GoodTherapy | Fetishes and the DSM: When Is a Kink a Mental Health Issue? is inextricably linked to cultural norms, and the latest version of the Diagnostic and Statistical Manual of Mental Disorders—psychiatry’s diagnostic bible—makes this readily apparent. Although sexual kinks are still a source of cultural controversy, their taboo status is steadily lifting, and the DSM-V treats unusual sexual behavior differently than previous versions of the manual.

Changing Sexual Norms

A little over a century ago, Sigmund Freud, modern psychiatry’s godfather, argued that clitoral orgasms were a sign of immature sexuality. For Freud, healthy adult sexuality meant nothing less than a vaginal orgasm. Contemporary sex researchers now emphasize the fact few women can reach orgasm with vaginal stimulation alone, and sex therapists frequently advise people having trouble with orgasm to focus on the clitoris. There have been other advances in thinking, of course, when it comes to sexuality. Until 1973, homosexuality was listed as a disorder in the DSM. Contemporary psychologists and psychiatrists now condemn conversion therapy, a treatment designed to “cure” homosexuality.

Contemporary sexual fetishes run the gamut. Many people have engaged in or acted on some form of sexual fetish at one time or another, and groups dedicated to advocating for the rights of those with unusual sexual interests have sprung up all over the Internet. More and more sex researchers recognize these behaviors as part of a sexual continuum and not necessarily indicative of a mental health issue.

The DSM-V’s Stance

Like their predecessors, contemporary mental health professionals frequently wrestle with the intersection of cultural norms and mental health, and the new DSM reflects this ongoing dialogue. Previous editions of the manual listed atypical sexual behaviors as diagnoses. For example, the DSM-IV listed the behavior of sexual masochism as a disorder. The new version, however, is largely silent on behavior, and defines fetishes as problematic only when they cause significant distress. Thus, masochistic behavior is now termed sexual masochism disorder only when the behavior causes problems for the individual.

When Is a Kink a Problem?

So when does a sexual kink cross the line into a disorder diagnosis? Some sexual behavior is inherently disordered, according to the new manual. For example, pedophilia remains a diagnosis because it’s impossible to act on a sexual attraction to children without breaking the law or causing harm to others. But for those who are blissfully dedicated to feet, bondage, or garter belts, the manual no longer defines the behavior itself as a problem. Instead, the so-called disorder is partially in the eye of the beholder. If your sexual fetish causes serious problems in your romantic relationships or significant personal distress, it may be time to consult a professional. Otherwise, the creators of the DSM-V are content to allow people to engage in whatever sexual behavior they want to without finding issue.

Ongoing Controversy

Not everyone is happy with the changes to the manual. Sex-positive writers and researchers point to the fact the new book still provides a list of sexual fetishes, which serves to label some sexual behaviors as inherently deviant even when they don’t cause problems. And the fact the DSM has changed its approach to diagnosis doesn’t mean every mental health professional has followed suit. The American Association of Sexuality Educators, Counselors, and Therapists publishes a list of therapists who adopt a nonjudgmental stance toward kinks. People who engage in non-normative sexual practices such as swinging, polyamory, and sexual fetishism report that they often struggle to find professionals who don’t view their behavior as deviant.

References:

  1. Paraphilic disorders [PDF]. (n.d.). Arlington: American Psychiatric Publishing.
  1. Parry, W. (2013, May 30). Normal or not? A sexual attraction to objects. LiveScience.com. Retrieved from http://www.livescience.com/36982-is-fetish-normal-dsm5.html
  1. Savage, D. (n.d.). Finding a sex-positive therapist isn’t always easy. Creative Loafing Charlotte. Retrieved from http://clclt.com/charlotte/finding-a-sex-positive-therapist-isnt-always-easy/Content?oid=3043389

Research on borderline personality (BPD) has explored various avenues in search of risk factors. But according to a recent study, some of the biggest risk factors for BPD may develop in the womb. Cornelia E. Schwarze of the Department of Psychiatry and Psychotherapy at the University Medical Center Mainz in Germany led the study that looked at the prenatal conditions of 100 individuals with BPD and compared them to 100 participants with no history of BPD.

Schwarze interviewed the mothers of the participants and reviewed prenatal and medical records. She looked at factors such as prenatal smoking, stress, family conflict, and medical problems. Schwarze also assessed environmental risk factors for the participants by evaluating levels of childhood adversity including maltreatment, neglect, physical and sexual abuse, emotional abuse, or other traumatic events.

The results revealed that the mothers of the BPD participants were more likely to have smoked during pregnancy when compared to the mothers of the 100 non-BPD control subjects. Additionally, the mothers of the participants with BPD also had higher rates of prenatal medical problems, stress, and conflict. Other risk factors that increased the likelihood of BPD were childhood sexual abuse and other childhood trauma. However, prenatal smoking and prenatal medical problems and stress had the strongest associations with BPD.

Exposure to prenatal smoke has been linked to impulsivity, identity issues, affective problems, and some borderline personality symptoms. The results of this study support existing research in this area. Schwarze also noted that medical problems that occur during pregnancy can have a significant impact on neurological development and specifically, on regions of the brain that affect emotional regulation. Although this should be explored further in future research, the strong link between prenatal medical problems and later BPD in children supports this as well.

