When parental involvement is limited, children typically receive scant mirroring or encouragement. They have no one reflecting back to them that they are worthwhile, admirable, or interesting. When parents are over-involved, their excessive control over how their children define themselves in the world provides few opportunities for the child to self-reflect and have his or her own positive thoughts and feelings. In both cases, the development of self-confidence and self-esteem are compromised.

At the age of 25, “Carol” came to therapy feeling depressed and anxious. She had little sense of what she wanted for herself in life and no belief that if she knew what she wanted, she had what it took to get it. She had been a sociology major in college and was now working as a salesperson in a women’s clothing boutique; she had a few girlfriends and dated very occasionally. Tearfully, Carol told me, “I am so unhappy. I look around and see other people my age having fun, loving their jobs, feeling good about themselves. I feel like such a nothing. I don’t have a clue about what I want to be when I grow up. I’m scared to death when I go on a date that the guy will find me stupid and boring. I feel so awkward and uncomfortable around people.”

I asked Carol about her family. “My parents were divorced when I was 8,” she said. “My father remarried a year later, and I lived with my mother. I saw my father and his wife every other weekend at first and then less and less. My mother never remarried, but she was married to her job. I didn’t see her much since she always seemed to be working. I had a lot of babysitters when I was young. I had no siblings and was by myself a lot. Maybe from middle school on, I didn’t have many friends, so I would just go home by myself and watch TV. I was an average student, but really, I guess I was apathetic. Sometimes I think I’m smart; I don’t know. I didn’t care much about anything.”

Sounding sad and angry, Carol continued: “As long as I went to school and got Bs and Cs, my mother didn’t say much. She never helped me with my homework. She never asked me about my life. She was cheery and not mean, but not very involved. My father became mostly a phone call. He paid for my college but was totally uninvolved. I talked to the guidance counselor and chose a bunch of colleges to apply to, but really, I didn’t care much. I was kind of scared to go away on my own, but I never told anyone. I got through college OK, but it wasn’t any different than life before. I had a couple of friends, but I didn’t get involved much. I don’t know what else to tell you. There really isn’t much of interest about me or my life.”

“Sally” was also an only child who, unlike Carol, had parents who doted on her. She was a high achiever in school, which earned her substantial praise and admiration from her parents. When Sally came to therapy at age 23, she, too, was depressed and anxious. When I asked Sally to describe her family, she told me, “I have a very close relationship with my parents. I love them so much and rely on them for everything. They are always there with their ideas and opinions and suggestions. It’s very confusing to me that I feel so miserable so much of the time. My parents are such cheerleaders for me; I don’t know why I don’t feel better about myself.”

Over the many months that Sally and I explored her negative feelings about herself and her lack of self-confidence, a pattern of relationship between Sally and her parents began to emerge. It was quite clear that Sally’s parents were very engaged with her life and always had been. Sally related, “When I was in elementary school, my parents would simply beam when I told them my grades or the compliments I got from teachers. They were very hands-on. When I wanted to take music lessons, my mother, a musician herself, discouraged me, saying that it wasn’t something I really excelled at, so why bother—it would only make me feel second rate. They had definite ideas about what I should do and guided me about everything. When I wanted to join the swim team, my father convinced me it wasn’t a good idea because I wasn’t a top-notch swimmer. I remember feeling a little badly, but I figured he knew best.”

Sounding proud of her parents’ involvement, Carol told me, “Both my parents helped me plan my college education. They chose the college, and we all agreed that I would go on to law school after graduation. Somewhere in college, I started to get depressed and I couldn’t think about law school. I would tell them I was feeling down, and they would say how that didn’t make sense, that I had so much going for me. I know they wanted what’s best for me. I really didn’t want to go to law school when I graduated, but they told me it was foolish, I would make a great lawyer. I didn’t think so, but it’s so confusing because I’m clueless about what I do want to do. I have no real idea of who I am. I am my parents’ daughter, but I guess I don’t feel like my own person.”

Both Carol and Sally experienced severe low self-esteem and lack of self-confidence. For Carol, the emotional absence of her parents from her life, and the minimal appreciation and recognition they offered, contributed significantly to her inability to develop a separate self with feelings of value and confidence. Without the experience of parents responding to a child’s spirit and achievements (whether taking first steps, laughing at their jokes, making a diorama, or going on a first date), children are deprived of the building blocks for self-confidence and self-esteem. To feel “I can do it,” or even more important, “You are proud, pleased, and delighted with me,” is a crucial experience that Carol never had.

A parent’s pleasure at a child’s achievements and with the person becomes a platform from which a child ventures out into the world with the knowledge that he or she will be OK. Sally’s parents seemed to convey a total belief in her ability to be successful in the world. Or did they? Sally’s experiences and choices in the world were overseen by her parents, who communicated they always knew what was right for her. Feeling protective, they tried to eliminate anything that might cause Sally frustration or feelings of being less than excellent. However, they never gave her the emotional space to make her own choices, to make mistakes, and to learn that she was resilient. The only way she knew how to assess and think about who she was and how she was doing in the world required reliance on her parents’ view of her. As Sally and I talked, it was clear that she couldn’t rely on herself or her peers in decision making, or even to feel good about herself. It was not surprising that Sally hadn’t developed the ability to think about herself as an individual separate from her parents or to know what she wanted to do with her life.

