Why Do People Transition?

A person might realize they are trans (that their gender identity does not align with their birth sex designation) at any point in life. Some people may first experience an internal sense of identity that does not match their external characteristics in early childhood. Others report realizing this in puberty or later. Societal gender norms and expectations may contribute to a person’s realization of their true gender identity. These assumptions can also contribute to dysphoria, as a person might first attempt to conform to societal expectations by expressing a gender identity they do not have.

Gender dysphoria, which is believed to result from a mismatch between the brain’s internal map of the body and the actual physical body, is experienced by many trans people. The feelings of distress frequently associated with this condition may have a negative impact on a person’s quality of life.

Transition, whether social, through hormone therapy, through surgery, or through some combination, often improves feelings of dysphoria, though it may not relieve them completely. The goal of many is for their gender to be perceived correctly by others, which is often referred to as “passing.” Typically, people transition to align their physical appearance and characteristics with their gender identity. Many people begin the process after years of dysphoria and distress, and transitioning may help them feel as if they are finally able to be their true selves.

Understanding Transition

Family members and friends may find a person’s true gender difficult to accept. “You’ll always be ____ to me,” a mother might say, without the intention of harm. But this type of remark may be invalidating and cause distress in individuals who no more chose their gender identity than they chose to be born with blue eyes or brown hair. Participating in therapy or counseling sessions can help family members accept a person’s gender identity. In counseling, they may be able to ask questions, come to a better understanding of what it means to be transgender, and learn more about what transition entails.

According to Kimber Shelton, PhD, a licensed psychologist in Duncanville, Texas, transitioning can have significant psychological, social, and physical benefits: “In my experience, individuals who transition express that the desired effects of hormones and surgery outweigh the potential risks (such as increased acne or balding from hormone replacement therapy).”

Anxiety and depression caused by gender dysphoria may diminish as dysphoria improves. Individuals who no longer have to make uncomfortable adjustments—such as hiding unwanted physical characteristics—may not only feel better physically but may have greater confidence and self-esteem, Shelton also said.

Social Transition

People generally begin the transition process on their own before seeing a therapist or doctor. Even if a person has decided on medical transition, it may not be possible to begin immediately. Social transition is the first step for many, and some people may transition only socially.

Socially transitioning means a person makes changes in appearance and social situations to reflect their gender. This may include changes to hairstyle and clothing, name and pronoun changes, and use of different bathrooms/gendered facilities. When a trans person first comes out as trans, they often share their correct pronouns and their chosen name. They might share this widely—at home, school, or work—or they might disclose these changes only to family and close friends. Using the correct pronouns and the name a person has chosen shows support and acceptance of that person’s identity, but using an incorrect name and pronouns, beyond invalidating that person, could place them in danger or subject them to discrimination, harassment, or abuse in some situations.

Legal Transition

The legal process of gender transition typically requires several steps, and in America, the process varies widely between states. All states allow name changes, but birth certificates issued in the states of Idaho, Kansas, Ohio, and Tennessee cannot currently be changed. This restriction can prevent trans people who desire to change their gender marker from being able to fully transition. Many trans people do not wish to disclose the fact they are trans, but being unable to change their gender marker may force them to do so and can prevent them from changing other documents.

Seeking education about the issues and concerns trans people face and offering acceptance and support can be of great benefit not only to a trans friend or family member but to the trans community.

Some states or individual treatment agencies require the completion of certain aspects of transition before providing others. For example, several states require gender confirmation surgery before issuing a birth certificate bearing the correct gender marker. Because this surgery is expensive and often not covered by insurance, it may be out of reach for some  who desire it. Individuals who choose to transition without surgery but want their legal documents to reflect the correct gender may also be prevented from achieving this goal.

Steps for legal transition might include:

• Changing name (may require a court order)
• Updating Social Security card (often necessary for an updated driver’s license)
• Updating license/other identification (may require an amended birth certificate). A U.S. passport or passport card reflecting a person’s correct gender can be obtained with a letter from a physician, regardless of the requirements in that person’s state of residence.
• Changing gender marker on birth certificate
• Updating other documents such as wills, transcripts, or diplomas

Hormone Therapy

Some people choose to take hormones as part of their transition process. Hormone therapy, which helps people develop secondary physical characteristics that reflect their true gender, can greatly impact those who are transitioning. People who choose to take hormones may see changes right away, but it can take years before the changes are complete. Some changes are not reversible, but others are, and hormone therapy will typically continue for the rest of a person’s life, unless that person chooses to stop taking hormones. The effects of hormones may vary, and changes cannot be predicted or controlled. They may take effect more quickly in some individuals than in others.

In most states, individuals seeking hormone therapy need a letter from a mental health professional confirming the presence of gender dysphoria and recommending hormone therapy to treat it.

Male to Female (MtF) Hormone Therapy

People assigned male at birth who choose to take hormones will generally take estrogen and anti-androgens, also known as androgen blockers. Estrogen both feminizes features and helps to suppress testosterone, while anti-androgens block the effects of testosterone. Effects may include:

• Breast development
• Redistribution of body fat and loss of muscle mass
• Changes in thickness to body hair
• Increased skin sensitivity and softness
• Changes in feelings and mood
• Decreased libido and fertility, as well as other sexual side effects. The testes will shrink, as may the penis.

MtF hormone therapy does not have an effect on beard hair or voice. Voice therapy can help women reach the desired pitch and modulation, while laser hair removal and other treatments may be necessary for lasting facial hair removal.

Female to Male (FtM) Hormone Therapy

Testosterone is taken people who were assigned female at birth. Effects of testosterone may include: 

• Development of acne due to thicker, oilier skin
• Increased libido
• Clitoral growth
• Stopped periods
• Redistribution of body fat and increased muscle mass
• Deepening voice
• Possible hair loss, change in hair growth pattern
• Body hair growth
• Changes in feelings and mood

Testosterone does not cause breast size to decrease, though the redistribution of body fat may make them less firm, and it cannot change the size of a person’s hands or feet. Anecdotal evidence suggests some men may experience a small growth spurt, but a slight increase in height might also be attributed to change in posture.

Nonbinary Hormone Therapy

Society has traditionally adhered to a gender binary that recognizes male and female identities. Many trans people do transition from female to male or male to female, but those who have a nonbinary, genderqueer, or other identity may also transition (though some nonbinary people do not identify as transgender). Though in the past the Standards of Care for the Health of Transexual, Transgender, and Gender-Nonconforming People reflected a gender binary rather than a wider spectrum of gender, the current edition uses language reflecting the acceptance of nonbinary and genderqueer people.

Though society is beginning to recognize and accept the existence of nonbinary identities, some people may find it difficult to accept other genders or understand why nonbinary individuals want to transition. It may be helpful to remember nonbinary individuals are no less transgender than those who have a gender that may be more familiar. They can still experience dysphoria, be misgendered, and desire to pass in society as a member of their gender, and hormone therapy can benefit them in the same way it benefits other trans people.

Hormone Therapy for Adolescents

Some youth may know they are transgender and want to begin transition, but their parents or doctors may want them to wait until they are more “certain” of their gender identity. However, waiting can be harmful, as changes that occur in puberty may induce dysphoria, which can have an effect on mental health. Trans teens often experience high levels of depression and substance abuse and have a high risk of suicide. Those who are able to transition typically report significant improvements in mental health and emotional well-being.

Health care professionals often prescribe puberty blockers, which delay the development of physical characteristics associated with sex assigned at birth, to trans youth until they are considered old enough to begin hormones. Some researchers suggest waiting until age 16, as the effects of hormone therapy on developing bodies are not entirely known.

Gender Confirmation Surgery (GCS)

Previously known as gender reassignment surgery or sex reassignment surgery, GCS alters a person’s genitalia and/or chest in order to reflect their gender. Calling these procedures “gender confirmation surgery” may help reinforce the fact gender identity is not a choice.

In the past, GCS was typically considered cosmetic, and trans people could expect little to no help from insurance companies. Today, many of these surgeries are known to be medically necessary for trans people, as aligning the physical body with internal identity can greatly relieve distress, mental health symptoms, and suicidality. All major psychological, psychiatric, and medical organizations in the U.S. have made statements to this effect, and many insurance companies now cover some GCS procedures, including mastectomy, gonadectomy, and genital reconstructive surgery.

