Editor’s note: Sarah Swenson, LMHC is a private practice psychotherapist in Seattle, Washington, where she specializes in working with neurodiverse couples. Her continuing education presentation for GoodTherapy, titled “When Your Partner is on the Autism Spectrum: Individual Therapy for the Neurotypical Partner,” will take place on February 21, 2020 and is eligible for two CE credits. This event is available at no additional cost to Premium and Pro GoodTherapy Members (Basic Members and mental health professionals without membership can view this event live for $29.95). Learn more and register here.

Author’s note: Sometimes, of course, the neurotypical partner in a neurodiverse relationship is a man. I also work with gay and lesbian couples, and couples who are polyamorous. This article describes the client I encounter most frequently, a neurotypical woman married to an autistic man. Also, please bear in mind this guiding principle: If you’ve met one autistic person, you’ve met one autistic person. Nothing in this article will apply to everyone.

In my clinical practice as a therapist and in my international work as a coach, my clients are neurodiverse couples in which one partner is autistic and the other is not. As a result, I have come to know well one of the most misdiagnosed clients you will likely encounter. I’m speaking of a woman married to an autistic man who may or may not be formally diagnosed with autism (ASD).

When this woman comes in for individual counseling, she may have a flat affect. Her presenting concerns might sound vague, including hints of depression or anxiety. She may be self-effacing and ready to blame herself. She may stop and start, not seeming to know how to explain herself. She may appear embarrassed to be taking up your time.

Or she may seem full of rage. Her language might sound pressured, disorganized. She may be close to tears. She is the victim here, and she is furious.

Or she may simply present as hopeless.

I am not describing three separate women. You are likely to see all of this in the same woman in one session. Would you know how to understand her and offer her the support she needs?

She will not fully understand that over time, she has learned to minimize her needs and desires because conflict avoidance has become her chief survival strategy.

Meeting the Neurotypical Partner in Therapy

Most often, these clients are experiencing complex trauma (C-PTSD). They won’t be able to identify a specific traumatic injury because they are in a relationship that inadvertently creates the conditions of ongoing trauma. And since in this relationship there in no intention to harm, no intention to abuse, she is confused. She loves–or did love–her husband. She will tell you he is a good man.

She will not fully understand that over time, she has learned to minimize her needs and desires because conflict avoidance has become her chief survival strategy. She will tell you that she has changed. She will tell you she is not the woman she used to be. She feels less joy in life. She has let friendships fall away. She can’t muster interest in the things that used to give her pleasure. When asked, she is unlikely to be able to express her needs. She can’t remember what she needs. She knows this, however: she feels alone. And she may fear she’s losing her mind.

You’ve read her intake paperwork, so you will know that her husband is successful in his career, which may be in a highly competitive and well-respected field. When you talk to her, you’ll hear about his high intelligence and how well-regarded he is at work. As you get to know her better, she will tell you that everyone thinks that the two of them have the perfect marriage because that’s what it looks like from the outside. She realizes all marriages have problems. Her well-meaning friends certainly share enough of their stories that she feels a little guilty when inside she’s thinking, “Yes, but you don’t understand what it’s like for me…it’s different…I can’t explain it…”

She may sound petulant, self-involved, or impossible to please, due to the fact that she can express her pain but can’t put her finger on exactly what the problem is. She knows it has something to do with her husband and the way he treats her. Yet she has painted a picture of him that impresses you. You may think she is exhibiting narcissism as a result.

Another possibility is that he is a good man, but for some reason, he cannot seem to keep a job. He’s intelligent. He’s talented. But the financial strain of his chronic unemployment has pushed her to the brink. She is the sole earner. She manages the household. She supervises and provides for the children. She hides this internal familial dysfunction from her friends and her family. She has no one else to rely on. She is embarrassed. She is utterly exhausted. She can’t see a way out of her distress and she fears it may kill her. You may diagnose depression.

Sometimes, from session to session, you’ll see her condemn her husband and the way he cannot seem to do anything right, from loading the dishwasher (“I even made a little diagram and taped it to the counter!”) to listening to her when she’s upset (“He always wants to fix everything and doesn’t even notice I’m crying!”). Next session, she will be filled with compassion for him because he honestly seems to be doing the best he can. She’s just expecting perfection from him. He’s human. (“Why do I always have to be like this? Why can’t I just let him be himself?”) You may wonder if you’re seeing borderline personality.

And when she paints a complex picture of her experience with him that screams “Run for your life!” you may wonder why she can’t decide to leave. You consider codependency.

This is the woman married to an autistic man before she understands that he is autistic and before she understands what autism means in a relationship. I agree with you that it is difficult to identify her based on the information described above. Here are some important things to consider that may help you sort this all out.

Signs You’re Working with the Neurotypical Partner in a Neurodiverse Relationship

The primary area of conflict for many neurodiverse couples can be broken into two components: emotional connection and communication. Many of the women I work with identify the courtship phase of their relationship as short, comfortable, and consistent. More often than not, however, they can look back and identify what they call red flags: his quirky manners, his deeply focused conversations on things he’s interested in and silence when he’s not, his apparent discomfort at expressing emotion. At the time, they interpreted these things to be endearing eccentricity, intelligence and skill, and admirable reticence–the stiff upper lip.

For reasons of misinterpretation like this, they went forward to the commitment of marriage. Only with time did the veil slip away, and they realized they were habitually filling in with projections about what their partner’s behaviors and comments meant on the basis of what they would mean if they did these things themselves. In other words, they applied neurotypical standards and expectations to the behavior of an autistic individual. Slowly but surely, their sense of who their husband actually is erodes until they often become quite uncertain about who he actually is.

The primary area of conflict for many neurodiverse couples can be broken into two components: emotional connection and communication.

Over the course of the marriage, this woman will feel minimized and criticized. She will express her husband’s constant negativity and say that she’s begun to feel negative about everything, too. Her descriptions of their sex life will be particularly illuminating.

Generally, by the time these women come to therapy, their sex lives are completely ruptured. They have to think when you ask them about it. They’ll tell you they don’t remember precisely when or how, but at some point, things just stopped. For some, it has been months, but for most it’s been a matter of years. And, frankly, when their sex lives were more active, it wasn’t all that rewarding: it felt mechanical, always the same, with no foreplay and no sense of intimacy.

She doesn’t miss the specifics of sexual encounters with her husband, but she craves sexual intimacy. She craves intimacy, period. She wonders whether she should have an affair, though she doesn’t really want to go outside her marriage to have her needs met. She’ll just stifle them for a while, hoping they subside. Instead, she worries that they will continue to grow. She may not be able to look you in the eye at this point. She is desperate not to be viewed as promiscuous, and she fears you will judge her.

There are exceptions. Sometimes, a woman will tell you she feels like a sex doll to her husband’s routine and frequent sexual demands. She continues to participate. She hates herself for her inability to stand up for herself, but she has tried, and it just seems pointless. She continues to acquiesce. She is becoming numb to her own sexuality, to any physical sensations at all. She cannot afford to feel aroused because she knows she will be disappointed once again.

As you know, diminished sexual intimacy in a relationship is usually a sign of severed communication. In the neurodiverse relationship, this is most often the case. The woman needs emotional connection before she can feel sexually vulnerable. She is unlikely to feel this with her autistic husband. I often hear from these women that they don’t feel safe enough emotionally to present themselves sexually to their husbands. She does not feel seen or heard or known by her husband, whose sexual needs are often more physiological than emotional. He doesn’t understand her withdrawal any more than she understands the way he treats her.

Work with Neurodiverse Couples: Moving Forward

If you see enough of these signs in your client, I suggest asking whether she has considered that her husband might be autistic. In order to do this well, you’ll have to be certain she understands what you mean and why you’re asking. If she has not thought of this possibility herself, you’ll need to explain to her that autism is a result of neurological variance and not mental illness or personality disorder. You don’t want her to reject your suggestion on the basis of having misunderstood you.

Many times, though, women come in for counseling after having read articles of mine or other material on the internet and already suspect autism (some still call it Asperger’s) in their husbands. They want to know what to do. In this case, we discuss all the points mentioned above in terms of what it would mean if their husband were in fact autistic. I do not ever volunteer a diagnosis of autism without having met someone, but we do reality testing to rule it in or out as a differential. Then I suggest couple work. I help her with language for bringing this up to her husband, which is a sensitive task in itself.

Sometimes, after several sessions, we schedule a couple session, if the husband is willing to explore the possibility. It is often a watershed moment in a couple’s life to learn that there are reasons that explain their problems and that we can work together on psychoeducation and on communication strategies and skills that offer a path toward improved intimacy. The relationship will never be neurotypical or autistic, but it can become more rewarding for both partners.

Sometimes, the husband is unwilling to consider autism and will not come in for a couple session. He fears being judged. Labeled. Vilified. She cannot get through to him that this is a supportive process. He locks into his fears and there is nothing more to be done. In this case, I continue to work with the woman alone to help her understand her choices. They are not always binary. There are more options than staying married or getting divorced. We explore them all.

It is important never to minimize the experience and challenges faced by the autistic partner.

It is important never to minimize the experience and challenges faced by the autistic partner. This work is about identifying differences and creating more successful ways to communicate. There are good reasons why the autistic partner behaves the way he does and says the things he says. I have never met an autistic person who sets out intentionally to hurt his wife, and seldom have I encountered an autistic person who lies. Misrepresenting something has its own rational pathway for an autistic person, and I distinguish this from intentional lying. This is an example of the kind of subject we explore in couple sessions. Sometimes, the intense anger of the neurotypical partner can be diffused with education and compassion. Sometimes, the weight of this anger and feeling responsible for the relationship is too much for her.

If you have any suspicion about autism in a client’s partner, please tread carefully to explore the possibility. But do take the chance: otherwise, you could be missing the core challenge your neurotypical client is facing, which is the hub from which all her other apparently confusing behaviors emanate. The challenges to communication in the neurodiverse relationship are not insurmountable, but to ameliorate them requires sensitive counseling support. Educating yourself on the nature of autism, how it creates the lens through which a person experiences and interacts with reality, and how to help a couple bring implicit expectations to explicit and comprehensible statements are essential in this work. For initial solid grounding in the field of autism, I refer therapists to the work of Tony Atwood, PhD, and Simon Baron-Cohen, PhD.