For both Carol and Sally, talking in therapy opened up new possibilities for thinking about self. Carol became aware of her anger toward her parents and realized that blaming them was keeping her from taking charge of herself in the world. After expressing much resentment and sadness about the experiences she missed out on since childhood, Carol started to push herself and risked trying new things. Even though it made her anxious, she went online and began dating. She decided to try and reconnect with people who were “almost” friends in college. She started to talk to me about taking some courses to explore some possible career paths. It was scary, and each step caused great anxiety. But each success added to her feelings of self-worth and self-confidence.

Sally started to recognize that she had been idealizing her parents and is slowly becoming more comfortable with seeing them as humans with frailties. This allows her to accept her own lack of perfection and tolerate the frustration of trying new things and not easily succeeding at them. She has been calling her parents less frequently and risking making decisions on her own. She has also been sharing more with friends, something she didn’t do in the past. She is clear she doesn’t want to go to law school and has been considering going back to school to become a teacher.

The self-esteem and self-confidence of both women were affected by the over- and under-involvement of their parents. While it helps that children know their parents are there to support them practically and emotionally, parents also need to be comfortable stepping back to allow their children to make decisions, struggle, fail, and succeed. This balance between providing support and giving children the freedom to discover their own individual desires, strengths, and weaknesses is the basis of how children develop self-confidence and self-esteem.

Research has shown that people with attention deficit hyperactivity (ADHD) have cognitive and functioning deficits. They often have high levels of impulsivity and low levels of task attention. These deficits can result in social, personal, and academic difficulties. In the study of ADHD, numerous strategies have been tested to improve attention and decrease impulsivity. Among them are behavioral and cognitive approaches, some of which have been shown to be successful.

But an existing theory at the core of ADHD research is that of reward motivation, which suggests that people with ADHD respond better and demonstrate less impulsivity and more attention when rewarded compared to when there is no reward for a task. To test this theory further, Ivo Marx of the Department of Psychiatry and Psychotherapy at the University of Rostock in Germany recently recruited 38 adults with ADHD and 40 without ADHD for a controlled experiment. In the experiment, the participants underwent a battery of cognitive tests with and without rewards. The response times, false positives, impulsivity rates, and overall performances were measured and compared.

Marx found that the individuals with ADHD exhibited higher levels of impulsivity and lower levels of attention when there was no reward present. However, when a reward was offered, they were less impulsive and their outcomes had fewer false positives. In other words, their performance was better and far improved in the presence of a reward. In fact, the participants with ADHD performed similarly to those without ADHD when they were motivated by a reward.

Marx believes that these findings, which are in line with existing research, underscore the importance of reward motivation for people who tend to be impulsive. The results suggest that perhaps being motivated by a reward encourages individuals with ADHD to slow down their reaction times and engage a “stop-and-think” strategy. Additionally, these results show the importance of such a strategy for improving outcomes for cognitive tasks. This could be extremely useful at helping ADHD individuals improve their cognitive outcomes in various settings, including personal, academic and professional arenas. Marx added, “Taken together, our results support the existence of both cognitive and motivational mechanisms for the disorder, which is in line with current models of ADHD.”

Reference:
Marx, I., Höpcke, C., Berger, C., Wandschneider, R., Herpertz, S.C. (2013). The impact of financial reward contingencies on cognitive function profiles in adult ADHD. PLoS ONE 8(6): e67002. doi:10.1371/journal.pone.0067002

“I am indeed rich, since my income is superior to my expenses, and my expenses are equal to my wishes.” —Edward Gibbon

Self-love, self-respect, and self-compassion are all helpful when it comes to creating inner balance and a healthy outlook. They are also prerequisites for a good relationship with money. Interestingly, one’s relationship with money often mirrors one’s relationship with oneself, as changes in either affect the other. So, if you decide to do some financial house cleaning, you will reap rewards in increased self-confidence, self-respect, and self-compassion.

Let’s take a closer look at how that actually plays out. If you are saddled with debt, for example, you can easily feel stressed, self-doubting, insecure (both financially and emotionally), strained in your relationships, and limited in future plans. Luckily, though, there is something you can do about your fiscal situation, and it’s far easier than you might think. Read Your Money or Your Life by Vicki Robin and Joe Dominguez; there is an updated version (2008) and the original (1999), both of which should be available at your local library. It is a quick, easy read that has the power to change your relationship with money. Unlike many books preaching financial freedom, this one really shifts your perspective on some essential levels. In other words, it is not about investing—it focuses on day-to-day choices and how they impact your present and future financial life.

Let’s take one example of how financial neglect can have deleterious effects on mental and fiscal health. We all know people who say they never balance their checkbook, which is fine if it works for them. However, I think a balanced checkbook can mirror a greater feeling of balance in other areas of life, as it can be one more area that feels under control. You can’t control whether your boss fires you, if the stock market falls, or whether you suddenly get sick; however, you can decide to consciously manage your money by taking the reins of your spending habits. Every dollar you don’t spend translates to less money you need to make, which lowers your stress level.