Finally, prenatal stress, resulting from maternal stress during pregnancy, can be caused by a number of factors, including relationship problems, psychological issues, occupational conditions, or socioeconomic conditions, just to name a few. Each of these may also have a unique impact on the development of BPD or increased risk for BPD in unborn children. Schwarze added, “Future prospective longitudinal studies are essential to verify the impact of the observed potential prenatal risk factors.”

Reference:
Schwarze, C. E., et al. (2013). Prenatal adversity: a risk factor in borderline personality disorder? Psychological Medicine 43.6 (2013): 1279-91. ProQuest. Web.

When choosing friends in childhood, many young people seem to gravitate toward peers with a history of delinquency or delinquent behavior. Delinquent peer affiliation (DPA) occurs most often during adolescence. Theories on DPA suggest that some teens may choose to associate with delinquent peers because they share similar beliefs and behaviors. Similarly, these children may be rejected by peers who do not engage in delinquent behavior, and therefore may be forced to choose other sources of social support. Along these same lines, some researchers believe that DPA is a result of genetics, causing some people to be predisposed to delinquent behaviors and thus, delinquent peer affiliation.

However, S. Alexandra Burt of the Department of Psychology at Michigan State University wanted to see how environment affected DPA. Using a sample of 726 twin children from a state registry, Burt conducted a study looking at environment, genetic predisposition, and other factors and how each affected DPA.

Burt found that although genetics were somewhat influential of DPA, environment played a much bigger role in the selection of delinquent peer friendships. In fact, the environmental conditions that influenced delinquency in the twins was a significant risk factor for negative behavior in those with strong and robust DPAs compared to participants with few DPAs. This finding suggests that a child’s environment, their family life, and social support within their world may serve as motivators for delinquency and delinquent affiliations. Burt also believes that perhaps these children find reinforcement and positive affirmation for their delinquent behavior from their DPAs, further strengthening the bonds they develop.

Burt also noted that when children have high DPAs, these friendships can increase the environmental risks and elevate their levels of delinquency. In some cases, children who befriend other delinquent children may then experience higher levels of parental disapproval. This can lead to higher stress levels within the home, more conflict and potentially increased delinquency.

In conclusion, this study shows that although genetics may plant the seed for delinquent behavior, environmental influences provide the food and water that allow it to grow. Burt added that this study provides new evidence into the effect of environment, but more research needs to be conducted. She said, “Future research should build on the present findings by examining these associations as they develop from childhood through early adolescence.”

Reference:
Burt, S. A., and K. L. Klump. (2013). Delinquent peer affiliation as an etiological moderator of childhood delinquency. Psychological Medicine 43.6 (2013): 1269-78. ProQuest. Web.

Occupation can be a risk factor for suicide. In addition to psychological issues, poor physical health, and general life stress, the occupation that someone holds can present an additional suicide risk via access to lethal means. According to a recent study conducted by S.E. Roberts of the College of Medicine at Swansea University in the United Kingdom, doctors, nurses, and veterinarians had some of the highest suicide rates by occupation in the past 30 years. The results of this study reveal some positive trends and raise awareness about other occupations that can pose a heightened risk for suicide.

Roberts looked at occupation, access to deadly means, socioeconomic status, gender, and national economic condition over a 30-year period to determine which factors most influenced occupational suicide rates. The results revealed that in the early 1980s, veterinarians, dentists, doctors, pharmacists, and farmers had some of the highest suicide rates. This could be influenced by easy access to pharmaceuticals and weapons.

Then, in the early 2000s, these occupations saw decreases in suicides. At the same time, manual labor occupations had increases in suicides. These occupations included construction, merchant marines, coal mining, trash collectors, and drivers, among others. Roberts believes that the reorganization within these industries could be partly responsible for increased rates of unemployment and subsequent increases in suicides.

When Roberts looked at socioeconomic status as a risk factor, it was revealed that suicide rates doubled in the 30-year period for those most economically disadvantaged. Unlike early statistics, it appears that socioeconomic condition has emerged as a more salient risk factor than access to lethal means in this British sample. Further, men were more likely than women to commit suicide across all occupations and socioeconomic statuses.

Another risk factor that was identified was isolation, as artists, actors and entertainers had higher rates of suicide than some other occupational groups. Despite increases in some areas, Roberts pointed out that interventions aimed at reducing suicide in high risk occupations, such as one tailored for farmers, have proven to be effective at reducing suicides over time. Roberts added, “This indicates that carefully targeted suicide prevention initiatives for other occupations could be important.

Reference:
Roberts, S. E., B. Jaremin, and K. Lloyd. (2013). High-risk occupations for suicide. Psychological Medicine 43.6 (2013): 1231-40.ProQuest. Web.

male caregiver walks with elderly manThe work of caregivers is difficult, at best. This is particularly true for those who provide care before they start the workday and after they come home in the evening. I am often amazed by the stories I hear from caregivers.

I recently learned something from a group member that I want to pass along to other caregivers. It is so simple that it may seem unlikely to make a difference. But don’t let the simplicity of it fool you—the people in our group totally got it when she talked about it. Had I tried to teach it to them in the language of a therapist, I doubt the result would have been a collective “wow.”

Managing Resentment and Anger as a Caregiver

The question of how to manage resentment is frequently a theme in our support group. Caregivers grapple with guilt about experiencing resentment—both regarding the unfairness of being thrust into the role of caring for their partner or spouse, and about spending more time as a caregiver and less as a partner/spouse.