Separation anxiety is one of the most common challenges parents face. It can make leaving a child with a caregiver or at daycare difficult and can undermine quality of life for both the parent and child. Separation anxiety is also completely normal, especially in very young children.

Children naturally long to be close to their caregivers, and separations compromise that closeness. Managing separation anxiety requires parents to balance the child’s need to be close to them with the expectation that children will become progressively more independent as they get older.

In some children, separation anxiety persists well beyond the toddler and preschool years, affecting their ability to comfortably attend school or spend time with friends. This type of severe separation anxiety affects 4% of children and 1.6% of teenagers.

Separation anxiety usually begins when a child is 6 or 7 months old, then peaks in the toddler and preschool years.

Separation Anxiety in Children: Symptoms and What’s Normal

Separation anxiety usually begins when a child is 6 or 7 months old, then peaks in the toddler and preschool years. Older children may have occasional bouts of separation anxiety, especially in new situations such as before going to sleepaway camp.

Babies and young children may have symptoms such as:

• Not wanting to sleep alone
• Crying when a caregiver leaves
• Throwing tantrums to prevent a caregiver from leaving
• Being anxious about serparations
• Clinging to a parent before serparations

Older children may have additional symptoms, including:

• Lying and other behaviors to avoid going to school
• Changes in behavior as a separation approaches
• Excessive worry about a parent or other loved one

When Separation Anxiety Is Extreme: What Is Separation Anxiety Disorder?

When separation anxiety is severe and chronic, or when it interferes with daily life, it may be considered a mental health diagnosis.

Researchers do not know what causes separation anxiety disorder. Like other mental health conditions, it is likely a combination of social, biological, and psychological factors. Children with a history of trauma or abuse may be more vulnerable. Symptoms usually appear in elementary school, between third and fifth grades. They include:

• Being terrified to sleep alone
• Excessive, chronic worry about the safety of a parent
• Refusing to go to school or crying each day before school
• Nightmares about separation
• Physical complaints such as muscle pain and stomach aches
• Not wanting to be alone
• Chronic worry about getting lost
• Unusual safety concerns
• Being clingy in a way that is not age typical, such as when a 10-year-old wants to be with their parents and not their friends
• Not wanting to do fun things or spend time with friends if it means being away from home

How to Deal with Separation Anxiety

Separation anxiety is no one’s fault. It is not a sign that a child is spoiled or manipulative. The distress children feel is very real, though as children get older, they learn that vocal expressions of distress may stop their parents from leaving. When dealing with separation anxiety, parents should not:

• Punish children.
• Lie about separations. Sneaking out of the house after promising not to leave can erode trust.
• Say things that might trigger anxiety. If a child is showing no signs of separation anxiety, don’t reassure them or tell them how brave they are to go off on their own.
• Make goodbyes last too long. It’s natural to want to comfort a crying child, but long goodbyes and long buildups to inevitable departures may actually prolong a child’s suffering.
• Panic or look distressed. Parents love their children and do not want to see them sad. But when parents express sadness or fear about separations, this can make the child think there is real danger.
• Reward children for separations. Rewards and punishments are controversial for many reasons. Even experts who support them agree that they work best for behaviors children choose—such as cleaning up a bedroom or doing homework. Separation anxiety is an emotional reaction, not a behavioral choice.

Choosing the right care provider is also critical for reducing separation anxiety. Daycare providers, nannies, and babysitters who are sensitive to the child’s needs can help. Talk to care providers about the importance of comforting and distracting the child—not ignoring them while they cry or punishing them for becoming anxious.

Some research suggests that forming a close attachment to a loving, accessible secondary care provider can ease separation anxiety. This means that daycares that provide the same carer each day, nannies, and consistent babysitters may be better options than an ever-shifting roster of childcare providers.

Some other strategies parents can adopt to ease separations include:

• Develop a comfortable (but short) ritual for separations. Some children like to have a special blanket, sing a song, or get a set number of kisses.
• Talk to children about why they are anxious. Young children may have trouble articulating their fears, but older children can often explain them. You may find that the problem is not separation, but something else, like a mean teacher or bully at school.
• Explain departures in language children can understand. For example, you might tell a toddler that you will see them after their nap, at dinner, or in “three sleeps.”
• Be honest and keep promises. Don’t say you won’t leave, that you will only leave when the child gives permission, or that you will be back in just a minute if these things aren’t true.
• Practice separations in low-stress contexts. Try dropping a child off at grandpa’s house for an hour or inviting a beloved uncle or aunt to take them on an outing. This gets the child used to separations and can help with preparing for the transition to school.
• Don’t spend lots of time talking about the separation before it happens. This can build anxiety.
• When your departure draws near, talk about the fun things your child can do while you are gone.
• Be loving and affectionate, not distracted or frustrated, during departures.
• Develop a plan with caregivers for supporting a child with separation anxiety. Each care provider should have several strategies they can try to help calm a child who is anxious or upset. Care providers should never ignore or punish a crying child.

Separation anxiety can be difficult for both parents and children. Parents may feel stress at each separation or adjust their entire lives to reduce separations when a child has intense anxiety. This can affect an entire family, and even undermine careers. A therapist can help families manage separation anxiety in a way that minimizes trauma and honors the needs of every family member. GoodTherapy can help you find a therapist.

References:

1. Bowlby, R. (2007). Babies and toddlers in non-parental daycare can avoid stress and anxiety if they develop a lasting secondary attachment bond with one carer who is consistently accessible to them. Attachment & Human Development, 9(4), 307-319. doi: 10.1080/14616730701711516
2. Ehmke, R. (n.d.). What is separation anxiety?. Retrieved from https://childmind.org/article/what-is-separation-anxiety
3. Krecklow, L. L. (2018, August 28). Separation anxiety: Dos and don’ts to help your child (and you) be brave. Retrieved from https://gozen.com/separation-anxiety-dos-and-donts-to-help-your-child-and-you-be-brave
4. Separation anxiety disorder in children. (n.d.). Stanford Children’s Health. Retrieved from https://www.stanfordchildrens.org/en/topic/default?id=separation-anxiety-disorder-90-P02582
5. Swanson, W. S. (2015, November 21). How to ease your child’s separation anxiety. Retrieved from https://www.healthychildren.org/English/ages-stages/toddler/Pages/Soothing-Your-Childs-Separation-Anxiety.aspx

People with narcissistic personalities may often have disturbances in both their self-regard and in their connections with others. Some believe that the narcissistic personality is created in early life as a result of maladaptive attachment.

One school of thought is that narcissism is a result of arrested development, in which the person remains fixated at an infantile or very young age and only manifests in terms of their wants and needs. For example, an infant does not think about what their mother wants or needs; they are only concerned for themselves. Similarly to infants, narcissists tend not to be concerned with the other person’s feelings, only their own.

It has been theorized that those who are “pathologically narcissistic” (a normal level of narcissism is essential for healthy self-esteem) are not fully “fixated” in a phase of early childhood development–the “me” phase, or narcissistic phase of development–but have instead developed pathologically. This affects their inner working models for self-love and object-love (the love of others).

People with narcissistic personalities often do not present seriously disturbed behavior and may function quite well socially and vocationally.

Narcissism in the Context of Object Relations

Objects are attachment figures. In object relations theory, the object is the person one attaches to in early development, usually the mother or primary caregiver. As a person progresses in age, new objects come along and become attachment objects as well.

Object relationships are the relationships people form with significant others. The first significant other is often the mother. As a person is developing, they are learning mental representations of the following:

• The object as perceived by the self
• The self in relation to the object
• The relationship between the self and the other

These concepts set the stage for all of one’s future relationships, both with the self and others.

The Development of Narcissistic Defense Mechanisms

Narcissists tend to have one or both parents who are chronically cold and covertly aggressive. While they may appear superficially well-organized, they may have an underlying degree of callousness, indifference, and nonverbalized aggression when parenting (Kernberg, 1992).

Part of development involves differentiation of the self from the other, where normal reality testing should occur. When early attachment objects are inconsistent, abusive, or neglectful, the developing individual needs a psychological mechanism which allows them to escape the conflict between the need for the external object and the dread of it (Kernberg, 1992). Coping or defense mechanisms may then ensue.

People who have developed narcissistic personalities often do so because they have not been able to internalize a “good” object; rather, they have internalized a frightening one, one which they are unable to draw comfort from. Because of this, instead of attaching to others in a healthy manner, they utilize defensive coping mechanisms for relating. One of these is idealization:

These individuals identify themselves with their own ideal self-images in order to deny normal dependency on external objects and on the internalized representations of the external objects. It is as if they were saying, ‘I do not need to fear that I will be rejected for not living up to the ideal of myself which alone makes it possible for me to be loved by the ideal person I imagine would love me. That ideal person and my ideal image of that person and my real self are all one, and better than the ideal person whom I wanted to love me, so that I do not need anybody else anymore.’ —Otto F. Kernberg, MD, FAPA

In other words, the normal tension between actual self (developing child with unmet needs) and the actual parent (emotionally unavailable parent) on the one hand, and ideal self and ideal object on the other, is eliminated by the creation of a fantasy self-concept and fantasy other-concept within. Concurrently, the images of the “unacceptable” true self are repressed and then projected onto others.

Note: This is why people in relationships with narcissists are often devalued and discarded–they are receiving the narcissist’s projection of their true beliefs about self as well as the disappointment and anger of not really being an ideal or fantasy partner/child/object.

How Narcissists Relate to Self and Others

People with narcissistic personalities may find it difficult to internally grasp the basic concepts of healthy connection. They may not have experienced it in order to internalize it appropriately. Healthy relating and attunement might not have been sufficiently “mirrored” onto the developing child. Thus, the child has an attachment deficit.

Narcissists may be especially deficient in feeling deep emotions, such as longing and sadness, and in relationships with others, they may experience feelings of indifference. The deep emotions narcissists feel are most often those that relate to personal ego-injuries. In these cases, narcissists will feel the emotions of rage, envy, and resentment.

The types of primitive coping or defense mechanisms for relating to others include splitting (all bad/all good), denial, projection, grandiosity, and idealization.