It is amazing how modern-day life has made past luxuries into necessities. I am certainly not exempt from these societal shifts, whether it is eating chocolate daily, watching what I want when I want from Netflix, or simply doing yoga any time of day or night. And I take all these luxuries for granted. That said, the chocolate doesn’t break the bank, I subscribe to Netflix because I cut my cable years ago and bought a Leaf antenna for a one-time fee of about $35 (which saves me a small fortune yearly), and my subscription to My Yoga Online costs me only pennies per class. The point is, by making some minor changes, I cut my expenses and still enjoy three daily pleasures. With just a little forethought and intention, it is possible to live well for less.

As counterintuitive, and almost shocking, as this next tidbit might seem, there is anecdotal evidence that doing your finances will relax you. Again, it is probably the increased sense of control and mastery that accrues as you handle your money in ways that provide more choices and fewer unknowns.

Paradoxically, among those choices is giving more away. By now, most people are familiar with the studies that show a greater sense of well-being comes from being charitable. The same pleasure centers light up in the brain when you are being generous as those that light up for food and sex. It need not be writing a check—it could be volunteering or simply giving things you aren’t using to people who need them. By developing a regular practice of sharing, you will not only be helping others, but getting an endorphin high and clearing out some clutter, leaving more space for all that lovely energy to flow.

Getting back to the original concept, the more you keep your fiscal house in order, the more you will feel self-loving, self-respecting, and self-compassionate. That, coupled with a slightly different spin on your true wealth, will help you resist impulse buying (no small feat in our current point-click-buy Internet culture), and encourage you to take joy in saving, planning, and consciously choosing your purchases.

Note: Much debt in America these days is from health expenses that most people simply can’t afford no matter how diligently they might have saved. Naturally, this article is not directed at fellow travelers in those challenging and anxiety-provoking situations.

Great question—simply and clearly put—and I enjoy thinking about it. Thank you. I’m afraid my answer is going to be pretty long, though, because the question touches on a variety of issues.

Let’s start with the difference between secrecy and privacy. I’d like to keep my weight private. But if I wear a body stocking sometimes, that’s my secret because I’m a little ashamed about it. Someone else might not be. The contents of my email are private and I don’t want my husband to read them—even if I don’t keep any deep and dark secrets from him. My diary is private, and may contain a few secrets too; I don’t want anyone to read it. Sometimes privacy and secrecy overlap. Clearly, what’s private and what’s secret varies from one person to the next, but the development of boundaries of what is private grows with a child’s increasing independence from his or her parents. A child might ask the therapist, “Can I tell you a secret?” but really mean “Can I trust you? Can I tell you something that you will keep private?”

Privacy between people, called confidentiality when it refers to communications between therapist and client, is a prime value in therapy—the therapist under most circumstances must keep everything said in session private so the client can speak freely. This rule is a bit different when working with minors.

First off, there are legal issues which apply to minors in therapy. Minors are unable to consent to treatment; their parents consent on their behalf. There are exceptions to this (minors who are married or in the armed services), but generally anyone under the age of 18 is not legally able to make treatment decisions. A parent who consents to treatment for a minor child has the legal right to know the content of the child’s treatment. For more information, please consult this American Psychological Association page: http://www.apa.org/monitor/mar02/confidentiality.aspx. Reports on content may be more or less detailed, depending on the agreements the parents, child, and therapist have made with one another. Often, a general sense of progress or lack thereof is reported; specifics may not be.

Privacy issues in clinical practice are not as clear as the legalities are. The child needs privacy, and needs to be able to speak freely and know that the parents will not be told about what is said, in order to foster independent growth. Children’s needs for privacy grow as they mature, and the therapist might encourage the child to develop personal boundaries about what the parents (and others) should know and what they do not need to know—what should be kept private. This seems to conflict with the law.

To preserve clarity, remain within legal boundaries, and protect the child /client, therapists should make clear at the outset of treatment what the therapist’s relationship will be with the child and with the parent and how information will be shared—in short, who will know what and when. Clearly, as the child matures this will change—people need more privacy as their independence and individuality develop. When this happens, the therapist will meet with parent and child to explain that the structure previously agreed upon must be adjusted.

At the same time, the therapist cannot promise the child that all information will be kept private if it is felt helpful to the child to tell the parent. If the therapist feels the parent may harm the child as a result of information the therapist might report, the therapist should seek legal advice. The therapist is mandated to report indications of possible harm to the client or others; neglect or abuse must be reported in most states. This applies to both children and adults.

All my best,
Lynn

Electroconvulsive therapy, sometimes called shock treatment, has been the subject of controversy for generations. Decades ago, ECT was sometimes administered involuntarily, but current ECT treatments are voluntary and much safer. ECT is one of the most effective treatments for treatment-resistant depression, but its results are unpredictable and the side effects can be troubling. Some people, for example, experience long-term memory loss after undergoing ECT.