Most are clear that the resentment and anger they feel is directed toward the ailment or disability, but we all know how easy it is for our anger and resentment to spill over into other areas or be misdirected. The last thing most caregivers want to do is allow their resentment or anger to taint their relationships with those they care for.

Someone in our group raised this issue again recently: How do we deal with the seething resentment that we feel? How do we prevent this rage from spilling over into our relationships?

It was clear that everyone in the room knew what he was talking about. Everyone responded with the perfunctory nods of agreement and reminders to breathe, be grateful, and hang in there. These are veteran caregivers who already do most of the things recommended for self-care: exercising, setting boundaries, eating well, getting as much rest as possible, etc. The urgency of their desire to address this issue was apparent.

How Do We Change Our Feelings?

Luckily, one of the women who had asked the same question in the past spoke up. She shared that she had intuitively discovered something that helped. She talked about how she had automatically shifted her feelings one day while helping with an unpleasant task. This generous soul has granted me permission to share this with you.

What my friend found was that by focusing on the process of what she was doing—by mindfully paying attention to each tiny step in the task at hand—she was able to change her feelings. She inadvertently alleviated the resentment and dread!

She changed her thoughts from, “I hate this; this is horrible. I can’t believe I have to do this every day and night for the rest of my life” to, “Okay, now I need to do this… put this here, then take it over there. Next I do that… yes, like that. Oh, that was much better than last time.”

As she explained it, my friend was able to “relax her brain, much like releasing a tightened fist.” By relaxing her brain, she was able to release the resentment and dread. She described it as letting go—releasing the breath that she had been holding. And in doing so, she discovered how to give up her resentment and anger.

Attention Is Key

Remember that when you truly focus your attention to the task, the switch to thinking mindfully about your action results in a change in your feelings and behavior. By forcing her attention to the minute processes of her admittedly unpleasant task, my friend also gained control over her emotions. She stopped the negative thoughts. Your mind can only hold one thought at a time. What you choose to think about creates your emotions.

It is your choice. Choose to focus on the process—the actions. That is mindfulness. By changing your focus to each step of the process (whether washing dishes, filing, changing a catheter, or meditating) you are also altering your feelings.

It takes practice. Begin with something easy, like learning to laser focus on your breathing. Feel the air going into your nostrils, your stomach rising, the air moving through your head and into your lungs, and then moving back up and out of your nose.

Next, try mindfully taking a bath or shower. Feel the water on your skin, smell the soap… feel the cloth in your hands and your hands moving over your body. Don’t allow your mind to wander to other things. Keep it contained in the actions and senses.

Finally, try this when doing a difficult task. Make your thoughts about what you are doing step by step. There is no room for thoughts that create dread and resentment.

Try it, and let us know how it works for you!

Woman opens window and looks out at sunThe ignorance about mental health issues that continues to exist among otherwise intelligent individuals is perplexing. In today’s modern world, with continuously increasing tolerance for human differences, many of yesterday’s taboos have become today’s facts of life. Issues from racism to sexual identity have been stridently tackled and, while much work remains to be done, we have come miles. The recent Supreme Court ruling regarding gay marriage is a perfect example of how far we have come.

However, there still remains what some have referred to as “the last taboo.” Namely, depression continues to be one of the most stigmatized mental health issues out there. This is ironic, given that by the year 2020, according to the Centers for Disease Control and Prevention, depression is estimated to be the second most common health problem in the world. Further, because of the unjustified stigma that still exists, a large percentage of those who experience depression will not be treated.

So, what is the missing piece to this puzzle? Why is the message not resonating with the greater population? Why is stigma still so prevalent in our society? As mental health practitioners and social advocates, what can we do to eradicate this social dilemma?

When it comes to obtaining treatment for medical ailments as benign as the common cold, people don’t think twice about running to the doctor, or the acupuncturist, and spending the money on treatments to feel better. So, why do so many who suffer from depression continue to hesitate, despite all of the treatment options available?

[fat_widget_right]In addition to the externalized stigma or discrimination toward those with mental health issues that exists in society, there comes internalized stigma, or self-shame. This makes the experience of mental health issues all the more devastating. Many times, it is the internalized shame that stops people from acknowledging psychological problems and receiving treatment, since many see it as akin to admitting that they are weak or damaged in some way.

According to the U.S. Preventive Services Task Force, a panel that sets treatment guidelines for primary care physicians, an estimated 6% of teens in the United States suffer from clinical depression, yet most go undiagnosed and, therefore, untreated. This information alone strongly indicates a dire need to raise awareness.

But where do we start?

How about with the media? Instead of programs like Criminal Minds perpetuating the stereotype of schizophrenia as a violent disease, let’s have some intelligent programming that humanizes mental health issues. What Will and Grace did for sexual identity, perhaps the same can be done for depression. Since we are a society so attached to the media, why not take advantage of the opportunity to educate people?

Why is it that when we learned about Abraham Lincoln or Walt Whitman in school, we learned almost everything about them except the fact that they experienced psychological problems?