In addition to this, those with narcissistic personalities will adapt themselves to the moral demands of their environment as a “payment” or “price to pay” in order to gain narcissistic supply, such as praise and admiration. Don’t be fooled. Narcissists only do that which brings them a payoff for self. They are not conforming to society’s norms for any other purpose. In fact, because of this narcissistic point of view, they may also believe others think the same way; hence, they project this viewpoint onto others, which is why they tend not to trust other people.

Narcissists are known to lack caring about the feelings of other people. They may see others as mere objects, put in place to meet their own needs. However, this can cause a problem for narcissists, because in order for them to benefit from the praise and admiration of others, those others must, on some level, have value.

In essence, a narcissist may see others in a sort of shadowy form, an idealized representation of the narcissist’s internal, idealized self. This creates a duality and dilemma for the narcissist, but it explains a lot about the targets of narcissistic abuse. They may have been both idealized and devalued when in a relationship with a narcissist, both projections of the narcissist’s self-loathing and of their self-aggrandizement.

References:

1. Kernberg, O. (1992). Borderline conditions and pathological narcissism. Northvale, New Jersey: Jason Aronson, Inc.
2. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press.

For many, the holidays are a joyous time to celebrate our traditions, spread cheer, and love on those we care about. For others, however, the holidays bring up a lot of negative emotions. Some even dread the holidays.

Below are three tips for dealing with difficult family members.

3 Tips for Dealing with Difficult Family Members

1. Establish Boundaries Before the Holiday

If being around certain family members brings up negative emotions for you, one idea to consider is time spent with them. Think about how much time you want to spend with them during the holiday. For instance, it’s okay to put some time restraints in place. Instead of spending the entire day, you might consider spending a couple hours together. If you are traveling across the country, staying in a hotel or an Airbnb might be a better option than staying in your family member’s home.

You may want to think about an exit strategy from certain conversations.

You may want to think about an exit strategy from certain conversations. For example, if you feel like your family member is starting to get on your nerves, you might say something like, “I think I may go see if some help is needed in the kitchen.” This gives you a polite way of ending the conversation.

2. Steer Away from Touchy Topics

One of the wonderful things about the world is how diverse it is. Imagine for a moment, if everyone thought the same way, looked the same way, or acted the same way⁠—how boring the world would be? Keep in mind that many families have differences of opinions, beliefs, and faith traditions. If you are aware of your differences and know that conversations around those topics can quickly escalate, you may want to steer clear of those topics. For instance, if you have a more liberal bent politically and your parents are conservative, perhaps talking about if the president will win a re-election isn’t the best party starter. You may consider sticking to more to neutral topics. ⁠

3. Let Bygones Be Bygones

Many people struggle to let go of the past, especially when it comes to family members. If you find you fall into this camp, consider doing something different this year. For instance, if a family member has offended you and you are holding on to the hurt, think about letting it go. It could make all the difference in your holiday season.

What many people don’t realize is that holding on to grudges, resentment, and hurt feelings takes a lot of emotional energy. It impacts your mental health and well-being. Letting go of the hurt doesn’t mean you don’t do or say anything about it. What it means is that you are choosing to do something about it. In so doing, you are empowering yourself. Perhaps talking to a therapist or a trusted friend about it could be helpful.

You don’t have control over what people say or how they behave. However, you can take responsibility for how you respond to being offended. If it warrants a conversation, think about reaching out to your family member prior to the holiday and asking if you can talk to them. A simple conversation might look like: “There is something that has been on my mind that I would like to talk to you about. When would be a good time?” If they agree, set up a time to talk. It’s quite possible you can have a healing conversation, if done well. It could prove to be a life changing conversation for your relationship.

Of course, not all past offenses are so easy to resolve, and having a healthy conversation may not even be possible. If that’s the case, you still have a choice in how you will let their offense influence you. You can still choose to let the offense go, understanding that it may be about the other person and not you. You can also choose to forgive the person even when it feels like an unforgivable offense. You get to decide how you want to respond.

You have more control over your holidays and difficult family members than you may think. Decide today what type of holiday you want to experience. You may consider politely asking everyone in your family to be patient, kind, and loving. Keep the focus on your reason for celebrating this holiday season.

Many might assume that the intergenerational transmission of trauma from parent to child occurs through abuse or neglect, but this is not always the case.

Trauma can also be passed on through changes in gene expression. This is known as the epigenetic transmission of trauma. Epigenetics is understood as changes in gene function that are heritable and not associated with changes in one’s DNA sequence (Dupont, Armant, & Brenner, 2009). It is thought that epigenetic changes can occur as a result of extreme stress, such as in the case of parents with histories of trauma.

Heritability of Trauma

Research with children of Holocaust survivors has indicated that children can inherit the traumatic memories of their parents. The evidence is so compelling that some have argued children can inherit the unconscious minds of their parents. Some children of Holocaust survivors have even been known to have genocide-themed nightmares. Although it can be argued the children receive Holocaust imagery through shared stories and narratives, it does not explain their increased vulnerability to stress-related diagnoses such as complex trauma (C-PTSD) and posttraumatic stress (PTSD).

While may be more difficult to prove the inheritance of traumatic memories, we do know that psychological stress can affect gene expression patterns via the nervous system.

While may be more difficult to prove the inheritance of traumatic memories, we do know that psychological stress can affect gene expression patterns via the nervous system. It may be that the disposition to develop PTSD and C-PTSD is passed down through an epigenetic route (Kellermann, 2013).

When Symptoms Occur Without a History of Trauma

It is important to understand that trauma can be inherited independently of difficult family circumstances. A child can develop anxiety, depression, or other stress-related issues such as PTSD as a result of an inherited vulnerability rather than direct trauma.

Research has shown that secure mother-child attachment is key for childhood development (Meins, Bureau, & Fernyhough, 2018). A recent study shows that “good-enough” parenting is adequate for a child to develop a secure attachment to its mother. What this means is that perfect parenting is not required for the child to grow up securely attached, a state that is associated with the best outcomes for mental health (Lehigh University, 2019).

The research has two sides. On one, the research shows us that we do not require perfect parenting and a stress-free environment to be secure and healthy. The flip side of this research is that some children will inherit trauma even with a gentle upbringing. In these cases, a child can inherit symptoms of trauma, including nightmares and anxiety, even without being exposed to trauma.

Can Epigenetic Changes Lead to Positive Outcomes?

While the news that trauma can be passed down despite good parenting may sound disheartening, epigenetics also creates changes in a positive way as well. When we have good nutrition and are raised in a nurturing and loving environment, over generations, epigenetic changes can also occur for the better. Researchers investigating epigenetics in animal models have found that rat pups with mothers who lick and groom them often are more likely to grow up to be calm, while pups who are not groomed frequently by their mothers may grow up to be anxious (Kirkpatrick, 2017).

What we know from epigenetic research as it relates to the intergenerational transmission of trauma is that we can have at least some influence on our children’s ability to be calm and resilient to stress. By providing a loving and nurturing environment for them, we can diminish the intensity of inherited trauma. Each succeeding generation can whittle away at the effects of trauma through consistent nurturing and loving parenting. Trauma does not have to continue from one generation to the next.

References:

1. Dupont, C., Armant, D. R., & Brenner, C. A. (2009). Epigenetics: Definition, mechanisms and clinical perspective. Seminars in Reproductive Medicine, 27(5), 351-357. doi: 10.1055/s-0029-1237423
2. Kellermann, N. P. (2013). Epigenetic transmission of Holocaust trauma: Can nightmares be inherited?. The Israel Journal of Psychiatry and Related Sciences, 50(1), 33-39. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24029109
3. Kirkpatrick, B. (2017, December 12). Cuddling can leave positive epigenetic traces on your baby’s DNA. Retrieved from https://www.whatisepigenetics.com/cuddling-can-leave-positive-epigenetic-traces-babys-dna
4. Lehigh University. (2019, May 8). ‘Good enough’ parenting is good enough, study finds. ScienceDaily. Retrieved from https://www.sciencedaily.com/releases/2019/05/190508134511.htm
5. Meins, E., Bureau, J. F., & Fernyhough, C. (2018). Mother–child attachment from infancy to the preschool years: Predicting security and stability. Child Development, 89(3), 1,022-1,038. doi: 10.1111/cdev.12778

Dependency on others is the hallmark characteristic of dependent personality disorder (DPD). This can create problems within relationships, since nearly all adult relationships need a degree of interdependence to be considered healthy. Interdependence, simply put, means the people in the relationship maintain their sense of self while working together to meet each other’s needs as well as their own.

“In a healthy relationship, partners ask each other’s opinion, take it in, and then arrive at a decision together that takes both people into account. This is what the Gottman research calls accepting influence — and it is not the same as deferring. Deferring erases one person; accepting influence keeps both people in the room.”

If you live with DPD, you may have an intense and overwhelming need for others to take care of you, so much so that you fear being abandoned or left alone. To avoid the possibility of abandonment, you might find yourself going out of your way to make certain you have the continued support of your romantic partner, family members, or friends. This might cause you to go to great lengths to please them, often by doing things you’d prefer not to do.

This behavior may seem to help you get your needs met, but it often leads to unhealthy or imbalanced relationships. You might end up staying with a partner who isn’t right for you, or even one who’s toxic or takes advantage of you, simply because you don’t want to be alone.

But it is possible to build healthy relationships when you have DPD. Awareness of the condition, and how it affects your interactions with others, is a good first step.

According to the DSM-5-TR, dependent personality disorder affects approximately 0.5-0.6% of the general population, with slightly higher rates among women (0.6%) compared to men (0.4%). If you live with DPD, you may have an intense and overwhelming need for others to take care of you, so much so that you fear being abandoned or left alone.

What Is Dependent Personality?

In basic terms, dependent personality means you rely on other people to take care of you. You might experience serious distress at the thought of having to do things on your own, because you don’t think you can care for yourself. You might feel helpless or unable to make decisions for yourself—both significant decisions, like the career you choose, and minor decisions, like what you’ll make for dinner. The difficulty is often not a lack of intelligence or ability. Instead, making choices may trigger intense anxiety, self-doubt, or fear of making the wrong decision. Over time, relying on others to choose can become a deeply ingrained habit that feels safer than trusting yourself. You might lack well-developed self-esteem and have little confidence in your own abilities.