Surgery to alter facial features, contour the body, modify the voice, increase breast size, or change nose shape or size may assist in the masculinization or feminization of physical characteristics. However, most insurance companies still consider these procedures cosmetic.

To receive gender confirmation surgery, individuals typically need to provide one or two letters of referral from a qualified mental health professional. Some providers require the individual to have had hormone therapy and lived as their gender for a period of time before receiving surgery (though this requirement may be waived in some cases).

Adults who do not have sufficient insurance may have to pay for medical procedures out-of-pocket, which may not be feasible for some. Shelton points out the ability to transition through surgery or hormone therapy is a privilege not everyone has. Some trans people do not have access to any health care resources at all and are unable to pursue any type of medical transition.

How to Offer Support

Some people believe trans people are confused, that they want to transition to be “different,” or that the surgery and hormones they need are nonessential. However, research has shown transgender people are not confused; hormone therapy and GCS can greatly increase quality of life; and the potential risks of hormone therapy and surgery are often far outweighed by the positive effects of transition. Seeking education about the issues and concerns trans people face and offering acceptance and support can be of great benefit not only to a trans friend or family member but to the trans community as a whole.

Immediately referring to a person by the correct pronouns and their chosen name, when that person has shared that information, is one way to show support. If a mistake is made with a person’s name or pronouns, apologizing, correcting the mistake, and moving on is often the best way to handle it.

Avoiding questions that could be considered invasive is also a way to show support. Being expected to provide information about “all things trans” can place the burden of being an educator on people who may not want or be able to take on this role and may lead to them experiencing emotional distress. This expectation may also be colored with the assumption that every trans person will take the same approach toward transition.

Some people may willingly discuss their transition, but it is important to respect their boundaries by allowing them to begin the conversation, direct it, and end it when they no longer feel comfortable.

Simply offering acceptance can be a significant mark of support, and doing so is likely to help an individual transition with greater ease.

1. American Counseling Association. (2010). American Counseling Association Competencies for Counseling with Transgender Clients. Journal of LGBT Issues in Counseling, 4(3), 135-159.
2. American Psychological Association. (2015). Psychological practice guidelines with transgender and gender nonconforming clients. American Psychologist, 70(9), 832-864.
3. Ashbee, O., & Goldberg, J. M. (2006). Hormones: A guide for MTFs. Vancouver: Canadian Rainbow Health Coalition and Vancouver Coastal Health.
4. Changing birth certificate sex designations: State-by-state guidelines. (2015, February 23). Retrieved from http://www.lambdalegal.org/know-your-rights/transgender/changing-birth-certificate-sex-designations
5. Chen, A. (2015, July 22). Health effects of transitioning in teen years remain unknown. NPR. Retrieved from http://www.npr.org/sections/health-shots/2015/07/22/424996915/health-effects-of-transitioning-in-teen-years-remain-unknown
6. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., Fraser, L. … Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender non-conforming people, version 7. International Journal of Transgenderism, 13:165-232. Retrieved from https://www.researchgate.net/publication/254366000_Standards_of_Care_for_the_Health_of_Transsexual_Transgender_and_Gender_Non-Conforming_People
7. FAQ on access to transition-related care. (n.d.). Retrieved from http://www.lambdalegal.org/know-your-rights/transgender/transition-related-care-faq
8. Gender Identity Research and Education Society. (2007). A guide to hormone therapy for trans people. London: DH Publications. Retrieved from http://www.teni.ie/attachments/9ea50d6e-1148-4c26-be0d-9def980047db.PDF
9. Gender reassignment surgery. (2015, October 23). Retrieved from http://www.aetna.com/cpb/medical/data/600_699/0615.html
10. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J. Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey, executive summary. National Center for Transgender Equality and National Gay and Lesbian Task Force. Retrieved from http://www.thetaskforce.org/injustice-every-turn-report-national-transgender-discrimination-survey-executive-summary/
11. Hoffman-Fox, D. (2014, May 7). Ask a gender therapist: Can I transition if I’m non-binary or genderfluid? Retrieved from http://darahoffmanfox.com/ask-gender-therapist-can-transition-im-non-binary-genderfluid
12. Information on transitioning and transgender health. (n.d.) Retrieved from http://www.revelandriot.com/resources/trans-health
13. James, A. (2015, May 31). Legal issues for transgender people. Retrieved from http://www.tsroadmap.com/reality/legalindex.html
14. Medical/Hormonal: Typical Results. (n.d.). Retrieved from http://www.transgendercare.com/medical/resources/tmf_program/tmf_program_6.asp
15. The rights of transgender people in Washington state. (2016, May 27). Retrieved from https://aclu-wa.org/docs/rights-transgender-people-washington-state
16. Schechter, L. S. (2012, April 20). ‘Gender confirmation surgery’: What’s in a name? The Huffington Post. Retrieved from http://www.huffingtonpost.com/loren-s-schechter-md-facs/gender-confirmation-surgery_b_1442262.html
17. Segal, C. (2015, June 9). What hormone therapy means for transgender people. PBS NewsHour. Retrieved from http://www.pbs.org/newshour/rundown/hormone-therapy-means-transgender-people
18. Social affirmation (transition). (2015). Retrieved from http://www.ftmaustralia.org/transition/social-transition
19. Tannehill, B. (2014, October 11). 16 myths about gender confirmation surgery. Retrieved from http://everydayfeminism.com/2014/10/gender-confirmation-surgery
20. Transition. (n.d.). Retrieved from http://transwhat.org/transition
21. Understanding the passport gender change policy. (2014). Retrieved from http://www.transequality.org/sites/default/files/docs/kyr/passports_2014.pdf

Dissociation is a way people, to varying degrees, disconnect from their thoughts and feelings in order to avoid pain or traumatic memories. It represents a “lack of normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory,” serving as an unconscious strategy the mind uses to protect from distress. It is a refuge of sorts into an altered state of mind that is often characterized by obsessive thoughts, fantasies, or even non-thinking states. It can be employed consciously or unconsciously as a defense mechanism and can range in intensity from mild daydreams to feeling separate from one’s body.

In our current digital age dissociating is easier than ever. You can simply turn on the television or, better yet, turn on your computer or mobile device and find yourself on a high-speed train through the internet highway, encountering all kinds of people, distracting yourself with all kinds of information, and stimulating yourself in all kinds of ways. Recent research indicates that digital environments and social media can contribute to dissociative experiences, particularly among adolescents and young adults. All the while, your body is there, in the chair or wherever it is, coping with the emotional unrest residing deep inside.

Although dissociation can be an effective short-term strategy for pain management, it often wreaks havoc on relationships.

The Impact of Dissociation on Relationships

Relationships flourish when the participants relate to each other, which requires mutual sharing of thoughts and feelings not just about each other but about their lives and the world around them, about their pasts, and about the future. Relating is the “food” of a relationship.

Dissociation can distress relationships because it undermines the ability to relate and thus starves the relationship over time. Recent research describes this as “dissociative collusion,” where split-off aspects of one or both partners are mutually dissociated in a complementary fashion that becomes destructive to the relationship. It is a bit of a catch-22: people often (unconsciously) choose partners who will bring up elements of their painful past in order to grow, heal, and develop. For those who dissociated during that original pain, however, employing the strategy now starves the relationship of the food of relating to each other.

Many people who frequently dissociate find that relationships can feel quite stifling. Inevitably, painful memories and feelings arise in the relationship and they (unconsciously) dissociate. At the same time, they see this other person there feeling hurt that they’ve disconnected or “left,” and feel trapped. They can’t leave, but they can’t stay, either. It can feel agonizing, lonely, and confusing to both partners when dissociation occurs.

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How Couples Counseling Can Help

A good couples counselor can be an invaluable resource and guide to finding a new way forward, both for the individual who dissociates and for the distressed couple. Evidence-based guidelines from organizations like the International Society for the Study of Trauma and Dissociation support comprehensive treatment approaches that integrate multiple therapeutic modalities. Specifically, couples counseling can help by:

Identifying and naming the issue: It may be hard for a couple to recognize that dissociation is causing distress in the relationship because it often is an unconscious coping process and is easily confused for intentional emotional distancing. If there is something beyond dissociation going on—and there often is—a therapist should be able to help identify that, too.