We can also begin in our school system, making mental health education a part of the curriculum. As has been discovered in other areas such as sex education, knowledge can be a powerful tool in prevention. Why is it that when we learned about Abraham Lincoln in social studies, or Walt Whitman in literature class, we learned almost everything about them except the fact that they experienced psychological problems? Why were these facts omitted from the textbooks and class lectures? We need to make stigma a thing of the past and teach our future leaders of tomorrow that it is okay to recognize, and seek treatment for, the experience of clinical depression and other mental conditions.

Before we begin with the masses, let us also first look at ourselves as therapists and mental health caregivers. We must look at our own core beliefs and biases, which can directly affect the work we do. We may be unknowingly perpetuating the stigma of depression and other psychological issues. Change must begin within the mental health community. To change others’ minds, we must first change our own.

References:

  1. Depression statistics (2008). Retrieved April 3, 2009 from: http://depression.emedtv.com/depression/depression-statistics.html
  2. Panel: All teens should be tested for depression. (2009). The Associated Press. Retrieved from: http://www.msnbc.msn.com/id/29945008/

woman-screaming-during-business-meetingYou’ve probably seen videos of big, furious guys going after little guys. It doesn’t look like a fair fight at first, but there can be surprises—and sometimes the little guys win. I’ve been studying tai chi, learning how people can defeat themselves by misusing their energy and losing their center of balance.

Sometimes life feels like a wrestling match. We’ve all been there—stuck with someone who is just relentlessly on the attack, who pushes all our buttons looking for a fight. “Arlene” grew up like that, and for a long time she equated rage with strength because her parents did. In her family, people fought to prove that they were powerful and in control. They did this because they needed to take their anger out on other people, and because they believed they lived in a dog-eat-dog world and they wanted everybody else to live there, too. Arlene couldn’t bear to live in a world like that. She worked hard and long, and with therapy, yoga, and the help of her husband’s patience and good nature, she learned to have better control of her anger. She found out that the world can be very different. She learned how to walk away from meaningless fights.

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Sometimes, anger is justified. If someone stomps on your foot, you might yell. If you grew up in a bad neighborhood anger can be a protection, but if you stay angry long enough, everywhere you look you’ll find something or someone who makes you mad. For some people, getting mad can be a circular process—the madder you are, the madder you get—until there’s just no stopping. A few people seem predisposed to anger; they are just born that way.

Which brings us to “Ramona.” She thinks everyone is against her, so she fights with everybody, which turns people against her and kind of proves she’s right. If someone makes an innocent joke, she often takes it the wrong way; she gets upset if she thinks people aren’t paying her enough attention or giving her the admiration she feels she deserves. It’s all about her. She takes everything literally, feels threatened, and has little sense of humor. She’s controlling—it’s her way or the highway. Ramona is always angry and disappointed.

This is tough on her friends, family, and coworkers. Ramona needs to be adored and obeyed, and if she doesn’t get what she wants, she goes into a rage. Some people admire her; she is smart, talented, and can be very funny. Many people are scared of her; they don’t tell her what they think because she yells long and loud, so they just clam up and ride out the storm.

One day Arlene was hired at Ramona’s workplace, and the two of them were put in the same unit. When the unit met for its weekly conference, their supervisor, “Alonzo,” led off the meeting, saying the company needed to make more sales. Ramona spoke at length about improving the business and had plenty of ideas, some very good ones, but she wasn’t interested in listening to anyone else and interrupted when other people were talking. She interrupted Arlene, too, who called her on it, and then Ramona went on the attack and yelled at Arlene. Other members of the group tensed up, anticipating a shouting match, but Arlene had a different tactic. She said she admired much of what Ramona thought, but wanted to hear what others had to say and to share her own ideas, too. Ramona got very angry and screamed even more at Arlene, who just listened. The other members of the meeting were watching Arlene. After the meeting was over, Arlene told Ramona not to yell at her anymore.

There was another meeting. Ramona yelled at Arlene again. Arlene had previously warned Ramona that the next time Ramona started yelling Arlene would leave the meeting, which is exactly what happened. Arlene got up and walked out, ending the meeting.

Alonzo called Arlene into his office and asked what happened. Arlene said, “Ramona never stops talking and yelling, and a lot of people don’t like it but they’re too scared to say anything. I tried over and over to get her to stop, but she didn’t listen. She’s always like this. So I just walked away.”

“Why didn’t you yell back?” Alonzo asked. “Were you too scared?”

Arlene answered, “No, she doesn’t scare me. I just refuse to be yelled at, so I walked out. Yelling back at her would never work; it would be a shouting match, and I don’t like yelling anyway. I simply told Ramona that if she yelled at me I wasn’t going to shout back or stand around and listen to her scream, either—I was going to leave, which is exactly what I did.”

“Don’t you stand up for yourself?” Alonzo said.

“Leaving was standing up for myself,” she replied. “This argument was basically meaningless. If we don’t agree, we can discuss things, but not Ramona. She just likes to yell. I mean, yelling? What are we, in junior high?” Alonzo agreed that Ramona was out of line.

Alonzo transferred Ramona to a position where her intelligence and creativity were called into play, but where she didn’t have to work with others. It was a horizontal move, not the promotion that Ramona thought she deserved and that Arlene got—she took over Alonzo’s job when he was promoted.

Arlene won. Ramona defeated herself.

GoodTherapy | Women and Virginity: Preparing for the First TimeMost of my blogs over the years have been written for people who are already sexually active and have experience with pivi (penis-in-vagina intercourse). Today I’m going to address young (and perhaps not-so-young) women who are interested in losing their virginity. (I hope guys will read this as well—virgins or not.)