“The statements people with DPD say to themselves — ‘I can’t do this,’ ‘Someone else would do it better,’ ‘They’ll leave me if I disagree’ — sound like facts about the self, but they are usually beliefs learned in environments where speaking up or trying alone did not go well. Treating them as beliefs that can be examined, rather than truths about who you are, is the first move.”

Many people with dependent traits gradually discover that these assumptions can be questioned, tested, and replaced with more balanced ways of thinking. Because you need continued support from loved ones, you may withhold normal, healthy responses, like anger, frustration, or disagreement, even if they do something problematic or upsetting.

This condition is diagnosed in adulthood according to criteria specified in the DSM-5-TR, and only in people who do have the ability to make decisions on their own without excessively depending on others. People sometimes experience dependency as a result of a health condition or other mental health condition, and this isn’t quite the same as DPD. It’s also important to note that people in abusive relationships may display traits that seem similar to those associated with DPD, such as extreme submissiveness or fear of disagreeing with the abuser. If these behaviors only happen in the abusive situation, DPD wouldn’t be diagnosed.

It’s important to understand these characteristics aren’t your fault. Personality disorders are complicated issues that develop from a multitude of factors, and it’s not always easy to recognize there’s something problematic about your behavior. In some cases, dependent patterns develop in environments where a person’s feelings, preferences, or decisions weren’t consistently encouraged or valued. Over time, relying heavily on others may become a coping strategy rather than a conscious choice. These traits are ingrained—a part of your personality—and they can be difficult to change. But change is possible.

Romantic Relationships and DPD

There’s nothing wrong with consulting your romantic partner about decisions you make, especially those affecting you both. In fact, this is pretty normal (and beneficial) in a healthy relationship. Healthy relationships involve influence, not surrender. Partners consider each other’s perspectives and allow those perspectives to shape decisions without giving up their own opinions, preferences, or values. What sets this type of dependency apart from DPD? In a healthy relationship, you don’t wholly depend on your partner. You ask their advice, consider it, then make a decision that works for both of you.

If you have DPD, it may seem natural to turn to your partner for help with decisions, since you may feel incapable of doing anything alone. You might ask them to choose what stores you shop at, what kind of clothing you buy, what you do with your free time, and whether you should go for a promotion. You might harbor your own opinions about these choices, your partner’s behavior, or other issues that pop up in daily life. But because you worry expressing your true feelings will lead to disapproval and withdrawn support from the people who take care of you, you don’t say what you truly feel.

“In couples work, the everyday substance of connection is what researchers call bids — small reaches toward the other person. People with dependent traits often make plenty of bids, but the ones they hold back are usually the most important: a true opinion, a quiet ‘no,’ a disagreement. Practicing those is where the relationship actually changes.”

If these behaviors resonate with you, it can help to practice making your own decisions in your relationship. A caring partner can support you by:

• Stepping back to let you make your own decisions
• Encouraging you to take responsibility for household matters
• Encouraging you to express your true opinions

Supportive partners often find a balance between offering encouragement and taking over. Staying emotionally available while allowing you to make your own choices can help build confidence and independence over time.

Many people with DPD end up in relationships with people who take advantage of them. A few signs of abuse include:

• Threatening to withdraw emotional or financial support
• Belittling or attempting to control you
• Insisting on sexual acts you aren’t comfortable with as a condition of support

A therapist can offer guidance and support if your relationship is abusive.

Parenting and DPD

Having dependent personality means you may not trust yourself to make your own decisions. You believe you can’t function without the help of others. This can contribute to the distorted view that your child is more capable of making decisions for you.

Accordingly, parents living with DPD may overly rely on children to handle tasks or decisions children aren’t emotionally capable of making. This may be more common in situations where you’re a single parent living with DPD and don’t have another person to rely on.

It’s normal for children to have opinions on things like meal planning, where to purchase their clothing, or how to spend free evenings. And children, especially older children, should also contribute around the house and help manage their own schedules and responsibilities. But it’s not healthy for parents to ask children to take care of all household tasks and responsibilities or make decisions about adult responsibilities or social situations.

“Children learn how to be adults, in part, by watching adults make adult decisions. A parent who turns adult choices over to a child is often trying to share the burden, but the child experiences it as the floor giving way. Holding the line — even imperfectly — is itself a gift to your child.”

As a parent, you may have interest in what your child thinks of your romantic partner. But there’s a difference between asking, “What do you think about (Partner’s name)?” and “Should I keep dating (Name) or should we break up?”

Workplace Relationships and DPD

DPD can make workplace interactions challenging, if you struggle to get necessary tasks done on your own. Your coworkers may notice your difficulty with self-starting, and some might consider your continued need for prompting and encouragement troublesome.

Others may experience you as needing more support, reassurance, or direction than the role allows, which can create challenges or misunderstandings in the workplace. If you’re left to work alone, you might believe you can’t complete the task or project successfully and end up not doing it at all. However, you might do fairly well when you have supervision or support from someone else.

Work can also provide a useful place to practice greater independence. Because workplace tasks are often structured and feedback is usually more direct, some people find it easier to experiment with making decisions, taking initiative, and expressing opinions at work before applying those skills in closer personal relationships.

Friendships and DPD

If you have DPD, you may notice your friendships follow a pattern similar to your romantic relationships. Your fear of being left alone can play out in ways that make you seem clingy and needy. You may worry disagreeing with friends will result in them no longer caring for you and avoid expressing personal opinions and desires to ensure their continued support. While staying agreeable may seem like a way to protect the friendship, consistently hiding your preferences or disagreements can prevent friends from truly getting to know you. Over time, the relationship may feel less authentic or emotionally satisfying.

You might also readily volunteer to help friends out, even when you’d rather not do something (like help them move or clean their house). Because you want them to continue to be there for you, you sacrifice your time, but less-than-ethical friends may take advantage of this trait.

Good friends should be there for each other and support each other in times of need, but true friends should also encourage you and support you in doing things for yourself.

Treatment for Dependent Personality: Does It Get Better?

It’s very difficult to address personality disorders without help from a therapist trained to recognize symptoms and help you work through them effectively. But therapy can always have benefit. Personality disorders can’t be cured, but therapy can help you address behaviors causing problems in your life and learn new ways of relating to others.

Dependent personality treatment can be incredibly beneficial, since it can lead to more fulfilling, healthy relationships. Current research shows that psychodynamic and cognitive behavioral therapies have shown promise in addressing maladaptive patterns associated with DPD. Some therapists may also incorporate skills drawn from dialectical behavior therapy (DBT), including mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. These skills can help people become more comfortable making decisions, managing anxiety, and expressing their needs directly.

Talk therapy is considered to be the most effective treatment, with the aim to help people with this condition make more independent choices in life.

 “Good treatment for dependency is rarely about teaching someone to need less. It is about helping them build, gradually, a life they experience as worth living — defined by what matters to them, not by the absence of other people. Independence becomes a by-product of that life, not the goal itself.”

A trained therapist can support you as you work to realize your own capabilities, both when it comes to making decisions and taking care of yourself. Since people with DPD can sometimes transfer feelings of dependency to their therapist, it’s important to work with a therapist experienced in helping people with DPD. This isn’t something to feel ashamed of. In many cases, the therapy relationship becomes a safe place to observe dependent patterns as they happen and gradually practice new ways of relating.

In therapy, you might:

• Practice self-sufficiency and assertiveness skills
• Learn to cope with fears of being alone
• Practice decision-making
• Become comfortable spending time on your own
• Learn to express disagreement in productive ways

The most lasting improvements are often seen through longer-term therapy, though many people begin experiencing benefits from new coping and communication skills much earlier in treatment. DPD can often occur with other conditions. Childhood illness, attachment issues, or separation anxiety sometimes play a part in its development. But DPD can also factor into the development of concerns like social anxiety or depression. Therapy can help you address symptoms of these conditions, as well.

For some people, treating co-occurring anxiety or depression can reduce distress enough to make it easier to engage fully in therapy and practice new skills. However, there are medications for depression and anxiety, which people with dependent personality disorder may also have. Treating these conditions can make it easier to treat DPD. For the best results, medication should be taken in combination with psychotherapy.

Healthy relationships should be fairly balanced. Some of the time, you might need more support from your partner than usual, and at other times, they may need more from you. But typically, it’s unhealthy for one person to rely solely on another.

If DPD makes it difficult to develop and maintain healthy relationships with others, the best option is to seek help from a compassionate, supportive therapist. Reaching out for help can feel especially difficult when you worry about disappointing others or handling things on your own. Yet taking that step is often one of the first signs that change is already beginning. Begin your search today.

• Hansen, B. J., Thomas, J., & Torrico, T. J. (2024, August 17). Dependent Personality Disorder. StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK606086/
• American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing.
• Villines, Z. (2025, September 1). Treatment for dependent personality disorder. Medical News Today. https://www.medicalnewstoday.com/articles/dependent-personality-disorder-treatment
• Dependent personality disorder. (2025, October 8). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9783-dependent-personality-disorder
• Dependent personality disorder: MedlinePlus Medical Encyclopedia. (2025). U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000941.htm
• Maccafferi, G. E., Dunker-Scheuner, D., De Roten, Y., Despland, J. N., Sachse, R., & Kramer, U. (2019, October 15). Psychotherapy of dependent personality disorder: The relationship of patient-therapist interactions to outcome. Psychiatry, 82(4), 346-361. https://doi.org/10.1080/00332747.2019.1675376

References:

1. Hansen, B. J., Thomas, J., & Torrico, T. J. (2024, August 17). Dependent Personality Disorder. StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK606086/
2. American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing.
3. Villines, Z. (2025, September 1). Treatment for dependent personality disorder. Medical News Today. https://www.medicalnewstoday.com/articles/dependent-personality-disorder-treatment
4. Dependent personality disorder. (2025, October 8). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9783-dependent-personality-disorder
5. Dependent personality disorder: MedlinePlus Medical Encyclopedia. (2025). U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000941.htm
6. Maccafferi, G. E., Dunker-Scheuner, D., De Roten, Y., Despland, J. N., Sachse, R., & Kramer, U. (2019, October 15). Psychotherapy of dependent personality disorder: The relationship of patient-therapist interactions to outcome. Psychiatry, 82(4), 346-361. https://doi.org/10.1080/00332747.2019.1675376

The world is full of suffering. People committed to helping others—including those in helping professions such as mental health and medicine, activists, volunteers, and highly empathetic people—face nonstop exposure to a wide range of suffering. Compassion fatigue is a type of vicarious trauma that happens when a person is overwhelmed by the trauma and struggles of other people.