Helping the couple understand what’s going on: Dissociation often leaves the other partner feeling abandoned, unheard, and unloved. A therapist can help both people recognize that this is not about a lack of interest or love but rather a deep survival mechanism. Research shows that dissociative defenses are particularly relevant for couples with histories of trauma. A dissociating person typically only wants to feel better, not make their partner feel bad.

Making space to slowly reduce dissociative symptoms: This is vital. A therapist can slow things down enough to help each person observe the dissociation and, over time, feel into the pain as a means of reducing symptoms. Individuals with chronic dissociation often struggle to feel safe, especially in relationships, making psychotherapy challenging but essential for healing.

Helping the couple find new skills: This is the creative aspect of therapy—helping the couple discover new ways to respond when painful feelings and memories arise. Individual or couples counseling can explore root causes of dissociation and develop coping strategies, offering stress-management techniques and enhanced communication skills.

If there is unresolved pain or trauma in the background of your relationship and you suspect dissociation may be hurting your ability to relate to your partner, contact a trained and compassionate couples counselor. You don’t have to suffer alone.

Please Note: This article is for informational purposes only and does not constitute medical or therapeutic advice. If you are experiencing severe dissociative symptoms or relationship distress, please consult with a qualified mental health professional for personalized treatment recommendations.

References:

1. Robinson, M. A., Purcell, J. B., Ward, L., Winternitz, S., Kaufman, M. L., Baranowski, K. A., & Lebois, L. A. M. (2024). Advancing research on and treatment of dissociative identity disorder with people with lived experience. American Journal of Psychotherapy, 77(3), 141-150. https://doi.org/10.1176/appi.psychotherapy.20230028
2. Černis, E., Chan, C., & Cooper, M. (2019). Identifying preliminary risk profiles for dissociation in 16‐ to 25‐year‐olds using machine learning. Early Intervention in Psychiatry, 25(2), 1-12. https://doi.org/10.1111/eip.13162
3. Costa, R. M. (2020). Dissociation (Defense Mechanism). In V. Zeigler-Hill & T. K. Shackelford (Eds.), Encyclopedia of Personality and Individual Differences. Springer. https://doi.org/10.1007/978-3-319-24612-3_1375
4. Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727-735.
5. D’Andrea, W., & Pole, N. (2012). A naturalistic study of the relation of psychotherapy process to changes in symptoms, information processing, and physiological activity in complex trauma. Traumatology, 18(2), 26-40.
6. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115-187.
7. Johnson, S. M., & Greenman, P. S. (2024). Emotionally focused couple therapy and attachment theory: Understanding emotion regulation in distressed couples. Journal of Couple & Relationship Therapy, 23(4), 295-312.
8. Loewenstein, R. J., Brand, B. L., & Schielke, H. J. (2022). Trauma-related dissociation and the dissociative disorders: Neglected symptoms with severe public health consequences. Frontiers in Psychiatry, 13, 1-24.
9. National Institute of Mental Health. (2024). Post-traumatic stress disorder. U.S. Department of Health and Human Services. https://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd

People are drawn to the helping professions for many different reasons. They may feel a calling to assist in relieving others’ suffering and to help them heal from their emotional wounds. They may have been traumatized themselves and wish to share the coping skills they’ve learned with others going through similar issues. Or they may feel caring for others brings meaning and a sense of purpose to their lives.

Whatever their reasons for becoming a therapist or other helping professional, they often experience vicarious trauma through the stories told by the people they work with. This secondary trauma, also referred to as compassion fatigue, can seriously hinder their work if they remain unaware of its negative impact and/or do not practice sufficient self-care strategies.

Becoming aware of the signs of compassion fatigue is the first step in addressing the issue. The following are some red flags:

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1. Preoccupation with the traumatic stories of the people they work with
2. Emotional symptoms of anger, grief, mood swings, anxiety, or depression
3. Physical issues related to stress, such as headaches, stomachaches, fatigue, or problems sleeping
4. Feeling burned out, powerless, hopeless, disillusioned, irritable, and/or angry toward “the system”
5. A tendency to self-isolate, be tardy, avoid certain people, or experience a lack of empathy and loss of motivation

Some of the professionals most likely to experience compassion fatigue include therapists, social workers, child welfare workers, emergency workers, police officers, firefighters, and ministers. However, anyone working with trauma survivors is susceptible to vicarious trauma. Helping professionals who have been subjected to trauma themselves also may be more at risk for developing compassion fatigue, especially if they have not worked through their issues.

Developing an adequate self-care strategy is key to preventing or overcoming vicarious trauma. Some of the techniques that can be used include:

• Maintain a good work-life balance. This involves taking time off to recharge and avoiding working long hours and/or carrying too heavy of a caseload or workload.
• Exercise to relieve stress. Developing a good workout routine is important to help increase feel-good endorphins and improve one’s outlook on life. Taking a yoga class, doing aerobic activity, or even just going for a walk can be invigorating and help change one’s perspective.
• Start a meditation practice. Initially, try sitting quietly for just 10 minutes a day, then gradually increase the time to 20 minutes. Meditation has many benefits and can assist one with feeling more peaceful and grounded.
• Develop a good social network. Having a good support system in place is important in order to be able to connect with others in a meaningful way.
• Use humor to unwind. Humor is good medicine when it comes to relieving stress and improving one’s mood. Watch a comedy, play with a pet, read a funny book—whatever moves you and helps you relax.
• Reconnect with Mother Nature. Being out in nature is therapeutic, whether you go for a hike in the woods, a walk on the beach, or just do a little gardening.
• Get involved with activities outside of work. Take your mind off of work by taking a class or engaging in a creative endeavor such as drawing, painting, or writing.
• Meet with a therapist to discuss concerns. Even individuals in the helping professions can benefit from meeting with a counselor, especially when they are experiencing compassion fatigue. A compassionate therapist can help put things in perspective and help identify additional coping skills.

Although all helping professionals are in danger of developing compassion fatigue, especially when working with individuals who have experienced traumatic events, having a self-care plan in place can help reduce the risks.

If you are already working on healing from a history of trauma, dissociation is likely a familiar concept. You are likely aware it is a system of coping that, in times of distress, offers protection from the full realization of trauma and its associated emotions, sensations, images, thoughts, and patterns of thinking.

The lack of realization and integration of these components creates the symptoms that bring people to therapy. The greater the extent and intensity of the traumas, the greater the complexity of the typical dissociative process and, of course, the treatment approach.

The “window of tolerance,” a concept introduced by Daniel J. Siegel, describes the equilibrium our systems need in order to heal from trauma. When we have unhealed traumas, our systems may not be fully present. They might not fully know or feel that the danger has passed and can become fixed in states of hypoarousal and hyperarousal or fluctuate between the two states.

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Hypo- or hyperarousal can result from the dissociative symptoms linked to the trauma, which may be positive (adding to the experience) or negative (taking away from the experience). Positive dissociative symptoms might include intrusive images, emotions, sensations, and thoughts. Negative dissociative symptoms may include amnesia, derealization, and depersonalization.

When we are stuck in these upper and lower zones of hyper- or hypoarousal, the full integration and healing of trauma cannot occur. But in the middle, within the window of tolerance, healing and integration can occur.

The shift outside the window of tolerance into hypo- or hyperarousal is the dissociative process, and it may be subtle or extreme. In those moments we experience what I call the “quantum leap effect,” where aspects of our former self, still stuck in the original trauma, do not have access to what the present self knows. That keeps us stuck in the reliving of the traumatic material, even though a part of us—an inaccessible part, so long as we are dissociating—knows it is in the past.

Anchoring Yourself in the Present

After noticing a dissociative shift into hypo- or hyperarousal, it may be helpful to utilize a skill that anchors you mindfully to the present. The anchor is not just about noticing you are “in the now.” It is imperative you notice and acknowledge the present is different from whatever you think you are stuck in. “I know I may be seeing old stuff,” you might tell yourself, “but that old stuff can’t be happening because I am in this room now, and these are the ways it looks different.”

The shift outside the window of tolerance into hypo- or hyperarousal is the dissociative process, and it may be subtle or extreme.

A more specific example might look like this: “The wall is brown, there is carpet, and I am 22 years old. I can’t be in that old circumstance. I am in the same room as this brown carpet. It must be over, because I am in a different room and I am older. I wasn’t wearing these shoes. In fact, I couldn’t fit in these shoes if I was in that time.”