Fortunately, if you’re experiencing treatment-resistant depression, ECT is only the most popular option, not the only one. Something as simple as a new therapist or medication could make a big difference, and if those don’t work, there are several other ways to compel your brain to stop making you feel depressed.

New Treatment Plan

ECT and treatments like it are therapies of last resort. If you’ve tried only one medication or therapist, it’s not time to give up just yet. Instead, try modifying your treatment plan or treatment team. If you’re doing interpersonal therapy, for example, you might try switching to a therapist who specializes in cognitive behavioral therapy. If your medication isn’t working or the side effects are too much to tolerate, it’s time to switch to something else. Educate yourself before you choose a treatment team, and ensure that the methods your treatment team is using have been proven effective.

Vagus Nerve Stimulation

A vagus nerve stimulator is a lot like a pacemaker for your brain. The device has to be surgically implanted, and uses tiny electrical shocks to stimulate your vagus nerve. This treatment has been used for years in people with epilepsy, and some doctors are now using it in people with depression. Studies are inconclusive about its effectiveness, but if you want to avoid ECT, VNS can be a less frightening option.

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation uses an electrical coil to produce electrical activity in a targeted area of the brain. The effects are similar to ECT because TMS electrically stimulates the brain, but preliminary studies indicate that there might be fewer side effects with TMS. However, the Food and Drug Administration advised against the marketing of a TMS device in 2007, arguing that it had not been proven effective.

Experimental Treatments

Experimental treatments are not currently available or are available only to those participating in treatment studies. However, in a few years, some of these treatments might be available to the general public:

• Some studies have indicated that ketamine—a veterinary tranquilizer that is sometimes used recreationally—may help alleviate symptoms of depression and some other mental health conditions.
• Magnetic seizure therapy is similar to ECT because it induces a seizure in the brain. It does not, however, require an electric current to be administered directly to the brain.
• Deep brain stimulation has shown promise in the treatment of neurological conditions such as Parkinson’s. Much like vagus nerve stimulation, deep brain stimulation works by implanting a device in the brain that sends electrical impulses to areas of the brain that affect mood.

References:

1. Brief summary from the neurological devices panel meeting. (2007, January 26). U.S. Food and Drug Administration. Retrieved from http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/ucm124779.htm
2. Hampton, T. (2006). Ketamine for depression. JAMA: The Journal of the American Medical Association, 296(12), 1458-1458. doi: 10.1001/jama.296.12.1458-a
3. Mayo Clinic Staff. (2011, August 23). Treatment-resistant depression. Mayo Clinic. Retrieved from http://www.mayoclinic.com/health/treatment-resistant-depression/DN00016
4. Treatment-resistant depression. (n.d.). WebMD. Retrieved from http://www.webmd.com/depression/guide/treatment-resistant-depression-what-is-treatment-resistant-depression

Women face overwhelming pressure to meet an often unrealizable “beauty” ideal. The result is that 80% of women report being unhappy with their appearance, and three-quarters of all women engage in some form of disordered eating such as crash dieting or skipping meals. Many companies have capitalized on this trend, offering a veritable cornucopia of products designed to “fix” women’s perceived flaws.

The advertisements for these products, however, frequently leave women feeling bad about themselves, particularly when images in these ads contain unrealistically “perfect” women. The overwhelming majority of cosmetic and clothing advertisements are digitally enhanced. Even Beyoncé fell victim to this practice, often called photoshopping, getting into a public dispute with H&M in early 2013 when the clothing retailer altered images of her modeling swimwear. But women are increasingly aware of the effects of digitally manipulated advertisements, and some retailers are abandoning the practice of presenting women with unrealistic images.

Photoshopping and Other Tricks

Although women continue to be bombarded with unrealistic—and perhaps even fake—images of models, the tide is slowly turning against photoshopping. Debenhams, a major British department store, recently announced that it will no longer manipulate images, even releasing photos demonstrating the “before” and “after” effects its previous photoshopping efforts had on models’ appearance. The National Advertising Division, an organization that makes recommendations for advertisers, has advocated for an outright ban on photoshopping in cosmetic advertisements.

Advertising tricks aren’t limited to photoshopping, though. The right lighting, heavy makeup, and clever clothing placement can leave models looking very different from how they look in real life. Some tricks mislead women about the effects of products featured in advertisements. Mascara manufacturers, for example, may resort to the use of false lashes or lash extensions to make the product look much more effective than it actually is. Women who buy the product are then left feeling like there’s something wrong with them because they can’t look like the model in the advertisement.

The Effects of Advertisements

Numerous studies have documented the negative effects that advertisements have on women, even when women know the ads have been altered. Women feel worse about themselves, for example, after reading advertisement-laden fashion magazines. Some women even resort to cutting out photos of extremely thin models as “thinspiration” for crash diets. According to research by sociologist Jean Kilbourne, regular exposure to advertisements can contribute to internalized sexism. Women may begin to see their appearance as the primary source of their worth, neglecting other interests in favor of the perpetual pursuit of aesthetic perfection.