In its early stages, compassion fatigue may cause a person to be preoccupied by injustice and the desire to fix it. As compassion fatigue intensifies, however, it can lead to apathy and burnout. This can undermine a person’s relationships and connection to others. And for people in helping professions, compassion fatigue may prove professionally disastrous.

What Is Compassion Fatigue?

Compassion fatigue resembles burnout in that it may sap a person’s physical, emotional, and spiritual energy. Unlike burnout, however, it appears only in contexts where a person is providing extensive emotional support or emotional labor. In some cases, the symptoms of compassion fatigue resemble those of posttraumatic stress (PTSD).

Compassion fatigue resembles burnout in that it may sap a person’s physical, emotional, and spiritual energy.

Some other ways in which compassion fatigue differs from burnout include:

• Burnout happens when a person’s environment is stressful, whereas compassion fatigue happens when a person’s interactions with other people saps their emotional reserves.
• People with compassion fatigue may begin avoiding situations in which they must confront another person’s suffering but may not avoid other work.
• Compassion fatigue may cause a person to lose empathy for others.
• People with compassion fatigue may feel cynical, apathetic, or disconnected from others.
• Burnout typically gets better when a person takes time away from the source of the burnout. Compassion fatigue may persist.

Who Gets Compassion Fatigue?

Anyone who spends significant time helping others or thinking about others’ suffering may develop compassion fatigue. Some especially vulnerable populations include:

• Very empathetic people who tend to serve as the “therapist” in their family or among their friends.
• People in dysfunctional families who continually try to support other family members without seeking support for themselves.
• People in medical and mental health professions, especially providers who work with traumatized, abused, or dying people.
• People in fields that confront systematic injustice. Lawyers who work on challenging cases or issues of social justice, activists, people who work in child abuse prevention, and others who work to end systemic issues are at risk. The work does not have to be paid work. A volunteer rape crisis counselor, for example, could easily develop compassion fatigue.
• Professionals who routinely intervene in traumatic or life-threatening situations. First responders such as firefighters, police officers, and EMS professionals may report vicarious trauma or compassion fatigue.
• Caregivers to chronically ill people. An adult child caring for a parent with dementia or another terminal illness may feel fatigued and burned out.

Some research suggests that compassion fatigue is more prevalent when a person receives inadequate support for their work. A caregiver for a person with dementia may be more vulnerable to fatigue when other members of the family refuse to help or constantly criticize their caregiving.

Symptoms of Compassion Fatigue

The symptoms of compassion fatigue vary from person to person and may change with time. They include:

• Symptoms that resemble PTSD, such as flashbacks, avoidance, disturbing dreams, and nightmares.
• An inability to show compassion or empathy. A once-caring doctor may begin blaming their patients for their maladies, while a social worker may lose interest in helping struggling families.
• Anger and resentment.
• Becoming socially disconnected.
• Feeling poorly understood by others.
• Having increasingly few boundaries between work and home.
• A decrease in productivity and effectiveness.
• Feeling trapped.
• Depression.

Strategies for Preventing Compassion Fatigue

Compassion fatigue is a common struggle, and it is not always preventable. It often comes on suddenly, even after a person has managed stress well for years. Certain prevention strategies, however, may reduce the risk and help a person better manage symptoms of compassion fatigue:

• Schedule time for self-care, including eating healthy meals, exercise, and spending time on enjoyable hobbies.
• Set clear boundaries. No one needs to answer calls 24 hours a day or provide constant care to another person.
• Take time away from work or from caregiving labor whenever possible.
• Spend time with people who support and understand the work you are doing. A public interest lawyer, for instance, may find support and help from weekly meetups with attorneys in similar fields.
• Practice mindfulness. Compassion fatigue can cause a person to feel distracted and overwhelmed. Meditation and mindful living strategies may counteract these sensations.
• Avoid taking work home. Don’t read upsetting emails or listen to voicemails during down time. People involved in unpaid caregiving or activism should schedule time away from their pursuits.
• Seek help. No single person can solve the world’s problems. Family caregivers should look in to paid care options or ask other family members for help. Professional helpers should explore additional resources to help their clients while reducing their own exhaustion.
• Reward yourself for difficult tasks. For example, plan an outing with friends following a meeting with a difficult client.

Treatment of Compassion Fatigue

Compassion fatigue is a response to chronic stress, not a mental health diagnosis. This means that treating compassion fatigue requires a person to get some relief from their stress. That might mean:

• Reducing their workload or seeing fewer clients.
• Taking time away from work.
• Establishing clear work-life boundaries.
• Changing one’s approach to work.

In some professions, it may not be possible to reduce the stress. For example, an emergency room doctor who treats abuse survivors may have little control over their workload, while a skilled death penalty attorney might be the only person in their region who can handle such complex cases. People in these situations may require extensive ongoing support, medication to manage anxiety and depression, and regular breaks from work.

No matter the cause of compassion fatigue, a therapist can help a person:

• Assess their boundaries. In some cases, a person develops compassion fatigue because they feel an obligation to “save” everyone.
• Create a better work-life balance. Time away from work, meaningful hobbies, exercise, and self-care may all help with compassion fatigue and burnout.
• Relax. Develop relaxation strategies such as meditation and cultivating mindfulness in the moment.
• Identify other resources that may help. For example, a doctor may gain significant stress relief by hiring an office assistant or relying more on their nursing staff.
• Gain new skills. New strategies to deal with personal or workplace challenges may help a person avoid compassion fatigue. For example, by learning to listen without offering advice, a parent might offer greater support to a struggling child without feeling so exhausted after each conversation.

GoodTherapy can help you find a therapist who specializes in compassion fatigue. Begin your search here.

References:

1. Compassion fatigue. (n.d.). The American Institute of Stress. Retrieved from https://www.stress.org/military/for-practitionersleaders/compassion-fatigue
2. Compassion fatigue. (2017, August 23). American Bar Association. Retrieved from https://www.americanbar.org/groups/lawyer_assistance/resources/compassion_fatigue
3. Gallagher, R. (2013). Compassion fatigue. Canadian Family Physician, 59(3), 265-268. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596203
4. Pfifferling, J., & Gilley, K. (2000). Overcoming compassion fatigue. Retrieved from https://www.aafp.org/fpm/2000/0400/p39.html

It’s not uncommon to hear “narcissism” and “narcissist” used to casually describe people who:

• Seem vain and self-centered
• Seem to care only about themselves
• Demand attention, admiration, and respect
• Exaggerate achievements
• Manipulate others for their own purposes

While these traits are all associated with narcissistic personality disorder (NPD), people with just a few of these traits may not necessarily meet criteria for diagnosis. What’s more, other significant characteristics of narcissism are less recognizable, so they aren’t always associated with the condition.

It’s generally a good idea to avoid labeling people with mental health diagnoses when you don’t have a full picture of their mental health. In other words, someone’s diagnosis is typically between them and their therapist or psychologist, unless they choose to share that diagnosis. But it is true that people with traits of narcissism generally show a mask of superiority and arrogance to the world. They may seem full of themselves, demand appreciation from others, and appear to have high self-esteem. But an inner core of insecurity often lies behind this mask.

Narcissism and Insecurity

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people with NPD almost always have a fragile sense of self-esteem. Because of this, they spend a lot of time thinking about how others perceive them and how well they’re doing in life. This insecurity contributes to the continuous demand for admiration associated with NPD.

Many people with narcissism struggle with pervasive feelings of insecurity underneath the outward superiority and entitlement they present to the world.

Many people with narcissism struggle with pervasive feelings of insecurity underneath the outward superiority and entitlement they present to the world. But this experience may be most commonly associated with covert, or vulnerable narcissism. Many people with this subtype of narcissism do show outward signs of sensitivity to criticism and insecurity. This insecurity, often tied to the concept of being less than perfect, can contribute to mental health concerns such as stress, anxiety, or depression.

This insecurity can manifest as difficulty accepting criticism, or anything seen as criticism, since critiques can trigger feelings of vulnerability. Someone with narcissism may, for example, take constructive advice from a supervisor as a personal attack and react angrily. They might offer a reply laced with contempt or derision or they make a passive-aggressive or mocking comment. This reaction, lashing out in response to a slight, can humiliate or reject the person offering the critique. People with NPD generally do this to help relieve the potential threat to their self-esteem.

NPD is a complex personality disorder that involves feelings of insecurity, but insecurity is not only linked to narcissism. It’s not uncommon to feel insecure or struggle with moments (or longer periods) of low self-esteem, even if you have no mental health diagnosis at all. One way to differentiate narcissistic insecurity involves looking at the person’s response to perceived criticism or other threats. Responding with aggression, rage, or passive-aggression could suggest narcissism, though this isn’t a definitive diagnostic tool.

Narcissism, Insecurity, and Relationships

Maintaining a relationship with someone who has NPD can be difficult, especially without support from a mental health professional. Many people living with narcissistic traits may have had a parent with NPD, experienced insecure attachment as a child, or have other attachment issues. It’s also not uncommon for people living with NPD to experience depression, anxiety, and suicidal thoughts, or abuse substances. These can all cause relationship difficulties, though dealing with the main traits of narcissism may pose the greatest challenge.

People with narcissism generally need a lot of admiration and approval, since receiving this admiration may help combat the underlying insecurity. But because NPD typically involves a lack of empathy, they usually don’t offer much in the way of reciprocation. This is one key reason why people living with NPD are usually labeled “toxic.” They need their romantic partners to praise them, listen to them talk about their feelings and topics of personal interest, and demand devotion and regard. They might talk about their envy for others or project those feelings by talking about how others envy them.