If you are trying to heal from trauma, think of this anchoring skill as a way to get aspects of your former self more current and stay within your window of tolerance. To really take root, it must be practiced over and over. But it is an essential coping skill for any trauma survivor, even before processing any traumatic material in therapy.

Reference:

Siegel, D. (1999). The Developing Mind. New York: Guilford.

Psychological trauma, defined as the experience of an event in which a person feels their life is threatened or in danger, may be accompanied by a sense of helplessness, horror, or numbing as the internal alarm system becomes activated.

We react to trauma in a number of ways, and certain factors put us at risk for more severe psychological difficulties. Fortunately, there are qualities we can build on to help us manage our reactions to traumatic events.

There are four main types of reactions we may experience following a trauma: emotional, cognitive, physical, and interpersonal.

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1. Emotional reactions include shock, fear, grief, anger, guilt, shame, helplessness, numbness, sadness, confusion, denial, abandonment, anxiety, and depression.
2. Cognitive reactions might include problems with concentration, indecisiveness, difficulty making decisions, and intrusive or unwanted memories. You may notice thoughts such as, “How could someone do this?” or, “It felt like time stood still.”
3. Physical reactions consist of bodily tension, feeling fatigued, insomnia, startling easily, racing heartbeat, nausea, change in appetite, chills, digestive problems, or profuse sweating.
4. Interpersonal reactions involve feeling a sense of distrust, experiencing a loss of intimacy, increased conflict with others, isolation from others, or problems at work or school.

Other reactions to trauma are less common and more severe, and may require professional intervention. These may include:

• Emotional reactions that include intrusive or unwanted reexperiencing of the event after it has happened such as nightmares, flashbacks, and terrifying memories
• Extreme emotional numbing that leads to a sense of emptiness
• Potentially harmful attempts to avoid intrusive experiences through alcohol or substance use, lying, self-injury, or suicide attempts
• Physical reactions that involve hyperarousal, panic, rage, extreme irritability, agitation, restlessness, or violence
• Ongoing anxiety, uncontrollable worry, helplessness, or obsessive or compulsive behavior
• Dissociation (or a sense of being separate from one’s body), having fragmented thoughts, lack of awareness of surroundings, or involuntarily spacing out

Not everyone will develop a mental health condition or posttraumatic stress (PTSD) following a traumatic event. There are certain risk factors that increase the chances of experiencing more severe reactions to trauma, including severe exposure to a disaster, low socioeconomic status, having a preexisting mental health condition, being part of an ethnic minority, lacking social support, and lacking social resources.

Although there are factors that increase the risk of severe trauma reactions, there are also at least seven personality characteristics, described below, that can help a person successfully cope with or manage trauma.

Locus of Control

Locus of control is the extent to which we believe or expect we can control the outcomes of events that affect us. Our locus of control may be internal or external. If we have an external locus of control, we believe our behavior is guided by fate, luck, or other external forces. If we have an internal locus of control, we believe our behavior is guided by our own decisions and efforts, and that outcomes are related to our actions.

Crises challenge our beliefs and expectations about the level of control we have in the situation. Attempting to assert some degree of control following a crisis can aid in more effective coping and can help create a greater sense of meaning and consistency. Some researchers have observed that an external locus of control is related to learned helplessness, a condition in which a person perceives no sense of control, expects that there can be no escape, and believes any attempt to escape will result in failure.

While an internal locus of control can have positive effects in moderation, those who attempt to unrealistically control events may need assistance adjusting their expectations about outcomes. For instance, someone with an unrealistic belief that they could have prevented a crisis on their own by doing A, B, or C may need help focusing on what they can realistically control.

Self-Efficacy

Self-efficacy is our belief about how capable we are to handle situations. If we have high self-efficacy, we exert effort to overcome challenges. If our self-efficacy is low, we avoid actions we think will exceed what we’re capable of. Self-efficacy builds on itself as we add to our successes. It is thought that people who expect to successfully cope with their emotions and moods are more likely to be proactive in their healing and to seek out something positive in threatening situations.

Optimism

Optimism is holding hope and expecting that good things will happen. Optimism is focused on a desired outcome and not on who is in control or how capable one is in reaching the outcome. Optimists emphasize the positive during difficult situations and have been found by some researchers to be less anxious, hostile, depressed, and self-conscious than those with pessimistic attitudes.

Hardiness

Hardiness as a personality characteristic describes someone who is curious, actively involved, believes they can influence outcomes, expects that life will present changes, and tends to believe that challenges are opportunities for development. People with hardiness have a willingness to learn something of value, and merge those lessons into their lives. Hardiness is also associated with active coping and decreased emotional distress.

Resilience

People with resilience are those who are at risk for failure early on in life but who nonetheless become successful. Resilient people can take responsibility for their own part in a situation and let go of responsibility for the things they cannot change. Some qualities of resilient individuals include active problem solving, perceiving difficult experiences constructively, gaining positive attention from others, and an ability to continue finding meaning in their experience.

Sense of Coherence

People with a strong sense of coherence understand that stress is an inevitable part of life and recognize that dealing with it successfully can be beneficial. Having a sense of coherence means we seek to comprehend, manage, and find meaning in situations. When we attempt to comprehend the crisis situation, we try to make sense of what happened and explain how it occurred. To manage the situation, it can be helpful to utilize available resources. Meaningfulness indicates the situation is worthy of our time and investment. Having high meaningfulness motivates us to search for ways to comprehend the situation and seek out resources to aid in managing the incident.

Creativity

The ability to creatively cope is related to one’s ability to let go of the usual ways of solving problems. People who can produce creative solutions are better able to cope with traumatic events in which there are limited opportunities to exert control. Creativity involves flexibility in dealing with one’s environment.

How we react to a traumatic event can be greatly influenced by a number of factors. There are several common ways we react to trauma, and some reactions are more severe than others. Numerous personality traits were identified here that can be learned or cultivated to deal more successfully with trauma and obtain what is increasingly being recognized as posttraumatic growth.

References:

1. Tedeschi, R.G., & Calhoun, L. G. (1995). Trauma & Transformation: Growing in the Aftermath of Suffering. Thousand Oaks, California: SAGE Publications, Inc.
2. U.S. Department of Veterans Affairs National Center for PTSD. (2010). Mental Health Reactions After Disaster. Retrieved from http://www.ptsd.va.gov/professional/pages/handouts-pdf/Reactions.pdf

How do you know what to commit to in your life, or what choices to make? What romantic interest, job, friend, trip, or task do you choose? There are so many options. How do you know how to make the right choice? What does choosing “right” even mean? Options and choices can lead to feelings of overwhelm and confusion. Feeling confused, in turn, can lead to stagnation because of indecision. Lately, I hear smart, driven people say they are so nervous about making the wrong choice, they’re making no choice. This is a problem in and of itself. When you are not making choices in life, you can’t make progress. Your choices create the flow in your life.

No choice, no flow.

I have held, and still do hold resistance to commitment. My natural tendency is to live more as a “free bird,” meaning I desire to go with the flow, take off on a whim, adventure, and sway away from a concrete plan. I love when choices reveal themselves to me. I love the organic nature of how life shows me what direction to go, although there are times when a straightforward decision is called for. So, what do you do then? What do you do when you need to make a clear choice?

Focus on the Now

When I’m making a choice and I look into the future of how the decision can affect my future and everyone in it, I begin to feel paralyzed. The fear that arises from focusing on the hypothetical future if I make a choice is just not a healthy approach. Instead, focus on the now and how that choice is going to affect you in the present. Your present reality is all you have, and all you need. Do your best to get in tune with what you are feeling and make the best choice you know how to make in the now considering what feels right.

[fat_widget_right]Ditch the Past

The past is generally a good predictor of what to expect and what is to come. However, sometimes there is no relevant connection from the present to the past, and it’s not productive to seek one. Looking at each choice you make with current and fresh eyes is a centered and more realistic approach. Being mindful not to bring the past into your current experience is a more positive way to approach life. Living in the “what used to be” or the “what might be” is a surefire way not to live in the now.