Losing your virginity is not a topic that most of us bandy around in casual conversation. But I’ve been privileged over the years to hear thousands of descriptions, most of them about experiences that were awkward, clumsy, and sometimes painful. It doesn’t need to be that way.

I heartily recommend that your first sexual partner be someone who is gentle and kind, with a good sense of humor. And please, please, please don’t be drunk or high your first time. Take it from me: Couples who do it sober have a happier and safer experience!

Losing your virginity with your sweetheart and soulmate would be a lovely option, but most of us no-longer-virgins are not even in touch with the person we did it with for the first time. One of the keys to having wonderful sex is knowing your own body.

Regular readers may have read comments recently from older women who are enjoying sex more and more the older they become. One reader celebrates post-menopause as a time when she knows her body well enough to say yea or nay in ways that her lover can truly understand. Another writes about discovering new delights about her body as she ages. Whatever your age, consider yourself at the start of a fascinating journey!

If you masturbate, you have an advantage in this department. If you haven’t explored your body this way yet, not to worry. I suggest you try for a time when you have 30 minutes to yourself or when you’re tucked under the covers for bed. First, wash your hands, then moisten your fingers. (I mistyped “finders” here—how perfect!) Let your fingers “find” pleasing places on your body—everywhere except your genitals.

Relax, breathe, and allow yourself to spend at least 10 minutes exploring up and down your body. You might want to imagine that your lover’s fingers/finders are discovering erogenous zones that you weren’t aware of before. Then, let your focus shift to the area between your legs, with your fingers gliding up and down and around your vulva, the outside part of what’s between your legs, as opposed to the vagina, where tampons and penises (sometimes) go.

Next, get your finger extremely wet (saliva works fine) so you can venture inside. Slowly inch your finger inside, allowing yourself to feel what your finger is “finding” inside as well as what your vagina might be feeling. Some women may want to explore more deeply, while others might feel quite nervous and hesitant. If you’re in this camp, this might be a good place to stop for now. Congratulate yourself for taking this important step and consider venturing a bit farther the next time.

If you’re eager to press on, let your finger keep going. Remember to breathe, and continue to ask yourself what your vagina is feeling and experiencing. You might want to consider adding a second finger, especially if you anticipate pivi.

I highly recommend a wonderful book by my colleague Lonnie Barbach, called For Yourself, about masturbation. Female virgins and nonvirgins alike may benefit from carving out pleasurable time “for themselves.”

If all of this seems too overwhelming, maybe it’s not the right time in your life to be losing your virginity. Millions of lesbians will attest that there are numerous ways that you and a partner can enjoy one another sexually without a penis going into your vagina!

toddler-staring-out-windowI see many people who struggle with self-esteem issues. In fact, self-esteem issues and depression almost always occur together. Which one causes the other is not always clear, but the majority of people seem to have the self-esteem issues first.

People often tell me they want to die—because they “shouldn’t exist,” were “never wanted,” never “fit in,” are a “burden,” “don’t deserve anything,” or even have the feeling they “did something horrible” but don’t know what.

Generally, this viewpoint comes from something that happened when the person was very young. We now know that even embryos traveling down the fallopian tube are being affected by their environment in ways that have implications for physical and emotional health throughout the rest of their lives.

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To work with this, sometimes I ask people if they deserved to live (or die) when they were an embryo, then a fetus, then a newborn, etc. Most people see themselves as innocent and deserving to live at some point. Going through this exercise helps them see that there was a time they could have compassion for themselves, rather than blame or condemnation. For others, as we advance in age, we come to a place where they can no longer say they were innocent and deserved to live. That can lead us to the origin of the issue. If they can’t say they were good anymore after age 2, 4, 10, or whatever, then we look for what happened at that age to change that. Almost always, it was some kind of abuse or trauma.

For example, I saw a woman who wanted to die and believed she didn’t deserve to live, despite the fact she was a kind, giving, loving person. She was severely depressed and obsessed about suicide. She told me if therapy didn’t work, she was going to kill herself. One of the things I did was to take her through this exercise. She reluctantly conceded that she was innocent as an embryo, fetus, and newborn. When we got to 2, she said she deserved to die at that point. When we explored it, she said something happened then to change this, but she didn’t know what. Few people have conscious memories from that age, so early memories can be challenging to resolve.

But then she said she had an image, but she was sure it didn’t happen—”it couldn’t have happened.” The image was of a sexual assault from a family member. It was very specific and unusual. We processed the image as if it was a memory with EMDR, and she felt enormous relief. She no longer thought she was so bad that she didn’t deserve to live. She finally saw that she had done nothing wrong and the shame wasn’t hers. It belonged to the adult perpetrator.

Others blame themselves for their parents’ divorce, or for their parents’ lost lives after marrying each other only because of the pregnancy. People blame themselves for being the gender the parent didn’t want, for their mother dying in childbirth, or for their parent’s depression. When children try to make sense of something that feels terrible in their world, and no one helps them, they tend to think they caused the problem. So many innocent children grow up feeling guilt, shame, and self-hatred because of this. Sometimes, they don’t even remember why. Once they can connect their adult perspective with their child beliefs, they see that it’s unreasonable to punish themselves the rest of their lives because when they were too young to be responsible, their parents made the choices they did.