This can be draining for romantic partners and family members of people with narcissism, particularly as people with NPD may also express insecurity by accusing partners of being unfaithful, not caring about them enough, or not doing enough for them. They might use emotional abuse tactics, including gaslighting, to try and control partners so they’ll remain in the relationship and continue offering admiration and regard.

These attitudes and attacks can cause a lot of emotional pain. They can also lead to feelings of insecurity in anyone involved with a person with NPD:

• Frequent negativity and derision can have a significant impact on self-esteem.
• Gaslighting can cause doubts about what’s really true and make the person affected feel as if they’re in the wrong.

Are ‘Narcissists’ Insecure?

Existing research on narcissism suggests people with NPD do tend to feel insecure, whether they display this insecurity outwardly or not. Insecurity may provoke many of the problematic behaviors associated with narcissism. Both a 2015 article looking at the diagnostic challenges of narcissism and a 2017 review examining the connection between narcissism and behavior on social network sites like Facebook suggest insecurity is more often seen in people with vulnerable narcissism, who might present as humble or reserved and tend to put themselves down.

Katherine Fabrizio MA, a licensed professional counselor in Raleigh, North Carolina, helps people who were raised by narcissistic parents heal. She explains, “At their core, the person with narcissistic personality disorder is deeply insecure. They feel unworthy, ashamed, and empty. They hide this emptiness from themselves and others with a set of defenses that act as a storefront. The cover-up story they tell themselves and others constitutes those defenses, which are designed to artificially fill them up—all while hiding the fact that they feel truly empty.”

It’s important to recognize that although people with narcissism may struggle with unwanted emotions and experiences that cause distress, these feelings don’t excuse their behavior. Insecurity can be hard to face, but it’s possible to work through this, along with any other emotional or mental health challenges like anxiety, without emotional abuse or other problematic behaviors.

If you often feel insecure, working with a therapist can help you overcome this mindset and develop a greater sense of personal empowerment. If you struggle to recognize or understand the feelings of others, or if you tend to lie or manipulate others to get your needs met, you may want to reach out to a therapist who can help you learn new ways of relating to others so you learn how to meet your own needs and support the people in your life.

Anxiety and insecurity can result from setting too-high standards for yourself or wanting to achieve things that aren’t realistic. But in either case, a therapist can help you recognize your capabilities and potential for success so you can set more achievable goals for yourself.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association.
2. Caligor, E., Levy, K. N., & Yeomans, F. E. (2015, April 30). Narcissistic personality disorder: Diagnostic and clinical challenges. The American Journal of Psychiatry, 172(5). Retrieved from https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.14060723?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&
3. Dickinson, K. A., & Pincus, A. L. (2003). Interpersonal analysis of grandiose and vulnerable narcissism. Journal of Personality Disorders, 17(3), 188-207. Retrieved from https://pdfs.semanticscholar.org/8db5/d181e5ec85fd61de162d3c43e70611eaf4a4.pdf
4. Gnambs, T., & Appel, M. (2017, February 7). Narcissism and social networking behavior: A meta-analysis. Journal of Personality, 86(2), 200-212. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jopy.12305
5. Jauk, E., Weigle, E., Lehmann, K., Benedek, M., & Neubauer, A. C. (2017). The relationship between grandiose and vulnerable (hypersensitive) narcissism. Frontiers in Psychology, 8, 1600. doi: 10.3389/fpsyg.2017.01600
6. Narcissistic personality disorder treatment. (n.d.). Retrieved from https://www.bridgestorecovery.com/narcissistic-personality-disorder/narcissistic-personality-disorder-treatment

Loneliness can be one of the most painful experiences in a relationship—especially when the relationship is neurodiverse. If you love your partner but still feel unseen, unheard, or emotionally distant, you are not alone. Many couples face this challenge, and understanding its roots can be the first step toward healing.

While loneliness can occur in any partnership, the dynamics in neurodiverse relationships bring unique emotional and communication challenges that deserve special attention.

Understanding Loneliness in Neurodiverse Partnerships

Many people experience occasional loneliness in relationships, but the loneliness in a neurodiverse partnership often has unique characteristics. Friends may reassure you by saying “that’s life” or “marriage is hard,” but these responses can dismiss what makes your situation different.

A person in this situation may feel guilty or wonder if they are making too much of the problem. They might try to convince themselves that things are fine—until the longing for emotional connection grows too strong to ignore.

How Autism Can Impact Emotional Connection

For some in neurodiverse relationships, deep loneliness becomes a constant presence, not just an occasional feeling. It may wax and wane, but it’s always there—woven into daily life, much like a wedding ring on your hand.

Autistic and neurotypical partners can both feel lonely, but for different reasons. A neurotypical partner may crave affective empathy—emotional attunement and validation—while an autistic partner may respond with cognitive empathy, offering solutions rather than emotional comfort. Neither is wrong, but the mismatch can create feelings of being unseen or unsupported.

Over time, these differences can lead to frustration, hurt, or even withdrawal from the relationship. In some cases, both partners feel equally isolated. 

Common Causes of Loneliness for Both Partners

• Communication gaps: Different ways of interpreting emotions and intentions

• Mismatched needs: One partner seeks emotional reassurance while the other prioritizes practical solutions

• Chronic stress or fatigue: Emotional distance can worsen when mental and physical resources are low (fatigue)

• Self-blame: Both partners may feel they are failing the other

• Depression and low self-worth: Persistent loneliness can lead to depression and negative self-talk

Strategies for Bridging the Understanding Gap

One of the most effective tools for working with neurodiverse couples is psychoeducation (learn more). This involves exploring both the autistic and neurotypical experiences—not to label one as “better” but to understand similarities and differences.

From there, couples can:

• Learn each partner’s communication style and needs

• Make the implicit explicit—clearly stating expectations and emotional experiences

• Develop strategies for expressing affection and empathy in ways the other partner understands

• Practice nonverbal communication (read more)

• Build trust through small, consistent actions

When to Seek Professional Support

If loneliness is leading to ongoing resentment, emotional withdrawal, or repeated conflict, it may be time to seek outside help. A therapist experienced in neurodiverse relationships can help partners:

• Translate and interpret each other’s communication styles

• Rebuild emotional connection

• Develop realistic expectations for the relationship’s dynamics

You can find a qualified therapist who understands both autism and relationship challenges.

Questions to Ask Your Therapist

• How do you help couples navigate neurodiverse relationship challenges?

• What strategies can increase emotional connection when communication styles differ?

• How can we each better understand and meet the other’s needs?

The Path Forward

Every relationship faces challenges, but in a neurodiverse partnership, understanding and acceptance are the keys to a deeper connection. A neurodiverse relationship will never be entirely neurotypical or autistic—it will always be uniquely yours. By learning to navigate your differences, you can deepen your connection and create a partnership that honors both individuals.

You don’t have to navigate this alone—working with a therapist experienced in neurodiverse relationships can help you and your partner build mutual understanding and emotional closeness. Find a qualified therapist on GoodTherapy today and take the next step toward a stronger, more connected partnership.

Very few people are one hundred percent happy with their physical appearance. Most of us have something about ourselves that we would like to change in some small way.

But for most of us, our perceived flaws do not interfere with our happiness or daily functioning. For those who have body dysmorphia, or body dysmorphic disorder (BDD), however, a small flaw—either real or imagined—can substantially reduce their quality of life. They may obsess and worry about the flaw for hours every day (Anxiety and Depression Association of America, n.d.). BDD is a serious mental health issue that can lead to suicidality and significant social and occupational dysfunction. Both men and women can experience BDD (Phillips & Castle, 2001).

People with BDD are often extremely preoccupied with their physical appearance and can become deeply upset over minor flaws that wouldn’t even be noticed by others. The person’s perception of the flaw, however unrealistic, often causes intense emotional distress and can trigger avoidance of social situations.

The preoccupation and obsession with flaws that comes with body dysmorphia can take away the ability to experience joy and healthy relationships. Some people with BDD undertake multiple cosmetic procedures to correct the flaw. Unfortunately, relief is likely to be short-lived at best. The root issue is not the flaw, which may be minor or even imagined. After the cosmetic procedures, the individual with BDD may simply focus on a different or “new” flaw.

The preoccupation and obsession with flaws that comes with body dysmorphia can take away the ability to experience joy and healthy relationships.

Emotional Neglect and Body Dysmorphia

Emotional neglect can be understood as a pattern in a parent-child relationship where the child’s needs are consistently ignored, disregarded, or devalued by the parent. Emotionally neglected parents often feel ambivalent towards their children’s emotional needs, particularly when they are distressed and crying (Didie et al., 2006). The parent may feel the child is impossible to please and—out of frustration—simply ignore and reject the child when they are upset. In this cycle, adults who were emotionally neglected as children tend to become emotionally neglectful as parents.

Emotional neglect is commonly found in both males and females diagnosed with BDD (Carey, Crocker, Elias, Feldman, & Coleman, 2009).

Emotional Neglect as Trauma

The body and the nervous system experience neglect in a way that is similar to abuse. The child who is not nurtured and cared for emotionally may experience continuous high levels of stress and sadness with no one to turn to for comfort. Over time, this can take a serious toll on the ability to develop resilience as the child matures into adolescence and adulthood.

Adults with histories of neglect often develop a range of emotional and mental health issues, including depression, low self-esteem, hyperactivity, and aggression. Neglect often leads to the child feeling unwanted and unloved, and it can lead to a distorted perception of the self.

In the case of BDD, emotional neglect may foster a distorted self-perception in terms of physical appearance. The individual with BDD may believe they are deeply flawed and unacceptable to others as a result of their physical appearance.

Developmental Timing and Neglect

The impact of physical and emotional neglect may be influenced by when it occurs during the child’s development. A child who is neglected during the early years of development can miss out on crucial opportunities for social, emotional, and cognitive development. An important factor that underlies each of these aspects of childhood development is the ability to develop resilience and cope with stress (Cicchetti & Toth, 1995).

Very young children and infants are not biologically capable of reducing the autonomic stress response once it is activated. During times of heightened emotional upset or fear, increased levels of stress hormones begin to circulate in the brain and nervous system. A child without comfort and guidance from an adult is forced to expend all of their energy in bringing the body and mind back to a balanced state. When the child is put in the position of having no help or comfort, all resources are expended and the child has little left for anything else. In this way, opportunities for development in other areas such as social and cognitive learning are lost.