Take a Step Back

Breathe. Take a break. Remove yourself from the situation. Focus on something totally different. Get a good night’s rest. Have fun. Take a trip. Very often when you are unsure of what move to make, allowing yourself to step away from the decision-making process can help you see things with more clarity. I’ve made the most monumental decisions in my life just after returning from trips. I go into the trip confused, unsure, and stressed about what to do. Magically, sometime during the trip or in reflection when I get back, I feel clearer about what I want to do. I’ve moved cities, quit jobs, and pressed some major reset buttons for my life after giving myself time away from the issue.

Trust Something Bigger

I know this is easier said than done, but try not to put so much pressure on yourself toward “figuring it all out.” Yes, you have choices and decisions in life to make, but there are also outside, higher-power forces that are bigger than you and your decisions. These forces show up as coincidences; missed trains, planes and buses; ironic happenings; etc. Letting go of the perspective that you have to do 100% of the action toward making something happen goes against the natural flow of life. Sometimes things, opportunities, and people fall into our lives without any work on our part. Trust that. When you do your best to live a life that feels good, these happenings occur with a lot more frequency.

Recognize Very Few Things Are Permanent

As we make decisions, it’s easy to get caught in the permanence of it all. The thing is, very few things in life are permanent. Many choices can be revised down the road and changed. For example, if you moved cities and it’s not the life you envisioned, move again. You’re dating someone and he/she is not what you initially thought, break up and switch it up. You started a career and it’s wearing on you to show up each day, start something different.

I understand, with compassion, that it’s far more complicated than those easy-breezy solutions. The point to take away from this is that it’s not impossible. People make major changes every day and survive. Very often, when you gain the confidence and trust to jump into the unknown, wonderful things are waiting for you once you land. I’ve yet to meet someone who moved away from a draining situation and regretted it.  Very often, it’s not one choice that will make or break you. Choices, usually, are small. You get the freedom to make choices for yourself all day long. One positive choice followed by another will lead you in a positive direction. By practicing decision-making with small choices, you have already carved out a positive path to walk. This lessens the confusion around a decision and leaves you with the control to make the best decision you know how to make at the given time. After you complete that step, you get to sit back and allow life to show you the way. Your awareness of who and what is around you will help you with your decision-making.  You got this.

Seniors who experience excessive fatigue during the day may have more brain atrophy than well-rested seniors, according to a study presented at SLEEP 2016, the 30^th Anniversary Meeting of the Associated Professional Sleep Societies (APSS). Researchers found atrophy was greatest in regions of the brain vulnerable to Alzheimer’s and age-related decline, suggesting fatigue could be an early sign of brain degeneration.

The Link Between Fatigue and Brain Atrophy

For their study, researchers worked with 1,374 cognitively normal seniors age 50 and older who participated in the Mayo Clinic Study of Aging. Participants completed surveys of sleepiness and fatigue and underwent magnetic resonance imaging (MRI) brain scans to establish baseline brain functioning.

Participants who reported high levels of daytime sleepiness had lower cognitive scores and more medical problems. They were also more likely to report sleep disturbances, pointing to a correlation between disturbed sleep and daytime fatigue.

Changes in Sleep: Early Dementia Warning Sign?

The study’s authors suggest these results may help doctors identify people at risk for dementia, increasing opportunities for early treatment. Previous research supports this claim. According to the Alzheimer’s Association, changes in sleep habits are common among people with Alzheimer’s. This may be due to the ways Alzheimer’s changes the brain. Some common Alzheimer’s-related sleep changes include:

• Insomnia and disturbed sleep.[fat_widget_right]
• Changes in dreaming patterns. Brain scans show people with dementia spend less time in both dreaming and non-dreaming sleep cycles.
• Changes in the sleep cycle, such as napping during the day, or feeling drowsy during the day.
• Sundowning, an experience characterized by behavioral and cognitive changes late in the afternoon or evening.

In the late stages of Alzheimer’s, seniors may spend as much as 40% of their nights awake, as well as a significant portion of the day sleeping.

The National Sleep Foundation says some age-related changes in sleeping are normal. The foundation recommends 7-8 hours of sleep per night for seniors 65 and older, compared to 7-9 hours for adults younger than 65. The American Academy of Pediatrics is also supporting a new revised recommendation from the American Academy of Sleep Medicine for children’s sleep guidelines. Also presented at SLEEP 2016, these recommendations now include as many as 16 hours of sleep for infants, 14 hours for young children, and 12 hours for school-age children.

References:

1. Brooks, M. (2016, June 14). New AASM guideline on optimal sleep for children. Retrieved from http://www.medscape.com/viewarticle/864846
2. National Sleep Foundation recommends new sleep times. (2015, February 2). Retrieved from https://sleepfoundation.org/media-center/press-release/national-sleep-foundation-recommends-new-sleep-times
3. Sleepiness and fatigue linked to brain atrophy in cognitively normal elderly. (2016, June 14). Retrieved from http://www.eurekalert.org/pub_releases/2016-06/aaos-saf061416.php
4. Treatments for sleep changes. (n.d.). Retrieved from http://www.alz.org/alzheimers_disease_10429.asp

Much of life is shaped by the choices we make. We choose where we want to work and where we will live. We choose friends and partners. Most of us also choose who we marry (if we choose to marry). When we commit to someone, typically we are agreeing not only to commit to them, but to what—and who—they bring with them. In many cases, family members are part of what a partner brings to a committed, long-term relationship. And although we can choose our partner, we cannot choose their family.

Building a relationship with a long-term partner’s family can be difficult for all involved. Everyone involved is adjusting to a major life transition: parents are trying to adjust to a new relationship dynamic with their child and build a relationship with their child’s partner. The couple is establishing and strengthening their own relationship and making their own life choices. If these choices conflict with what the parents envisioned for their child, the parents may perceive this as rejection, which can put strain on the relationship. Parents who miss their child and want to have more of a relationship may seem pushy or over-involved. Any number of other reasons may serve to complicate this particular relationship.

In my experience as a therapist, strained relationships with a partner’s family members, especially the relationship between a mother-in-law and daughter-in-law, are quite common. If you find building a relationship with your partner’s parents to be challenging, or if you just don’t like your partner’s parents, the following tips and considerations may be helpful:

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• Discuss the level of involvement you would like to have with your partner’s family. Do you envision seeing them every week for Sunday dinner? Do you envision seeing them for three hours on a major holiday once per year? If you choose to have children, what type of involvement should they have with them? If you and your partner disagree, you can talk through the reasons and try to reach a compromise that leaves you both satisfied.
• Work on building a positive relationship and focusing on the good. It can be hard to relate to someone if you don’t know them well. Try to have more shared experiences. Plan an activity, such as a picnic or mini-golf. Try seeking advice on small things, like which tablecloth is best or what dishes you could serve at a family meal. Maybe one parent is financially savvy and can help you figure out your mortgage application. Maybe the other parent is excellent at fixing things around the house. Seek out and enjoy each person’s strengths.
• This is a long-term relationship, so it is likely worth investing in. In most areas of life, it’s fairly easy to minimize contact with people we don’t like. However, in a marriage or other committed partnership, it may be worth trying to reach common ground. Discover the good aspects about your partner’s parents and learn what you can like about them.
• Hear their feelings behind the comments. When your partner’s mother asks, “Why don’t you move closer?” or “Why did you move so far away?” try to hear the feelings rather than the criticisms. Your partner’s parents are probably not trying to control you or tell you what to do. They may simply be trying to tell you how they feel about something, such as “I miss you and wish we could spend more time together.”
• Learn their love language as a way to communicate with them better. Gary Chapman’s The Five Love Languages as a tool for your in-laws. What are their love languages? Do they really appreciate gifts? Would they better appreciate an offer to help them with house and yard work once in a while? Giving to them, in a way they will appreciate most, can help them feel more positively toward you and may lead to a greater sense of connection. [amazon_affiliate]
• Not all events have to include all the members of the family. If it remains difficult—for whatever reason—for you to enjoy or even handle seeing certain members of the family, try instead to create (or allow) opportunities for them to see your partner or their grandchildren. Grandparents might be thrilled to spend time with your kids for a few hours or even a few days. You don’t have to attend every single get-together.
• Don’t force your partner or children to cut off their relationships. You may dislike your partner’s parents. You may have drastically different approaches to parenting. But allowing your children to spend time with their grandparents may really benefit them (and their grandparents). Preventing your children from building this relationship can be a huge loss (unless you have reason to believe they are in danger). And if your partner wishes to spend more time with their parents (with or without you) and you prevent them from doing so, conflict and resentment may be the result.
• Set boundaries. Doing this early on in your relationship is likely to make the adjustment easier for everyone involved. Assuring your partner’s parents they are an important part of the family may help them agree more easily to the boundaries you set without feeling as if you have cut them off. If they tend to overstay their welcome, try being specific: “Are you available from 1 to 3 on Sunday?” or, “Would you like to come for a visit for two nights next weekend?” If they express the desire to stay longer than you would like, simply say something like, “It would be better for us to just do two days this time.”
• Realize that your partner’s long-standing familial relationships and communication dynamics precede your relationship and are not likely to change. You may feel irritated by your partner’s interactions. Suddenly the confident and self-assured person you know cannot stand up to their mother! This may be infuriating, but try your best not to harp on it or try to change them. Your partner’s relationship and patterns of interaction with their parents (and siblings) are unlikely to change much. (However, if some aspect of this interaction or any family issue appears to be harmful or distressing to your partner, you may wish to discuss this, perhaps with a counselor.)
• Communicate clearly. If you primarily communicate with your partner’s family through your partner but find things often become muddled, try speaking directly to them instead. This not only shows them respect but can help prevent miscommunication and misunderstandings—and will keep your partner from being caught in the middle.