So if you think you are bad, disgusting, undeserving, unlovable, or inadequate, were you so as an embryo? A fetus? A newborn? An infant? A crawling baby? A walking toddler? A talking toddler? When did you become unforgivable, and why?

Bulimia nervosa is an eating issue that can be assessed using a variety of diagnostic tools. Because there are many different measures to evaluate bulimia, some researchers believe that overestimation or underestimation of bulimia exists. To cloud the issue further, a large majority of people who have symptoms of bulimia often have comorbid psychological conditions, including mood problems, anxiety, depression, and drug or alcohol use.

Less than half of the individuals who demonstrate bulimic symptoms seek treatment for them. Although many do enter treatment for comorbid issues, the bulimia is often discovered secondarily and does not always receive the attention it deserves. Bulimia can lead to serious negative health outcomes and even suicide. For clinicians to identify those most at risk and intervene at the earliest point possible, it is imperative that consistency in symptom assessment and diagnosis be achieved.

Katie Sandberg of the Department of Education Specialties at Loyola University in Maryland wanted to test the reliability, consistency and validity of the six most commonly used tools for assessing bulimia. She conducted an analysis of existing research involving studies using the Eating Disorder Examination (EDE), the Eating Attitudes Test (EAT), the Eating Disorder Inventory-3 (EDI-3), the Body Shape Questionnaire (BSQ), the Bulimic Investigatory Test, Edinburgh (BITE), and the Three-Factor Eating Questionnaire (TFEQ).

Sandberg found that all six measures were able to assess bulimic symptoms with relative accuracy, but in unique ways. Based on symptoms of purging, binging, laxative use, and overall body dissatisfaction, she found that the EDI and the EAT were the most reliable at assessing bulimia. When she looked at body dissatisfaction, the BSQ and the EDE emerged as the most reliable tools.

In sum, Sandberg believes these findings show the importance of utilizing multiple screening tools when evaluating clients for bulimia. She said, “The best way for clinicians and researchers to document treatment effects is to use a multitude of high-quality instruments to achieve triangulation.” Further, she believes implementing screening tools before and during treatment can provide clinicians with accurate measures of progress and can help clients and clinicians identify persistent symptoms that need further attention.

Reference:
Sandberg, Katie, and Bradley T. Erford. “Choosing Assessment Instruments for Bulimia Practice and Outcome Research.” Journal of Counseling and Development : JCD 91.3 (2013): 367-79. ProQuest. Web. 26 July 2013.

Young woman on pier at sunset.My mom has worked as a nurse for over 30 years. I remember she would sometimes come home from work and talk about how she had had a doctor or nurse as a patient that day. She would always say how health-care professionals were always the worst patients, usually because they would push themselves farther and faster than they should, which resulted in a longer recovery.

I think that as therapists, we are just as guilty of holding ourselves to a “higher standard.” I have seen colleagues and friends who are therapists give out excellent advice about the importance of seeking and accepting help and practicing good self-care, only to neglect themselves and fall into a cycle of depression, anxiety, and trauma symptoms, basically disregarding their own wise words.

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I previously wrote an article about secondary trauma for loved ones of people who had experienced trauma. I felt it fitting to write another article for therapists, as I believe we have the potential to also experience secondary trauma. Figley (1995) defines secondary trauma as “the stress resulting from helping or wanting to help a traumatized or suffering person.”

Think about it: Most therapists see anywhere from 10 to 40 people per week.  These people are coming to us for help with their problems, which could range from normal levels of stress to severe depression, anxiety, trauma, or other mental health difficulties. We listen and offer tools they can use to overcome their challenges. They leave the sessions armed with new skills to face their lives and challenges. And what are therapists doing between sessions? I can answer from my own experience: doing notes, writing up treatment plans and assessments, returning phone calls, following up with other professionals, preparing for the next session, etc. After work, many professionals have other commitments and obligations. Life can get very busy and chaotic, and many of us consistently put ourselves last.

Therapists are just as susceptible to secondary trauma as any other person. We are not superhuman, nor do we possess mental powers that make us resilient to depression, anxiety, trauma, and other mental health challenges. Sometimes as therapists we forget this and, therefore, neglect ourselves. One study found that therapists who treat people with trauma are susceptible to the effects of secondary trauma, particularly if they do not have the appropriate training, support, and self-care (Pearlman & Mac Ian, 1995). In my experience, this applies also to therapists who are treating other mental health issues.

So what do we do about it?

In conclusion, I believe one of the most important things we can do for people who see us is to take excellent care of ourselves. If we neglect our needs and ourselves, we are not able to give all we have to others. We can set a great example of self-care and avoid being susceptible to secondary trauma if we are just willing to follow our own good advice.

References:

  1. Figley, C.R. (Ed.) (1995). Compassion Fatigue: Secondary Traumatic Stress Disorders from Treating the Traumatized. New York: Brunner/Mazel, p.7.
  2. Pearlman, L.A., Mac Ian, P.S. (1995). Vicarious Traumatization: An Empirical Study of the Effects of Trauma Work on Trauma Therapists.  Professional Psychology: Research and Practice, 26 (6), pp. 558-565.

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Long-distance relationships (LDRs) present unique challenges that test the resilience and commitment of couples separated by geography. While the physical distance can create obstacles, recent research reveals that these relationships may offer distinct advantages and can be just as fulfilling as geographically close relationships when approached with the right strategies.