As the child gets older, it is understandable why neglect can lead to intense feelings of shame and a distortion of body image. Body image is connected to self-esteem. When children grow and develop in circumstances that teach them they are unworthy of love and even send messages that there is something wrong with them, the child is likely to internalize these perceptions as they grow.

Therapy for Trauma and Body Dysmorphia

Exposure therapy (Neziroglu & Yaryura-Tobias, 1993; Linde et al., 2015) and cognitive behavioral therapy (CBT) can help some people process and heal the effects of past trauma and neglect. Cognitive behavioral therapy may be helpful for BDD because it helps the person discover the source of distorted and unrealistic perceptions. Once it’s understood where the negative thought patterns are coming from, CBT teaches us how to correct these patterns and then move into a more realistic and healthy way of thinking (Neziroglu & Khemlani-Patel, 2002). In this way, CBT can be effective in treating distorted perceptions of the body. At the same time, CBT can help in developing healthier thinking patterns that address depression and anxiety, which often co-occur with trauma and BDD.

If you think childhood emotional neglect or body dysmorphia are issues that could be impacting you, support is available. Reach out to a licensed and compassionate therapist.

References:

1. Body dysmorphic disorder (BDD). (n.d.). Anxiety and Depression Association of America. Retrieved from https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/body-dysmorphic-disorder-bdd
2. Carey, W. B., Crocker, A. C., Elias, E. R., Feldman, H. M., & Coleman, W. L. (2009). Developmental-Behavioral Pediatrics E-Book. Philadelphia, PA: Elsevier Health Sciences.
3. Cicchetti, D., & Toth, S. L. (1995). A developmental psychopathology perspective on child abuse and neglect. Journal of the American Academy of Child and Adolescent Psychiatry, 34(5), 541-565. doi: 10.1097/00004583-199505000-00008
4. Didie, E. R., Tortolani, C. C., Pope, C. G., Menard, W., Fay, C., & Phillips, K. A. (2006, September 26). Childhood abuse and neglect in body dysmorphic disorder. Child Abuse & Neglect, 30(10), 1105-1115. doi: 10.1016/j.chiabu.2006.03.007
5. Linde, J., Rück, C., Bjureberg, J., Ivanov, V. Z., Djurfeldt, D. R., & Ramnerö, J. (2015). Acceptance-based exposure therapy for body dysmorphic disorder: A pilot study. Behavior Therapy, 46(4), 423-431. doi: 10.1016/j.beth.2015.05.002
6. Neziroglu, F., & Khemlani-Patel, S. (2002). A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectrums, 7(6), 464-471. doi: 10.1017/s1092852900017971
7. Neziroglu, F. A., & Yaryura-Tobias, J. A. (1993). Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behavior Therapy, 24(3), 431-438. Retrieved from https://psycnet.apa.org/record/1994-26859-001
8. Phillips, K. A., & Castle, D. J. (2001, November 3). Body dysmorphic disorder in men: Psychiatric treatments are usually effective. The BMJ, 323(7320), 1015-1016. doi: 10.1136/bmj.323.7320.1015

Psychotherapist Salvador Minuchin developed the concept of enmeshment to characterize family systems with weak, poorly defined boundaries. The entire family may work to prop up a single viewpoint or protect one family member from the consequences of their actions. In these family systems, individual autonomy is weak, and family members may over-identify with one another. For example, a child may be unable to see their own interests as distinct from their parent’s and may defend that parent’s interests even when doing so is harmful.

Enmeshment inevitably compromises family members’ individuality and autonomy and can enable abuse. Abuse within an enmeshed family system is a unique sort of trauma. Some survivors of such trauma may not recognize their experiences as traumatic and may even defend their abusers due to the complex emotional dynamics involved. Because boundaries are weak in these family systems, family members who correctly identify their experiences as traumatic may be ostracized or even labeled as abusive.

Characteristics of Enmeshed Families

Most healthy families are loyal to one another and may share certain values. In an enmeshed family, this loyalty and shared belief system comes at the expense of individual autonomy and well-being. For example, the entire family might support the idea of the father as a wonderful parent or great leader, even though he is physically abusive.

Enmeshment does not always lead to abuse, but it is a potent tool for shielding abusers from the consequences of their actions.

Some characteristics of enmeshed family systems include unclear boundaries that lead to confusion in roles and expectations:

Each family member fills a specific role. In most cases, these roles enable dysfunctional behavior from other family members. For example, the family peacemaker may smooth over conflicts the family abuser creates or might guilt other family members for attempting to build healthy boundaries.

Enmeshment often begins when one family member has a mental health condition or substance abuse issue. Enmeshment normalizes harmful behavior and can be a way to avoid treatment.

Enmeshed families often view dissent as betrayal and may become disengaged when members attempt to establish independence.

Enmeshed families may demand an unusual level of closeness even from adult children. For instance, an adult child with children of their own may be expected to spend every holiday with the family. If they spend a holiday with in-laws or with their own family, the enmeshed family may shun or otherwise punish them.

Family members’ emotions are tied up together, making it difficult to discern where one person’s emotions begin and another’s end. Adolescents with enmeshed family dynamics are often highly dependent upon their parents to help them manage their emotions.

There may be unspoken family norms that family members take for granted. Outsiders may rightly view these norms as unusual or dysfunctional. For example, an enmeshed family may have a norm of never calling the police on a family member who abuses their partner.

Some people also use enmeshment to refer to covert, or emotional incest. This is when a parent or other caregiver treats a child as a partner or equal, relying on the child for emotional needs that an adult relationship would usually provide.

How Enmeshment Enables Abuse

Enmeshment does not always lead to abuse, but it is a potent tool for shielding abusers from the consequences of their actions. Research shows that enmeshment can predict increases in behavioral problems when combined with family instability. Enmeshed family members may be reflexively defensive of one another and view even deeply harmful behavior as normal and good.

Enmeshment can make it difficult for a person to form close relationships with other people. Without these relationships, it is very difficult for enmeshed family members to recognize that their family’s relational style is not healthy.

Even when enmeshed family members do form outside relationships, their enmeshed family may intrude on these relationships. Alternatively, the enmeshed person may view their family as normal and their partner as the problem. For example, an adult who gets married may still prioritize their childhood family over their spouse or may expect their spouse to defer to family members or accept abusive behavior.

The Trauma of Enmeshed Families

Enmeshment itself can be traumatic, especially when enmeshment normalizes abuse. Current research indicates a bidirectional relationship between family functioning and trauma, where unhealthy family functioning increases trauma risk, while trauma can negatively impact family dynamics. In other cases, though, enmeshment is the byproduct of trauma. A serious illness, natural disaster, or sudden loss may cause a family to become unusually close in an attempt to protect themselves. When this pattern persists well beyond the initial trauma, enmeshment loses its protective value and can undermine each family member’s personal autonomy.

Enmeshed family systems are often dismissive of trauma. A parent might dismiss their drunken night of abuse as a normal reaction to a child’s bad grades. In adulthood, siblings may defend a parent’s abuse by insisting that the parent was under immense stress or that the abuse was actually the children’s fault. By dismissing trauma as normal or deserved, enmeshed family systems make it difficult for family members to understand their emotions and experiences. In this form of gaslighting, a family might consistently substitute the family’s collective judgment for an individual’s feelings. Over time, the individual family member may struggle to distinguish their own emotions from the emotions the family insists they should have.

Trauma Bonding and Enmeshment

People who experience trauma or intense emotions together may bond in unusual and unhealthy ways. Patrick Carnes expanded trauma bonding theory by emphasizing the addictive nature of these bonds, describing them as attachment-based and maintained by strong neurochemical reactions to fear, relief, affection, and reconciliation.

With trauma bonding, intermittent reinforcement of rewards and punishments is crucial to establishing and maintaining the bond. The abuser intermittently maltreats the victim through physical, verbal, emotional, and/or psychological abuse, interspersed with positive behaviors like expressing affection and care, showing kindness, giving gifts, and promising not to repeat the abuse. Some abusive parents attempt to compensate for their abuse with gifts, special outings, or intense love. Many survivors of abuse report that, when their parents were not abusive, they were extremely creative, dynamic, and loving.

Even when survivors correctly identify the abuse and establish boundaries or leave the relationship, trauma bonding and enmeshment can affect future relationships. Survivors consistently describe relationships as cycles of “highs and lows,” where emotionally intense reconciliations become the psychological glue. These emotional highs are often deliberately engineered, explaining why many survivors long for the initial loving version of the partner while recognizing present danger.

The cycle of abuse can feel normal in these situations, as an intermittent schedule of love and affection becomes the person’s point of reference for a relationship. This may cause trauma and enmeshment survivors to seek out and remain in abusive or enmeshed relationships. It can also make it easier for their family to pull them back into the abuse and chaos.

People who grow up in dysfunctional family systems may ignore their own emotions. They may question their memories, wonder if their trauma really happened, or believe that they deserve to be abused. Even when a person is able to see their family through a more objective lens, establishing boundaries can prove difficult. Holidays, family vacations, and other times of intense family closeness can trigger old habits and lead to new trauma.

Therapy can help a person draw clear boundaries, take their emotions seriously, and move beyond enmeshment. Current NIMH-supported research focuses on developing and improving mental health treatments that help trauma survivors, including approaches specifically designed for children, teens, and young adults. A therapist is also an outside voice who can help a person understand that the behaviors their family normalized are not healthy and that they do not have to remain trapped in their usual family role forever.

To begin your search for a compassionate therapist, click here.

Bacon, I., & Conway, J. (2022). Co-dependency and enmeshment — a fusion of concepts. International Journal of Mental Health and Addiction, 21(6), 3594–3603. https://doi.org/10.1007/s11469-022-00810-4

Coe, J. L., Davies, P. T., & Sturge-Apple, M. L. (2018). Family cohesion and enmeshment moderate associations between maternal relationship instability and children’s externalizing problems. Journal of Family Psychology, 32(3), 289–298. https://doi.org/10.1037/fam0000346

Davies, P. T., Cummings, E. M., & Winter, M. A. (2004). Pathways between profiles of family functioning, child security in the interparental subsystem, and child psychological problems. Development and Psychopathology, 16(3), 525-550.