Dealing with your partner’s parents may be one of the more challenging parts of your relationship, but it may be worth the effort to make your interactions with them as pleasant as possible, if for no other reason than to respect your partner’s bond with them.

Time and again, people share with me the difficulties they have in asking for help. When I hear this, I’m grateful they found their way to my office, because their first phone call to me was an example of having done so.

We all have moments in our lives when we require the assistance of others. We don’t ever know all there is to know or have the skills to do everything proficiently or successfully. We certainly don’t expect that of others, either. So it makes sense we would have occasion to ask someone for help at some point.

The biggest reason many seem to have for staying stuck rather than reaching out is fear. People fear they will be rejected or told “no,” fear being seen as “less than” or weak, or fear being “found out.”

Being told “no” does not have to be awful. We do not have to weave a story and personalize the rejection (make it about us). It may be that the person we chose to ask didn’t have the appropriate resources to help us at that time. It’s best to accept the “no” as the answer to our request, not a negation of ourselves. A “no” tells us not to waste any more time and energy asking this particular person, and guides us closer to someone who will say “yes.”

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Some equate being vulnerable with being weak, but asking for help takes self-awareness and courage. It’s important to know where our strengths lie and where they don’t. Sometimes the most efficient way to proceed is to focus our efforts where they have the most impact, and implore others to fill in the gaps according to their skill sets, leading to teamwork and collaboration. To be vulnerable is to provide the opportunity to connect and pool resources, thereby resulting in further strength.

The fear of being “found out” is akin to the fear of being exposed as a fraud (impostor syndrome). It can coincide with all-or-nothing thinking or perfectionism—believing that if we don’t know it all, we know next to nothing. In most roles in which we function, whether it be parent, employee, or partner, we are not expected to know it all. There are always opportunities for us to learn and grow. It doesn’t serve us to pretend we have every answer. However, it benefits us and others to know where to go for assistance when we need it, and then to avail ourselves of those resources.

What can you gain by asking for help?

• You gain the ability to move forward. Rather than staying “stuck,” you know how to proceed. Can you remember a time you hesitated in reaching out? Chances are you felt a certain degree of stress associated with this. You weren’t being as productive as you wanted to be. You may have felt foolish in not being sure of your next step. Not believing you could ask for help might have fueled symptoms of anxiety. That is, until you asked for help and felt the relief of finding out what you needed to know.
• You gain the opportunity to collaborate. If you’ve been tasked with something to do independently, it’s best to try to do it on your own. But if you’re stymied, seeking advice or assistance gives someone the opportunity to share with you. While not everyone is able to say “yes,” people are often honored by the request. It means you admired their expertise or abilities enough to inquire.
• You gain the opportunity to learn. Pay attention to who is willing to help and what they are willing to do for you. Really listen to strategies being communicated to you, and take notes so you don’t have to ask the same questions twice.

It’s also worthwhile to think about whether you’re willing to help others when asked. If you tend to say “yes” and are maybe even happy to be asked, then perhaps you can better see the value in asking for support from someone else.

Asking for help doesn’t devalue you in any way. It can enable you to advance, connect you meaningfully with others, bolster your productivity and ability to do things with greater ease, and better prepare you for your next challenge.

I work with a number of anguished parents who are surprised, hurt, and bewildered by changes in the way their adult children behave toward them. They describe relationships filled with coolness and irritation from their adult child and talk about being rebuffed when emails, texts, and phone calls go unanswered and responses to requests for dinner or birthday celebrations are ignored or refused. These parents feel pushed away and controlled by their children and clueless to understand this unexpected behavior. They come into therapy filled with a wide range of feelings, including rejection, anger, hurt, anxiety, depression, and helplessness.

Melanie came to see me because of difficulties with her oldest child, Barbara, 33, who is five years married with two young children.

“She was my first, and it was love at first sight,” Melanie said of Barbara. “We were so close. I don’t understand the change. It seems sudden, but I suppose it started after college when she became a little distant and there was some tension. Now I can’t say ‘boo’ to her without her becoming annoyed or angry. I’m always walking on tiptoe and never know when she’s going to have an outburst. She’ll yell and say awful things like I don’t understand her or I’m self-absorbed or the queen of criticism. I can’t imagine why she feels this way. I go from shock to crying to feeling outraged. I don’t know what she wants from me. Actually, it feels like she doesn’t want anything from me. It’s getting more and more difficult to get to see her or even get her to send me a picture of the grandkids or answer a text. When she ignored my birthday last month, that was the worst.”

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Melanie’s experience with Barbara is illustrative of what the distressed parents I work with describe: through adolescence they had close, loving relationships which became conflicted only after their children left home. The separation-individuation process which is expected to occur in adolescence didn’t emerge at the developmentally appropriate time. Without the benefit of individuation in adolescence, these children missed the experience of learning to navigate the power struggles and clashes with parents that are crucial for the formation of a sense of identity with feelings of autonomy and self-confidence. This experience is necessary to set the stage for feeling comfortably attached to the parent without fear of being controlled or influenced.

The Development of Saying Yes to Oneself

I have always been intrigued with the idea that 2-year-olds have to learn to say “no” before they can say “yes.” The “no” of the 2-year-old is a crucial component of the development of self. “No” is directed to the parent who engages with the child in a squabble. When there are wins for the child, their “no” is accepted, making it possible for the child to begin feeling authorship of their “yes.” “Yes” is a nod to the self, to one’s desires, needs, and drive toward autonomy.

During adolescence, this process continues. Now the parent has to shift from the position of benign authority they held with their younger child. They must find a balance between providing rules within a secure and safe framework and simultaneously allow room for the emergence of the adolescent’s “noes.” This means the child is given space to question and change the rules (although the parent will not always agree) as they move toward “yes,” i.e., developing their identity as autonomous adults.

The Adult Child’s Delayed Individuation Process

For some children, the struggle to individuate either begins or intensifies after adolescence, often during their late 20s or 30s. When this occurs, a strong need to pull away and extract oneself from the parental orbit feels necessary.

For parents who have not experienced the passionate conflicts of adolescence and may be known to happily remark “I got off easy,” their adult child’s fierce push to be separate can be heart-wrenching. When there is a delay or a reemergence of this struggle for autonomy, the parent is frequently taken by surprise and is unprepared for what may now become an intense process of individuation in which the adult child, no longer feeling required to adhere to the old rules, comes out fighting to claim a selfhood that will feel unfettered by parental influence. It can seem very sudden when a child starts to pull away, express anger, and assert themselves against the parent. Although the parent may be unaware of treating the child differently, what might have felt to both parent and child like interest or involvement in the past can now be experienced by the child as controlling or critical.

