’s self. It is in this therapeutic relationship that a quick foundation can be set for the basis of an honest dialogue with one’s partner, friends, and family. Rebuilding relationships with those we love and who love us is essential to recovery from addiction. Understanding ourselves and the reasons we might cheat and lie can enable us to pause just long enough to ask ourselves whether we really want to go ahead with the behavior or if we might be able to rely on those close to us to help us through the difficult times. Honest communication with the people in our lives is the only way we can become and stay sober or make meaningful and lasting changes in our lives.