Kivisto, K. L., Welsh, D. P., Darling, N., & Culpepper, C. L. (2015). Family enmeshment, adolescent emotional dysregulation, and the moderating role of gender. Journal of Family Psychology, 29(4), 604–613. https://doi.org/10.1037/fam0000118

Korun, B., & Bingöl, T. Y. (2025). Exploring family dynamics and spiritual well-being through the lens of family systems theory. Psychiatric Quarterly, 96(1). https://doi.org/10.1007/s11126-025-10201-2

National Institute of Mental Health. (2024). Science updates about post-traumatic stress disorder (PTSD). U.S. Department of Health and Human Services. https://www.nimh.nih.gov/news/science-updates/post-traumatic-stress-disorder-ptsd

National Institute of Mental Health. (2024). Traumatic events and post-traumatic stress disorder (PTSD). U.S. Department of Health and Human Services. https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd

Olson, D., & Olson, A. (1999). FACES IV and the circumplex model. Life Innovations.

Sturge-Apple, M. L., Davies, P. T., & Cummings, E. M. (2010). Typologies of family functioning and children’s adjustment during the early school years. Child Development, 81(4), 1320-1335.

Ye, L., Chen, Y., Wang, M., Zhang, L., & Li, X. (2025). Family functioning and anxiety in children: A narrative review. Translational Pediatrics, 14(9). https://doi.org/10.21037/tp-2025-324

References:

1. Bacon, I., & Conway, J. (2022). Co-dependency and enmeshment — a fusion of concepts. International Journal of Mental Health and Addiction, 21(6), 3594–3603. https://doi.org/10.1007/s11469-022-00810-4
2. Coe, J. L., Davies, P. T., & Sturge-Apple, M. L. (2018). Family cohesion and enmeshment moderate associations between maternal relationship instability and children’s externalizing problems. Journal of Family Psychology, 32(3), 289–298. https://doi.org/10.1037/fam0000346
3. Davies, P. T., Cummings, E. M., & Winter, M. A. (2004). Pathways between profiles of family functioning, child security in the interparental subsystem, and child psychological problems. Development and Psychopathology, 16(3), 525-550.
4. Kivisto, K. L., Welsh, D. P., Darling, N., & Culpepper, C. L. (2015). Family enmeshment, adolescent emotional dysregulation, and the moderating role of gender. Journal of Family Psychology, 29(4), 604–613. https://doi.org/10.1037/fam0000118
5. Korun, B., & Bingöl, T. Y. (2025). Exploring family dynamics and spiritual well-being through the lens of family systems theory. Psychiatric Quarterly, 96(1). https://doi.org/10.1007/s11126-025-10201-2
6. National Institute of Mental Health. (2024). Science updates about post-traumatic stress disorder (PTSD). U.S. Department of Health and Human Services. https://www.nimh.nih.gov/news/science-updates/post-traumatic-stress-disorder-ptsd
7. National Institute of Mental Health. (2024). Traumatic events and post-traumatic stress disorder (PTSD). U.S. Department of Health and Human Services. https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd
8. Olson, D., & Olson, A. (1999). FACES IV and the circumplex model. Life Innovations.
9. Sturge-Apple, M. L., Davies, P. T., & Cummings, E. M. (2010). Typologies of family functioning and children’s adjustment during the early school years. Child Development, 81(4), 1320-1335.
10. Ye, L., Chen, Y., Wang, M., Zhang, L., & Li, X. (2025). Family functioning and anxiety in children: A narrative review. Translational Pediatrics, 14(9). https://doi.org/10.21037/tp-2025-324

If you’ve ever sustained an injury and didn’t have access to immediate medical attention, you probably received some form of first aid. This temporary medical assistance likely helped treat the injury and kept it from getting worse until you could get to a hospital or see your doctor.

Like physical injuries, mental health concerns and substance misuse can have serious health effects. They can cause lasting harm and may even lead to death. But these emotional injuries tend to be less visible, and it’s not always easy to identify someone who’s struggling.

A mental health first aid training class is a public education program that aims to teach people how to identify risk factors and warning signs of these concerns. During this 8-hour training, you’ll learn to recognize a mental health crisis, provide immediate support, and help people access resources for longer-term care.

As with first aid for an injury, mental health first aid is not meant to be a long-term solution. The support of a trained mental health professional is essential for people living with mental health concerns or working to overcome substance misuse.

A mental health first aid training class is a public education program that aims to teach people how to identify risk factors and warning signs of these concerns.

In your mental health first aid training, you’ll learn the five-step action plan, ALGEE:

1. Assess for suicide/harm risk
2. Listen non-judgmentally
3. Give information and reassurance
4. Encourage seeking professional support
5. Encourage self-help and coping methods

Read on to discover how this looks in practice.

1. How to de-escalate a tense situation

Remaining calm is an important part of effectively handling a crisis. It can be challenging to help someone experiencing panic, hallucinations or other psychotic symptoms, or acute trauma reach a calmer state of mind if your mood is also elevated.

Someone dealing with acute emotional distress may talk about hurting themselves, which can be frightening to hear. Fear can cause some people to react with judgment, anger, or confusion. But these reactions can worsen a situation.

Mental health first aid training provides an opportunity to develop communication skills—both nonverbal skills like body language and verbal skills like knowing what to say. Knowing how to communicate compassionately can make all the difference when trying to reach someone in a crisis. You’ll learn to offer reassurance and respect, with an attitude that normalizes what someone is going through without blaming them. Role play activities during training give you the chance to practice applying these skills in a variety of scenarios.

2. How to gauge risk of harming self or others

You might worry someone living with depression or another mental health condition has a high risk of hurting themselves. Symptoms of certain mental health conditions, like schizophrenia, bipolar, or borderline personality disorder, are also often associated with increased risk of hurting the self or others.

It’s important to recognize the following:

• Most people with mental health conditions never harm anyone.
• Many people who have thoughts of suicide don’t plan to attempt suicide.
• Many people who self-harm don’t plan to attempt suicide.

However, it’s still important to talk to a trained professional about self-harming behaviors or suicidal thoughts. Recognizing certain warning signs can help you become more informed about when someone might be dealing with these challenges so you can better assess the possibility of harm. This can help you direct someone to the right resources.

Some possible warning signs of suicide include:

• Talking about dying, hopelessness, or feeling like a burden
• Talking about wanting a way out
• Withdrawal or isolation
• Rapid, dramatic, or significant mood changes
• Sleeping a lot or not enough
• Behaving in risky or extreme ways

Supporting a person experiencing hopelessness and thoughts of suicide might involve finding and reaching out to a therapist who can help them work through the underlying causes. But a person with a clear plan for suicide needs immediate, urgent help. The 988 Suicide & Crisis Lifeline can offer guidance at 1-800-273-TALK (8255), but you can also call your nearest emergency room.

3. Coping techniques

Coping and self-care techniques can help anyone manage distress, not just people living with mental health issues. But these techniques usually benefit those who experience emotional challenges regularly, since they can increase resilience and promote calm. People who use coping tools can often address symptoms before they become overwhelming.

During mental health first aid training, you’ll learn more about some of the many coping methods you might suggest, such as:

• Relaxation techniques
• Meditation
• Exercise or movement therapy
• Pet therapy
• Journaling, art, or music
• Peer and social support
• Cognitive behavioral self-help techniques

4. Supporting next steps and follow up care

Training in mental health first aid enables you to support someone through a mental health crisis or period of substance misuse. It doesn’t train you to provide long-term care or support. A key part of mental health first aid is learning how to refer people to the professionals who can offer the best type of treatment for their needs.

Depending on a person’s symptoms or concerns, you might help them locate any of the following types of health care professionals:

• Medical doctor
• Therapist or counselor
• Psychiatrist
• Social worker
• Peer support specialist

You can’t force anyone to seek treatment, but in mental health first aid training, you’ll learn how to encourage people to get help. This might include explaining how therapy or counseling can help or talking about available treatments. You might also help someone locate a nearby therapist or find a number for a clinic or helpline.

5. What to do when you, yourself, are in a crisis

Although you might find a profession that involves helping others find potentially life-saving support rewarding, you may also find it stressful. You might even feel drained or overwhelmed on occasion, as working with people in crisis can affect your own emotional wellness over time.

Mental health first aid providers help people learn to take care of their emotional health and access helpful resources when needed, but before they can offer this help, they must also know how to take care of their own well-being. By participating in a mental health first aid training course, you’ll be better positioned to recognize when your emotional reserves are running low. This awareness can help you know when to take time to recharge, prioritize self-care, and get help for yourself.

Awareness of mental health concerns and their varied signs and symptoms has increased in recent years. This awareness is a key factor in treatment. Compassionate understanding is another factor that’s just as important in preventing suicide.

Mental health first aid training teaches you how to offer this compassion and care as you help someone find resources for dealing with an immediate emotional crisis. Once they’ve weathered the immediate challenge, they can reach out for help. Compassionate therapists are only a few clicks away in our therapist directory, located here.

References:

1. ALGEE: The action plan. (n.d.). Retrieved from https://www.mentalhealthfirstaid.org/wp-content/uploads/2017/04/THE-ACTION-PLAN.png
2. Frequently asked questions. (n.d.). National Council for Behavioral Health. Retrieved from https://www.mentalhealthfirstaid.org/faq
3. Mental health first aid. (n.d.). National Council for Behavioral Health. Retrieved from https://www.thenationalcouncil.org/about/mental-health-first-aid
4. Risk and protective factors. (n.d.). Suicide Prevention Resource Center. Retrieved from https://www.sprc.org/about-suicide/risk-protective-factors
5. Stress management. (n.d.). Substance Abuse and Mental Health Services Administration. Retrieved from https://www.integration.samhsa.gov/health-wellness/wellness-strategies/stress-management
6. Wellness strategies. (n.d.). Substance Abuse and Mental Health Services Administration. Retrieved from https://www.integration.samhsa.gov/health-wellness/wellness-strategies
7. What you learn. (n.d.). National Council for Behavioral Health. Retrieved from https://www.mentalhealthfirstaid.org/take-a-course/what-you-learn