According to 2025 research, the prevalence of long-distance relationships has evolved significantly, with current estimates showing that 10% of married couples in the United States maintain long-distance relationships. Among university students and emerging adults, LDR prevalence ranges from 30% to 50%, making this a common relationship structure during formative years.

Current Research on Long-Distance Relationships

The foundation for understanding LDR dynamics comes from groundbreaking research published in the Journal of Communication. Research from Jiang and Hancock (2013) observed communication patterns in long-distance versus geographically close relationships, finding that emotional connections in long-distance relationships may be equally strong or stronger than their geographically close counterparts. The study found that long-distance couples engage in more adaptive self-disclosures and form more idealized relationship perceptions than geographically close couples.

This foundational research has been validated and expanded by numerous recent studies. A 2025 study examining emerging adults in long-distance relationships found that relationship maintenance behaviors predict relationship quality both directly and indirectly through dyadic trust. Research on communication patterns shows that LDR couples use remote communication more frequently than geographically close couples, with text messaging showing particularly strong links to relationship satisfaction in long-distance relationships.

Current research indicates that 34% of long-distance relationship couples experience significant anxiety about future reunion plans, highlighting the emotional challenges that come with maintaining relationships across distances. However, studies suggest that college students in LDRs may not be at greater risk for negative psychological outcomes compared to their peers in geographically close relationships.

The Science Behind LDR Success

Several psychological mechanisms may explain why distance can strengthen rather than weaken romantic bonds:

Enhanced Communication Quality

Long-distance couples demonstrate more intentional communication patterns, engaging in deeper self-disclosure and forming more idealized perceptions of their relationships compared to geographically close couples. 2025 research shows that attachment-security strategies for LDR couples, including creating psychological distance from negative triggers through mindfulness and perspective-taking techniques, can reduce harmful coping behaviors and improve relationship stability. Regular communication schedules, shared digital experiences, and planned visits help maintain secure attachment bonds across time zones.

While enhanced communication can strengthen emotional intimacy, it may also introduce a subtle risk: the tendency to idealize one’s partner. Because long-distance couples rely heavily on curated interactions, texts, calls, and planned visits, partners may unintentionally “fill in the gaps” with assumptions that reflect hopes rather than reality.

Clinical observations and emerging research suggest that this form of idealization can create a “fantasy bond,” where the relationship feels emotionally fulfilling but is partially constructed in the mind rather than grounded in everyday shared experience. Over time, this gap between perception and reality can become a source of distress, particularly during transitions to living together or increased in-person contact.

The Power of Anticipation

The cyclical nature of separation and reunion in LDRs creates heightened emotional experiences. Recent research on “relationship jet lag” reveals that couples experience no difficulty adapting when reuniting, with researchers noting that “the joy of being together may be enough to supersede that jet lag effect”.

However, the same anticipation that fuels excitement can also amplify contrast effects. Time spent together often occurs under unusually positive conditions, planned visits, time off work, and heightened emotional focus, which can resemble a “holiday mode” of relating. This context may temporarily intensify emotional and physical intimacy, but it does not always reflect how the relationship functions under routine, day-to-day conditions

Attachment Theory Insights

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Modern research examining attachment styles in LDRs shows that individuals maintain committed romantic relationships across significant geographical separation (averaging 1042 miles) for extended periods (averaging 3 years). Studies demonstrate that securely attached individuals report higher relationship satisfaction and greater interdependence in their relationships, while high relationship closeness predicts high satisfaction in long-distance relationships.

The Reunion Transition: When Distance ClosesOne of the most underexamined phases of long-distance relationships is the transition from distance to proximity. While much of the research focuses on maintaining connection across distance, clinical experience and emerging studies suggest that reunification can be a critical stress point.

When partners move closer or begin living in the same location, they often encounter a “reality adjustment period.” The imagined or idealized partner must integrate with the real, everyday person, complete with habits, routines, stress responses, and preferences that were less visible during long-distance phases.

This transition can affect multiple domains:

Research on relationship transitions suggests that these adjustments can temporarily decrease relationship satisfaction, even in otherwise strong partnerships. Recognizing this phase as a normal developmental stage, rather than a sign of incompatibility, can help couples navigate it more effectively.

Modern Communication Tools and Their Impact

Technology has revolutionized long-distance relationship maintenance, providing couples with unprecedented opportunities to stay connected.

Text Messaging: The Relationship Lifeline

Research consistently shows that text messaging is the most frequently used form of remote communication in both long-distance and geographically close relationships, followed by voice calls and video calls. Study findings add to growing literature on remote communication and suggest a uniquely positive role of texting within LDRs.

Gaming as Relationship Maintenance

Recent research reveals that playing games together is an increasingly common way for couples to maintain long-distance relationships. Digital games serve as a form of relational maintenance, though they remain relatively understudied for romantic relationship maintenance compared to socialization with friends and family.

Video Calls and Beyond

While video calling shows weaker links with relationship satisfaction compared to other forms of communication, couples in LDRs report more frequent video calling and perceive their partners as more responsive during video calls compared to geographically close relationships.

Innovative research on haptic technology, including devices like the Kissenger machine that simulates realistic kissing sensations through smartphones, shows promise for enhancing relationship satisfaction in long-distance couples during experimental trials.