Keeping Self-Esteem Intact

Even if photoshopping is banned, women will be exposed to images of models who have been heavily made up, who benefit from excellent lighting, and whose appearance differs substantially from the average woman. Although this practice can feel unfair and even overwhelming, women can take steps to empower themselves and avoid the self-esteem-crushing effects of unrealistic ideals. These include:

• Avoiding magazines that are focused primarily on beauty or that contain a lot of advertisements
• Turning off the television during commercial breaks
• Contacting retailers and cosmetic manufacturers to complain when advertisements are misleading or psychologically damaging
• Focusing on health and physical fitness rather than weight loss
• Critically evaluating claims made in product commercials and ads
• Focusing on valuing the self for personality traits rather than appearance
• Steering conversations with friends away from diets, makeup, and body shaming

References:

1. Edwards, J. (2011, December 16). US moves toward banning photoshop in cosmetics ads. Business Insider. Retrieved from http://www.businessinsider.com/us-moves-toward-banning-use-of-photoshop-in-cosmetics-ads-2011-12
2. ExtremeTech. (2011, December 16). US Watchdog Bans Photoshopping in Cosmetic Ads. Retrieved from http://www.extremetech.com/extreme/109375-us-bans-photoshop-use-in-cosmetics-ads
3. Grey, J. (2013, May 30). Beyonce outraged that H&M intended to photoshop her bootyliciousness. Business Insider. Retrieved from http://www.businessinsider.com/beyonc-outraged-at-hm-photoshop-2013-5
4. Helping your daughter see through advertising. (n.d.). Discover Your Daughter. Retrieved from http://www.discoveryourdaughter.com/for-your-daughter/self-esteem/helping-your-daughter-see-through-advertising
5. Kilbourne, J. (2000). Can’t buy my love: How advertising changes the way we think and feel. New York, NY: Simon & Schuster.
6. Ross, C. C., MD. (n.d.). Why do women hate their bodies? Psych Central.com. Retrieved from http://psychcentral.com/blog/archives/2012/06/02/why-do-women-hate-their-bodies/
7. Three out of four American women have disordered eating, survey suggests. (2008, April 23). ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2008/04/080422202514.htm
8. Women’s magazines and the cult of hypocrisy. (2012, July 5). Women’s Media Center. Retrieved from http://www.womensmediacenter.com/feature/entry/womens-magazines-and-the-cult-of-hypocrisy

Choices have consequences. Seems obvious, right? Choose well and we get to enjoy the positive consequences. Choose poorly and we usually suffer the negative consequences. Often the consequences—good or bad—teach us lessons or reinforce what we already believe. Generally, when we accept the consequences as natural results of our choices, accept responsibility for them, learn what we need, and move on, we can feel remarkably at peace about even some of our seemingly poorest choices. What I often see in my practice are the ways in which people get stuck in a place of judgment, often punishing themselves above and beyond the natural consequences of their choices.

I see this dynamic play out regularly. There’s a cycle of choice-consequence-judgment that perpetuates unhealthy beliefs and attitudes. For example, I had a client share with me a story about a dinner out with a friend. The friend wanted to order a particular dish to share, but my client knew that this particular dish, while delicious, would probably make her feel sluggish and headachy in the morning. She was torn. On one hand, she wanted to be accommodating, and the dish sounded really good. On the other, she wanted to take care of herself. She ordered the dish.

In the morning, as predicted, she felt sluggish and headachy. That could have been the end of the story. She knew what consequences that choice would bring, weighed them against the pros of ordering something that would taste good in the moment, choosing something that could be shared with her friend, and avoiding feeling like she was “difficult”—something that doesn’t feel good to her. She made her choice; she suffered the consequences. Done. Except it wasn’t. To all of that physically icky feeling, she then added a layer of judgment. These thoughts included, “I’m weak-willed. I can’t believe I did that. What’s wrong with me that I can’t make better choices? I’m a terrible person. I will never learn/get better/make good choices.” She came to see me feeling lousy both physically and emotionally.

[fat_widget_right]

This is but one example of many I see on a daily basis. People who make ostensibly poor choices kick themselves when they’re already down. It is not fun for them. It’s demoralizing. More importantly, it is unnecessary.

The truth is we all make poor choices sometimes. We do things we know aren’t great for us. We know that the consequences aren’t likely to be great. We may have very compelling reasons for making those choices. We might not—we might just do/say/eat something simply because we want to. As long as these activities don’t threaten significant permanent physical or emotional damage to ourselves or those around us, those choices truly are ours to make. If we own those choices, if we are deliberate about choosing and accepting the consequences, there is no need for the shame that comes with self-judgment.

So why do we do it?

A few months ago, I wrote a piece on “should” and how it contributes to anxiety. The should messages we tell ourselves generate feelings of dissatisfaction and, often, self-recrimination. Somehow we are not meeting the expectations we or others have set for ourselves. The choice-consequence-judgment cycle fits into this model. We feel we “should” know better somehow. We should always make the “right” choices. We are not able to simply accept that sometimes we make choices that don’t work so well for us. We are not able to see the value in making mistakes or the opportunities to learn from negative consequences. Somehow we’ve internalized the message that we must be right/perfect/good all of the time—even when we are trying something for the first time. Not being right/perfect/good somehow means that we are less than, are weak, are failures. Making poor choices feels like the end of the world. We create meaning to explain those choices—repeating messages we’ve heard or created along the way (I am lazy, I am weak, I’m irresponsible …). We spend a lot of time looking for excuses for those choices, sometimes putting the blame and responsibility outside of ourselves because blaming others feels more palatable than blaming ourselves. When we do blame ourselves, we look for defaults in our characters to explain why we chose the way we did.