As I got to know Melanie and learned about the development of her relationship with Barbara, it became clear that Barbara was late in separating from her parents. Through late adolescence, Barbara never went through a stage where she pushed against her parents. When she went away to college, she remained close with frequent calls and emails. Between her junior and senior years, however, she and her parents fought over her decision to remain at college for the summer to take an internship. This was the first big disagreement with Barbara where Barbara’s wishes won out. Melanie wondered:

As I got to know Melanie and learned about the development of her relationship with Barbara, it became clear that Barbara was late in separating from her parents.

“I’m not sure about this, but I think things changed after that. She never lived at home after graduation. She stopped asking for advice, and I was so surprised when she decided to move to a neighboring state for grad school. Maybe I shouldn’t have said I thought she should stay local for school, save her money, and live at home. She had made up her mind, and I remember she got angry and said I shouldn’t tell her what to do with her life. I was shocked. I was only trying to help. Since then, she bristles or gets angry at any suggestion I make.”

Melanie was feeling profoundly rejected by Barbara. She felt helpless to know how to relate to her and how to change the increasing negativity she felt from her daughter. She felt controlled and without any clear sense of why this was happening:

“I can’t ask questions without her getting enraged,” Melanie said. “I asked if she took my granddaughter to the doctor when she had a fever and she told me to stop butting in! I’ve asked her such innocuous questions, like ‘Are you planning a vacation?’ Or, ‘Are you thinking about sending the kids to daycare?’ Every time I ask a question, she accuses me of criticizing her. I don’t get it. I just want to be a part of her life. She doesn’t want to let me in. Worse, sometimes I think she hates me.”

It seemed to me Barbara’s individuation process had been delayed. I assumed that since there was little conflict with her parents during adolescence, Barbara’s “noes” and “yeses” were probably mostly shared by her parents. Thus, in adolescence, Barbara would have felt no need to differentiate her wishes and needs from those of her parents. Now, as an adult, she had no developed sense of self with feelings of autonomy. So she still needed to individuate and take ownership of the “yeses” and “noes” in her life. This would give her a sense of agency and self-confidence, enabling her to feel less threatened by her mother’s opinions, wishes, and needs. Differences between them would simply be differences, not cause for concern about losing herself to her mother’s influence. She would not have to be worried about being controlled because she would feel in charge of herself.

Melanie began to understand that Barbara equated connection with influence. She recognized that Barbara’s experience of being constantly criticized became the rationale for pushing Melanie away:

“I think I get it. If I ask a question, like did she take my granddaughter to the doctor, maybe she hears it as my opinion: ‘You should take her to the doctor.’ Or maybe, she hears it as ‘I don’t trust you to know what to do’ so then she feels criticized by me. I see she is fighting being influenced by me. It’s like if she lets me in, she loses herself. If she lets herself feel close to me, it threatens her sense of self. I don’t want to be in her life to control or influence her, I just want to love her and feel loved. How is that ever going to happen?”

Facilitating Individuation for the Adult Child

Melanie’s feelings of helplessness were palpable. She was developing an intellectual understanding of what was going on with Barbara, but it is quite another thing to find a way to change the dynamic between them so their bond could be restored. I made the following suggestions to Melanie:

• Be mindful of the content of your communications. Questions can be interpreted as criticism, shoulds, or judgments.
• Find an opportunity to talk to Barbara without being defensive, and tell her you want to hear how you can be a better parent.
• Let her know you respect and admire who she is and what she does in specific ways, e.g., “I love that you’re always reading to the kids,” “It’s great that you’re learning to play golf,” “Can I have your recipe for meatballs?” or “Your home looks so lovely.” These communications contain the idea (no guarantee that it will be interpreted that way) that you have positive and admiring feelings toward your child.
• Let Barbara control the amount of contact. She is engaged with you in a necessary separation-individuation process that was not resolved in earlier years. When it becomes resolved, she will have a more positive sense of self. This will enable her to develop a strong and loving attachment with you. Once Barbara is secure in the positive feelings of who she is, there will no longer be a reason to fear being unduly controlled or influenced.

Note: To protect privacy, names in the preceding article have been changed and the dialogues described are a composite.

“It’s like a mother: when the baby is crying,
she picks up the baby and she holds the baby tenderly in her arms.
Your pain, your anxiety is your baby.
You have to take care of it.
You have to go back to yourself,
to recognize the suffering in you.
Embrace the suffering, and you get a relief.”
—Thich Nhat Hanh

There’s some part in all of us that yearns to belong. This is our safety, our security. It means we can relax, that others are there to hold us, cherish us, praise us, and keep guard when we cannot. It means we matter.

When we’ve experienced a single relational disconnection, we generally recover. When it becomes a pattern—when someone who is “supposed to be there” for us finds ways to disengage or disappear on a daily basis—recovery feels intangible and unattainable. We make decisions about the self, saying, “I’m not wanted. I must be flawed.”

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Anxious Attachment Says: ‘You’re Not Giving Me Enough’

Those landing on the anxious side of attachment are often aware they are seeking others as a way to regulate their overwhelm. They may feel “clingy.” When living in this mode, many feel easily rejected or abandoned, becoming angry when partners fail to live up to perceived expectations. On guard, attuned to signs of others leaving, they easily fall into internal panic, exhibiting protest behaviors in often futile attempts to elicit caring responses. They may guilt or blame partners into submission, choosing to argue (and continue arguing) because it feels better than no connection at all, because preoccupation allows no other choice.

Many in this mode give up their own desires in attempts to win their partner’s approval, placing survival needs over authenticity. The “real” identity of their partner is often less relevant than the fact the partner presents as available just often enough for the preoccupied one to maintain an illusion of love. This can leave their partners feeling like disposable place-keepers, while for the anxious one, self-justification creates a paradoxical argument: “I would not put this much effort into someone who was not ‘the one.’ ”

Some have referred to this as “fantasy bonding”—in love with the idea of the person, often ignoring uncomfortable parts.

Many anxiously attached individuals recognize—in calmer moments, after the fact—they’ve been so involved with their own discomfort and dysregulation that they failed to catch unspoken emotional cues from partners that might have led to feelings of mutual connection and intimacy.

Anxious Relationship with the Self

Sometimes the panic itself becomes the enemy, and the anxious person develops strategies to hide or contain it, saying, “If others see this panic, they will leave me.” This message itself perpetuates internal conflict—self against self—amplifying pain as internal parts polarize.

While many, trapped in anxiety, function excessively in the presence of others (which can be perceived by others as demanding), when alone they may find tasks difficult to complete. Sometimes, in the absence of constant reassurance, they find their motivation dissolved. They may recognize an absence of perceived selfhood when not in the presence of another.

As familiar as the relational desperation becomes, they may find that when real intimacy is offered, they do not know how to be with it. It may fall flat. They may tell themselves they are just bored. They might distract themselves from it or sabotage it. It invokes too much shame, bringing to awareness parts of the self that they do not know how to meet.

Origins of Anxious Attachment

Many theories describe the creation of anxious attachment, citing both nature and nurture. One of the foremost frames the caregiver as someone overwhelmed by their child’s emotion. It might be a parent who appreciates or loves the baby while also feeling out of sync, helpless, as if there is no way to calm the baby. This is an unfortunate misattunement or inaccurate empathy. The baby, of course, gets more attention when crying, thus training it to use tantrums as a primary way to elicit attention and meet its security needs.

Another theory, one that could work in conjunction with the above: the caregiver who carries abandonment wounds actively (even subconsciously) creates dependence in their child, ensuring the child will need them and remain with them. The child of this parenting strategy is thus trained to remain a child, to take a dependent role in intimate relationships in order to get needs met.

Anxious Attachment in Conflict

Those on the anxious side of attachment fight in and for relationship, feeling incapable of calming until another person meets their needs for assurance. This often leads to long-term deterioration of the relationship as their partners learn to distance, placate, and resent rather than pursue seemingly endless conflict. This withdrawal by partners may perpetuate negative beliefs: “They are trying to leave me. I am not lovable. I have to make my emotion bigger to get a response.”

Open Letter from the Avoidant to the Anxiously Attached

I see your panic. I hear it in your breathing, your sighs, your many signs and gestures—the ones meant to elicit attention from me. I resent you in this mood because it means I lose a partner and gain a child. I become the parent. I become your “fix.” In your panic, my existence is no longer mine. I’m no longer free, whole, separate from you. With nobody in you to meet me, I am trapped and alone.