Evidence-Based Strategies for LDR Success

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1. Leverage Modern Communication Technology

Take advantage of diverse communication platforms, recognizing that 67% of international LDR couples struggle with scheduling mismatches. Available communication windows often shrink as work and social commitments increase. Consider:

2. Establish Clear Expectations and Timelines

Research shows that couples tend to experience less stress and uncertainty if they have a clear timeline for reunion compared to those uncertain about their reunion. Approximately 72% of successful LDR couples discuss boundaries and expectations early in the relationship. Planning visits and creating an end date for the long-distance phase are key factors, with couples having a concrete timeline being 30% more likely to stay together.

3. Focus on Quality Communication

Trust and communication are considered the two most critical factors for LDR success, with 85% of LDR couples reporting trust as their relationship foundation and 82% emphasizing the importance of clear, open communication. Rather than using your partner primarily to vent daily stress, focus on:

4. Maintain Romance and Connection

Emotional intimacy is crucial, with 74% of LDR couples sending care packages or thoughtful gifts to show love and affection. Maintaining emotional connection in creative ways helps fill the gap created by physical distance. Strategies include:

5. Maintain Individual Growth

Don’t put your life on hold during separation. Having friends, employment, and outside interests helps manage loneliness and makes you a more engaging partner. Research shows that students in LDRs have more positive affect when off-campus than on-campus, suggesting the importance of maintaining life outside the relationship context.

6. Discuss Realities of Daily Life

To reduce the risks of idealization, couples can intentionally incorporate elements of daily life into their long-distance interactions:

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Research and clinical insights suggest that couples who engage in reality-based interactions, rather than exclusively emotionally heightened exchanges, are better prepared for eventual reunification.

Challenges and Modern Solutions

Relationship “Jet Lag” and Transitions

Recent research identifies “relationship jet lag” as a phenomenon where individuals in long-distance relationships face unique barriers to both individual and relationship health. The transition difficulties upon separation can create negative associations with the relationship itself.

Time Zone and Scheduling Challenges

Time zone differences create psychological pressures beyond simple scheduling inconvenience. When partners operate on different circadian rhythms, 67% of international LDR couples struggle with scheduling mismatches that create cascading communication effects.

Digital Age Complications

The modern dating landscape includes challenges like “Nanoship” – ultra-short relationships that form and dissolve rapidly due to digital platform ease, creating additional pressure on couples trying to maintain long-term connections across distances.

Research-Backed Success Factors

Studies using serial mediation models show that relationship maintenance behaviors predict relationship quality both directly and indirectly through dyadic trust, with effective relationship maintenance behaviors playing a crucial role in maintaining relational balance and functioning.

Recent research examining adaptive models for long-distance relationships incorporates mindfulness, sexual function, religious, and online social support domains, with data from 366 couples (aged 18-57, averaging 34.82 years) demonstrating the validity of comprehensive support approaches.

Conclusion

Long-distance relationships, while challenging, can be as fulfilling and stable as geographically close relationships when approached with evidence-based strategies. The key lies not in the distance itself, but in how couples manage that distance through intentional communication, trust-building, and relationship maintenance behaviors.

Long-distance romantic relationships have become increasingly common, especially among emerging adults. This situation reveals the importance of understanding how these relationships are maintained and the quality individuals perceive from them. Success requires commitment from both partners, strategic use of available technology, and a clear plan for eventual geographic reunion.

References:

  1. Acosta-Rodas, P., Arias-Flores, H., & Ramos-Galarza, C. (2020). Long-distance relationships: Use of technology advances in communication, idealization and satisfaction. International Conference on Human Systems Engineering and Design, 110-115.
  2. Du Bois, S., Weber, D. M., Baucom, D. H., Wojda-Burlij, A. K., Carrino, E. A., & Sher, T. G. (2022). Relationship “jet lag” in long-distance and geographically close relationships: The impact of relationship transitions on emotional functioning. Couple and Family Psychology: Research and Practice, 13(3), 157-171.
  3. Holtzman, S., Kushlev, K., Wozny, A., & Godard, R. (2021). Long-distance texting: Text messaging is linked with higher relationship satisfaction in long-distance relationships. Journal of Social and Personal Relationships, 38(12), 3543-3565.
  4. Jiang, L. C., & Hancock, J. T. (2013). Absence makes the communication grow fonder: Geographic separation, interpersonal media, and intimacy in dating relationships. Journal of Communication, 63(3), 556-577.
  5. Körün, O. (2025). Even though the long distance: Are we still going on? Dyadic trust, relationship maintenance behaviors, and relationship quality among emerging adulthoods. Scandinavian Journal of Psychology, 46(1), 123-135.
  6. Murikkattu, N. N. E., Shah, N. D., Singh, N. N., Bhatia, N. M. S., & Sinha, N. A. (2024). The experiences of individuals in maintaining a long-distance relationship through social media. World Journal of Advanced Research and Reviews, 23(2), 2736-2743.
  7. Reframe. (2025). Long-distance relationship success: 2025 tips & science. https://www.joinreframeapp.com/articles/long-distance-relationships-anxiety-2025-statistics-attachment-security
  8. Roberts, A. (2007). Long-distance romantic relationships: Attachment, closeness, and satisfaction. Dissertation Abstracts International, 68(3), 1887B
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