Fortunately, we don’t have to do this. There is something tremendously empowering about owning our choices and accepting the consequences. If we weigh the pros and cons of our choices, understand the potential consequences, and accept what comes, we are the agents of our own lives. If we view our choices as intentional actions, expressions of want, not something we passively stumbled into, or worse—attempted to avoid, but were overpowered by—we no longer cast ourselves as victims, helpless in the face of overwhelming pressures. We learn that, next time, we can make a different choice, or even the same choice, for that matter. We learn we have the power to change. We allow ourselves to move forward and on to the next opportunity to choose.

On more than one occasion, previous clients have asked if we could remain friends during or after our therapy sessions. While I could envision being friends with some of my previous clients if circumstances were different, I usually refrain from doing so and explain why I don’t encourage it.

As clients, it’s wonderful when your work with therapists has developed a strong sense of trust and safety over time. You have successfully been able to open up, gain more insight, and work through the primary issues for which you initially chose therapy. Perhaps you saw the evolution of talking about intimate details to a virtual stranger who then became what feels like a friendly confidant.

Good therapists with appropriate boundaries often do not view the evolution and closeness of the change in the therapeutic relationship with the potential for a friendship after therapy concludes, as some clients may. It is not that therapists wouldn’t like there to be a friendship in some instances. Nor does it mean they don’t care about or are indifferent toward their clients.

Therapists are usually not friends with their clients for two reasons:

1. To maintain objectivity in the clients’ best interests
2. To avoid conflicting dual relationships.

While some dual relationships are inevitable, ethically and legally therapists must evaluate and avoid dual relationships that harm or hinder the work with their clients. Therefore, other types of relationships that evolve during or after the therapeutic relationship are not normally encouraged. As an example scenario, let’s say you are hosting a dinner and wine tasting party at your home, and invite your therapist to meet your new significant other. Your therapist declines, and you feel angry. How will this affect your next session? Will it affect whether you decide to show up or not?

In another scenario, maybe you have successfully terminated your sessions, and somehow remained friends with your therapist. But what if another issue comes up for which you would like to resume therapy? The nature of the relationship would then be clouded and the boundaries unclear.

The therapeutic relationship is not a symmetrical relationship where there is mutual sharing on both sides. There is a natural imbalance. While a good therapist is a caring and empathetic person who you feel became a friend, he or she is also an authority figure to whom you are choosing to turn for professional help and support.

In friendships, there is normally a two-way dynamic in which both parties get to know each other and can mutually share vulnerable information about themselves over time. In the therapeutic relationship, the client primarily holds the role of sharing vulnerable information with the therapist. The therapist does not usually do so in turn, especially on the clients’ time. When personal issues come up for therapists, they will often seek consultation, supervision, and even their own therapy when needed.

The role of therapists is to serve their clients through listening, empathizing, mirroring, offering a different perspective, and assisting their clients gain more insight into their situations and their reactions. They help their clients with coping skills and equip them with tools to deal with their situations or relationships in a healthier manner. The therapist focuses attention on the primary issues a client is struggling with, rather than the other way around.

It is never the responsibility of the client to take care of the therapist or to solve an issue a therapist is struggling with in his or her personal life. This is one of the primary reasons developing a friendship with your therapist outside the appointed session time is not highly encouraged.

Most good therapists generally care about their clients tremendously and want to genuinely see them improve. In order to do so, they will keep the therapeutic boundaries clear and intact.

I’m so impressed with you! First of all, in spite of your fear of being judged, you have taken the very courageous step of writing in with your question. Second, it sounds like the daydreaming and fantasizing have served as a very adaptive behavior—you have been able to get some relief from the depression and low self-esteem by escaping into your imagination. Unfortunately, it seems like this coping strategy has taken on a life its own and become somewhat of an impediment to your ability to function in your daily life.

In some ways, what you are describing isn’t completely dissimilar to how substance-abuse issues can develop—someone is in discomfort, seeks relief in alcohol or drugs in order to escape the discomfort, and ultimately comes to depend on the substance to an extent that it interferes with life. That said, one critical difference between what you are describing and substance abuse is that there is quite likely some real value in what you are using to escape. Most successful people begin their journey toward success by imagining it—they dream about their success and then they begin creating goals (and working toward them) that will move them toward their dream. I suspect that the life you have created in your imagination is closer to the life you desire than your actual, current life is. If my suspicion is accurate, then it makes sense to do what you can to start moving toward the life you have imagined for yourself.