Your dependence becomes a weight for me to carry. It’s like a child in you with nowhere to go. Sometimes it feels like an insatiable bully, entitled, demanding I care for it. But it has no sense of time, and I could meet it for hours, resenting you each minute. And nothing changes.

I want to be loved, not needed.

Part of me also yearns to be taken care of.

Therapy for the Anxious: Bonding with the Self

In moments of interpersonal conflict, many of us switch to younger states. We disconnect from present-day resources, reacting not to partners but to parents. Even with adult partners, we return to perceptions, expectations, and strategies learned at an early age. We become the child in the empty room, feeling ourselves empty until it fills once again. Or we become the child playing in our room, safe, away from the needs or threats of others throughout the house, hoping no one comes to the door.

Invariably, in order to heal and decrease dependence on others, those on the anxious end of the spectrum will find themselves exploring ways to build an internal support structure—some part of the self that remains strong, dependable, unthreatened by intense emotion. This might be framed as “self-validation” or as an “internal parent.”

In the beginning, though, they naturally seek others—friends, partners, and therapists—to provide this support, validation, and witnessing. “This isn’t the way life is supposed to be,” they may say. “We are supposed to be able to depend on others.”

Some may recognize a resentment of the therapy work, even a shame in it. They may view self-sufficiency or self-soothing as a secondary strategy, only used when one fails to belong in the world. They may feel conflict internally and with their therapist, feeling blamed while also feeling victimized in relationship: “I’m the one who feels so devastated when people leave me. Yet you’re saying I play a part in that.”

Another Way to Frame Anxious Attachment

If we reframe “preoccupation” as the ongoing abandonment feelings of an inner child, we begin to differentiate from the part feeling the pain. This is important for the present-day adult who feels hijacked by emotions. It is also vitally important for the hurting child (or the old neural network that takes over) to have a compassionate internal witness.

If we reframe “preoccupation” as the ongoing abandonment feelings of an inner child, we begin to differentiate from the part feeling the pain. This is important for the present-day adult who feels hijacked by emotions. It is also vitally important for the hurting child (or the old neural network that takes over) to have a compassionate internal witness.

It’s hard to take ownership of the child inside, noticing that it reaches out to make demands of others—a natural next step when it finds no internal caregiver available.

There’s a message often internalized in childhood: the unspoken message from a parent saying, “I can’t handle this child! Let someone else take care of it.” It’s a message repeated internally when emotion is high, when the old state is triggered. Many in therapy eventually realize they actually hate the child in them. They hand this emotional part of the self out to others, saying to friends, families, and partners: “I can’t handle this child in me! It’s too much! You take care of it.”

It’s important to begin separating parts in this way, to speak of each in third person, to gradually hear the dialogue already occurring between them. This is differentiation, and it is a necessary component of self-soothing. We cannot witness a part when we are that part. It requires some distance. Effective witnessing requires the development of an internal “other.”

Developing internal parts is something most of us have already done many times throughout life. We’ve developed internal guards and gatekeepers—judges, parents. These are the parts that judge and contain us today.

We can also develop an internal witness—one that does not judge, is not threatened by any emotion, does not attack, pull away, pity, analyze, or try to fix. One that meets us with empathy and compassion to witness our pains and joys in the ways we always wished an other would.

An intentionally developed part is just as valid as the parts that developed automatically in life. The compassion and affirmation we can give ourselves is just as real and valid as the internal abuse we already trust. It’s all internal dialogue between parts of the self. In therapy, we are just making that dialogue more conscious and intentional.

Certain therapeutic approaches, such as Hakomi and Internal Family Systems, work precisely to create an internal environment of acceptance and unity, facilitating integration through differentiation of parts.

Some Final Points and Considerations

• Our own perceptions are less accurate when the body is in fight-or-flight mode. We easily catastrophize when activated. Mindfulness practice can increase present-moment awareness of our bodily activation level. When it gets too high, it’s okay to take a break, to step away from the argument, and to connect with resources to help your body calm. Life looks different on the other side of the nervous system.
• Another way to tell if you are activated: Can you hear someone’s “no” and not take it personally?
• It’s important to begin recognizing the elements of fantasy in your relationships. Do you want an equal partner? Are there moments you really do want to be taken care of? Most of us experience both.
• This struggle is common. It is human.
• Do you give up your own interests, ideas, ideals, and pursuits in order to keep a relationship?
• It’s okay to grieve the fantasy.

References:

1. Karen, R. (1998). Becoming attached: First relationships and how they shape our capacity to love. New York: Oxford University Press.
2. Kinnison, J. (2014). Type: Anxious-Preoccupied. Retrieved from https://jebkinnison.com/bad-boyfriends-the-book/type-anxious-preoccupied
3. Levine, A., & Heller, R. (2010). Attached: The new science of adult attachment and how it can help you find- and keep -love. New York: Jeremy P. Tarcher.

Dear GoodTherapy.org,

I’m a wife, mother of two, and have a great career in the legal field. I’ve been supporting my husband since we got married three years ago while he finished his degree, which he did nine months ago. The plan was for him to start his own career after he graduated, but he has had no success finding a suitable job and is quickly losing hope for finding work in the field he studied.

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He has a history of depression, and I think he is quite depressed. The only types of jobs he can get right now are for minimum wage doing things like janitorial work. He is unwilling to do that type of work out of concern it will kill his spirits and make it harder for him to get a job he really wants.

Instead of focusing what little energy he has on finding the job he wants, now he’s talking about going BACK to school to study something else with better career prospects. Needless to say, I’m not too keen on this plan, as I didn’t think I was signing up to be the sole breadwinner for the first five to seven years of our marriage, if not longer. It’s starting to feel like he’s taking me for granted and instead should be redoubling his efforts to put the degree he just attained to use.

I think he expects me to go along with his new plan. It’s true that I can afford to provide for the family by myself indefinitely, but that doesn’t sit well with me and it doesn’t feel fair or reasonable. I am afraid to bring up my true feelings about this out of fear it will worsen his depression and sense of hopelessness. His mental health seems precarious as it is.

He’s a good father despite not being my children’s biological dad. He’s a good husband, too, aside from this ongoing saga. I just don’t know what to do. I want to be with him, but I don’t know if I’m willing to go down this road again. I don’t want to resent him, but it feels, in a way, like I have three children. What do you think? —Sugar Mama

Dear Sugar Mama,

It sounds like you and your husband BOTH may be depressed, and you appear to be somewhat angry, too, about his inability to find a decent job and help support the family. I feel for you both. It’s hard to carry this load alone, as you have been doing for three years already. I imagine it’s hard for him to be carried by you, too, and to not be able to find suitable work.

I don’t know what kind of career he has in mind for himself, but it is true that some fields are slow starters. Maybe he’s thinking he made the wrong choice for himself professionally and wants to correct this mistake. Maybe you’re thinking you made the wrong romantic choice and want to correct that, too. At the very least, you feel burdened.

You are afraid to talk to your husband about your fears. I understand your concerns, but communication is a top priority in a deep relationship. Learning how to discuss difficult things together is part of learning how to get along with each other. It will serve your relationship well both now and in the future.

Despite his real problems work-wise, you state he is a good father to your children, even though they are not biologically his, and he is a good husband to you. These are priceless gifts. His ability to be caring, loving, and nurturing are important contributions to a happy family life.

You are afraid to talk to your husband about your fears. I understand your concerns, but communication is a top priority in a deep relationship. Learning how to discuss difficult things together is part of learning how to get along with each other. It will serve your relationship well both now and in the future.

I wonder if you have each considered counseling. Your husband might benefit from consulting with a career counselor, and it sounds like you both could benefit from couples counseling and perhaps individual therapy, too. Your family seems strong aside from this issue, certainly worth working to save, in spite of your resentful feelings. Love is a great and important gift. If talking this through with your husband (with or without a counselor present) would help preserve your marriage, consider it an investment in your family.

This is a decision you must make together. If you both want to stay together, or if you’re deciding on perhaps parting, please act to find counselors or social workers who can help you with this choice. Professional help can allow space and clarity to make any important decisions.

Marriages need to be cared for by both partners, but sometimes outside circumstances don’t favor family life—in fact, it can seem like they conspire against you. I hope you’ll do everything you can, together, to prevail. Silent resentment never works.

Good luck and take care,
Lynn