Given your struggles with depression and self-esteem, you might be thinking: easier said than done! This is certainly true, but it does not mean that it is impossible to live a life closer to the one you imagine; it simply means that you need to get treatment to address the depression and self-esteem. Right now, these issues might be all that is keeping you from working on making your fantasy life a reality.

This brings me to your fear of disclosing your fantasy world to a therapist. First, there is no shame in the fantasy life that you have created; in fact, I believe it will ultimately serve as a road map to move you to the life you have been dreaming about. However, if you are still feeling anxious about sharing this world with a therapist, know that you don’t have to in a first, second or even third session. In fact, I would say if disclosing it is so anxiety provoking that it is preventing you from seeking treatment, do not disclose it until you are confident that you have a trusting, therapeutic relationship with a therapist. Sometimes when people disclose too much before a really strong working alliance is established, they feel exposed and vulnerable to an intolerable degree and they leave therapy prematurely.

You can avoid this by finding a therapist who you believe could be a good fit for you and setting up an initial session. You might even set up an initial session with a couple of different therapists and see who you feel most comfortable with. Once you believe you have a good match, work on building a strong therapeutic relationship and when you feel ready, open up about your fantasy life. As the depression and self-esteem issues begin to be addressed and you open up about your fantasies, you just might find that these very fantasies will become your road map and your therapist will serve as a supportive guide as you follow the map to your dreams.

All my best,
Sarah

But in his new book, What Do Women Want?, New York Times journalist Dan Bergner argues that women might actually find monogamy more challenging than men—and studies backing this claim are beginning to pile up.

Older Studies

Sex researchers often point to studies to prove that men crave novelty more than women. One popular study presents a college student with an attractive stranger and then asks the student if he or she would be willing to have no-strings-attached sex with the stranger. Unsurprisingly, men are more likely to say yes to the tryst than women. But critics have argued that these studies neglect important cultural factors. Women, for example, might be afraid of being alone with a stranger or feel ashamed of their sexual desires. Without controlling for these issues, self-reports don’t provide much insight.

Sex and Culture

The belief that men are more sexual than women hasn’t always been so popular. In the Victorian era, for example, mental health researchers argued that women were much more sexual than men, and women were more likely to be diagnosed with hypersexuality than men. Religious texts present stories of promiscuous women, and sometimes portray women as the more sexual sex, advocating for measures to control women’s sexuality.

Beliefs about sex and sexual behaviors are heavily influenced by sex. In a world where women are penalized for enjoying sex or behaving in a promiscuous fashion, they may be less likely to express sexual desire. And when men are told that they’re more promiscuous or sexual than women, it may serve as a self-fulfilling prophecy.

Recent Research

Recent research is calling conventional wisdom about monogamous women and promiscuous men into question. One recent study, for example, found that women were more aroused by fantasies involving sex with strangers, and a second showed that women favored pornographic images that were novel over those that were familiar.

Losing Interest

Bergner emphasizes that women are more likely to lose interest in sex with their partners than men are, and argues that this may mean monogamy is harder for women than for men. The fact women lose interest in sex has often been used as evidence that they’re less sexual than men. However, it could be that they’re simply less interested in sex with their partners and still entertain an active fantasy life involving new partners. Statistics on infidelity vary, but women and men usually have similar rates, and some studies even claim that women cheat more often than men.

Future Research

Scientists have long sought the holy grail of sexuality treatment: a pill that will increase women’s sexual desire. Some women’s advocates have argued that the fact there’s no female equivalent of Viagra is the product of cultural influence; many women are desperate for something that can bring their libidos back. But it may be that the issue has little to do with biology and everything to do with boredom. Research into how to recharge sexual desire in a stale relationship could be the next step toward helping both men and women maintain satisfying sex lives in monogamous relationships.

References:

1. Bergner, D. (2013, May 26). Unexcited? There may be a pill for that. The New York Times. Retrieved from http://www.nytimes.com/2013/05/26/magazine/unexcited-there-may-be-a-pill-for-that.html?pagewanted=all
2. Dawson, S. J., Suschinsky, K. D., & Lalumière, M. L. (2013). Habituation of sexual responses in men and women: A test of the preparation hypothesis of women’s genital responses. The Journal of Sexual Medicine, 10(4), 990-1000.
3. Marcotte, A. (2013, May 23). Women struggle with monogamy more than men. XX Factor. Retrieved from http://www.slate.com/blogs/xx_factor/2013/05/23/nytimes_on_lybrido_women_get_bored_with_monogamy_faster_than_men.html
4. Valenti, J. (2009). The purity myth: How America’s obsession with virginity is hurting young women. Berkeley, CA: Seal Press.

In a world increasingly centered on a work culture, it can be nearly impossible to fit in quality time with your significant other. An ever-increasing list of chores, stressful jobs, and demands from family, children, and friends can cause your relationship to slide to the back burner.

The challenges of juggling your schedule and your relationship can become even more daunting if you and your significant other work at different times. Freelancers might be perpetually on call, while a partner who works the night shift might struggle with chronic exhaustion. Managing conflicting schedules doesn’t mean giving up on your relationship, though. With a little ingenuity, you can have plenty of quality time together.

Creating a Family Schedule

Creating a goal list and scheduling your day can help you achieve work-related goals, but you can adopt the same system for scheduling time with your partner. Rather than hoping to get some time together when you both have a free moment, try actively scheduling time together and planning activities. Scheduling allows you to anticipate how long a particular activity will take, and encourages you to commit to time with your partner.

Taking Advantage of Flexibility

If you have some flexibility in your work schedule, work with your partner to create a schedule together. This can maximize the number of “off” hours you have at the same time. For example, if you work the night shift and your partner is a freelancer, try asking your partner to schedule meetings at the beginning of your shift so he or she has to spend less time working during your time off.

Prioritizing the Relationship

A never-ending list of tasks and work obligations can be incredibly daunting. Your relationship, however, is an important obligation and a source of emotional well-being. If you’re constantly busy, it’s tempting to refuse to do anything fun until you’ve completed all of your work-related activities. While this might make you efficient, it can also make you unhappy. Treat your relationship the way you treat work, and prioritize time with your significant other, even if it means delaying other tasks.

Taking Time Off

For couples who work different shifts, weekends, holidays, and vacations play a key role in spending time together. Take advantage of your time off, and schedule your breaks so that they coincide with one another. If your partner is a contractor whose busy season is the spring, for example, try constructing your own schedule so that you can take more time off during a less busy time of year.

Regular Communication

If you can’t spend regular time together, brief bursts of communication can help you maintain intimacy and give you a strong incentive to work together to prioritize the relationship. Send your partner text messages during the day, or take a few minutes to chat online or over the phone. A sweet note in your partner’s briefcase or a quick reminder via chat that you love your partner can help you feel close even if you have to spend long hours apart.

Establishing Clear Boundaries

Setting boundaries with your job or your clients is a must if you want to keep your relationship running smoothly. If you have control over your own schedule, ensure that your schedule is as consistent as possible, with clear “on” and “off” hours. Unless it’s an emergency, don’t take work-related phone calls or answer work emails when you’re home. It’s also important to set boundaries with your partner. This doesn’t mean shutting him or her out while you’re at work. Instead, it’s vital to ensure that your partner knows your schedule and knows when you are and aren’t working. This is particularly important for people who work from home or who are on-call. If your partner knows that you’re working or that it’s possible you might get called into work, your job won’t feel like as much of an intrusion.

References:

1. Cooper, S. (2012, May 22). Marriage-saving rules for couples working from home. Forbes. Retrieved from http://www.forbes.com/sites/stevecooper/2012/05/22/marriage-saving-rules-for-couples-working-from-home/
2. Tessina, T. (n.d.). Dr. Romance: Married, different shifts. Divorce360.com. Retrieved from http://www.divorce360.com/divorce-articles/causes-of-divorce/neglect/dr-romance-married-different-shifts.aspx?artid=1642

Palliative care is designed to provide comfort and peace to individuals facing terminal illness and end-of-life transitions. Caregivers who watch over someone in palliative care often get to spend precious moments with their loved ones in ways that would not be possible in a hospital or nursing setting. Individuals who are dying can benefit from palliative care by having those closest to them with them during their last days allowing for final wishes to be expressed and sentiments to be shared.

When death is sudden and tragic, as with an accident or unexpected illness, caregivers can experience shock and traumatic responses. Prolonged grief (PGD), also known as complicated grief, can occur when symptoms of grief are exacerbated and persist over lengthy periods of time. Experiences such as reliving the death event; being reminded of the death through mental, visual, or auditory stimuli; and even experiencing intrusive thoughts are all symptoms of posttraumatic stress (PTSD), which is not uncommon among bereaved parents and survivors of disasters or abuse.

But until now, few studies have examined whether or not caregivers of individuals who die expectedly are at risk for PTSD. To explore this issue, Christine Sanderson of Cavalry Health Care Sydney in Australia recently interviewed 32 caregivers grieving the loss of a patient who died from ovarian cancer six months prior.

The caregivers’ responses were assessed for signs of grief, emotional reactions to stimuli, language, and trauma response. For the most part, Sanderson found that the caregivers had high levels of resiliency, although some exhibited symptoms of PGD and PTSD. Specifically, trauma symptoms included strong reactions to sounds, smells, and sights that caregivers remembered from the palliative setting and also intrusive thoughts related to the death and the predeath period.

Sanderson believes that palliative care can be a cathartic experience for some, providing time for a dying person to be with family in the last days of their lives. But for some caregivers and loved ones, watching the death of someone close to them, while making no attempt to stop it, can be excruciating and lead to shock and extreme emotional distress.

Because caregivers are at increased risk for negative physical and mental health outcomes when compared to those who are not caregivers, exploration of resiliency or susceptibility after a patient’s death is essential. Sanderson added, “Skillful care of caregivers requires an understanding of the nature of their experiences, if we are to reduce traumatisation of vulnerable individuals.”

Reference:
Sanderson, Christine, et al. (2013). Signs of post-traumatic stress disorder in caregivers following an expected death: A qualitative study. Palliative Medicine 27.7 (2013): 625-31. ProQuest. Web.