“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.

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.

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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.

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.

Created by Dr. William Glasser, reality therapy and its theoretical underpinning of choice theory provide a wonderful lens through which to help clients evaluate their needs. Individuals are thought to have five basic needs that their behaviors seek to satisfy in order for them to be happy and fulfilled. These are: survival or self-preservation; love and belonging; achievement; independence or freedom; and fun. All behavior is believed to be an attempt to meet these needs—even when the behavior is unhealthy or harmful (Glasser).

Having children and adults evaluate their needs has multiple benefits. It immediately shows the therapist or counselor what is in abundance in these five areas of the client’s world and what is lacking. It provokes client awareness and a highly relevant dialogue, and is empowering for clients in that it helps them to see they are usually the catalyst of any hoped-for change.

In working with children, I utilize a graphing utility, designed by Arlin Peterson, called Pete’s Pathogram (Peterson). The five basic needs are depicted on the “X” axis, and the “Y” axis shows the degree to which the need is being met with a range from 0 (not met) to 10 (totally met). Children “score” their needs with me on the paper graph. Inner-city schoolchildren will often score themselves with a 3 or 4 on the “survival” need.

When asked a series of question that seek to provoke self-reflection, a conversation will usually ensue about the dangerous neighborhood in which they live, fears of gangs, shootings, violence in the home, and sometimes shortages of food. Counselor/therapist and children can process these very real fears and discuss if there is a way to improve the degree to which a need is being met. For instance, asking a child why that score is low and what it would take to make that survival need score a 5 might encourage a conversation about a move to a different neighborhood, their being alone less frequently in the home, providing them an additional meal at school, or having their parents come in for counseling. One by one, clients score each need.

Utilization of this exercise provides an opportunity for immediate insight into the client’s life at a profound level. As counselor/therapist and client reflect on the degree to which a need is being met, the balance or imbalance of the five basic needs in the client’s life becomes apparent. This exercise works extremely well with adults also. The workaholic will score himself/herself a 10 on the achievement need, but he or she will most likely rate low for love and belonging, fun, and freedom.

The evaluative, self-reflective, and internalizing elements of this exercise are extremely rich, in my opinion. Clients are supported to identify ways they can create change for the better. As with the creation of one’s quality world through the use of pictures and words (explained in my first blog), the client’s active role in examining the five basic needs with the therapist can rapidly provide rich content with which to work.

References:

1. Peterson, Arlin V. (2008). Pete’s Pathogram. Action Printing, U.S.
2. Glasser, William (1998). Choice Theory. A New Psychology of Personal Freedom. HarperCollins Publishers, Inc., N.Y.

The pages of women’s magazines are filled with articles offering methods for encouraging men to propose marriage and entire websites are dedicated to increasing a person’s marry-ability. Both men and women can be hesitant about marriage, and when romantic partners have different opinions of marriage, the conflict can be challenging to resolve.

It is possible, however, to have a committed and loving relationship without marriage, and some people who are uncomfortable with marriage ultimately change their minds. A disagreement about marriage doesn’t have to end your relationship, particularly if you both are committed to the relationship.

Avoiding Marriage

If you’re itching to get married and your partner resists, it’s easy to assume there’s a problem with the relationship or that your partner isn’t fully committed to you. These issues could indicate that it’s time to consider moving on. But there are myriad other reasons people are uncomfortable with marriage that have nothing to do with the relationship. Cohabitation is an increasingly popular option; one 2013 study found that 32% of couples chose long-term cohabitation over marriage. Some reasons your partner might be uninterested in marriage include:

• Discomfort with the events that surround a wedding, the costs associated with getting married, or family conflicts that can arise when a couple exchanges vows.
• Fear of divorce.
• Fear of losing one’s individual identity.
• Wanting to “test” the relationship a little longer before taking the plunge.
• Disliking the historical implications of marriage, which include viewing women as property and men as little more than providers.
• A desire to avoid an institution in which some same-sex couples can’t participate.

The Role of Communication

As with so many other relationship issues, open and honest communication is the key to resolving disputes about marriage. You might assume you know your partner’s reason for avoiding marriage, but you don’t really know until you ask. Hearing that your partner is concerned that marriage might change the relationship will likely feel a lot better than simply assuming your partner doesn’t want to get married because he or she doesn’t love you.

And for partners who want to get married, explaining clearly and logically why you want to get married can make a big difference. The benefits of marriage include automatic paternal legitimation for children, significant tax benefits, and shared insurance. Pointing these out to your partner could help, but addressing his or her concerns is equally important. You might be able to come to an agreement about when you’ll reevaluate the marriage question and how you’ll address insecurities and relationship logistics in the meantime.

While you might feel hurt if your partner doesn’t want to marry you, it’s important to consider that marriage might mean something completely different to your partner. Consequently, it’s wise to focus on other ways to get your needs met rather than making marriage a deal-breaker. If, however, you can’t stay in a relationship that doesn’t end in marriage, trying to push the relationship toward marriage can cause it to fall apart. It might be better to end things now.

Addressing Potential Concerns

If you and your partner agree to live together without getting married, you’ll have the freedom to pick and choose which marriage benefits you want to take advantage of and which you want to avoid altogether. A simple contract, for example, can outline who owns what property and how it will be divided if you split up. And if you have a child together, you’ll need to ensure that both parents are listed on the birth certificate or that the nonbiological parent adopts the child. You won’t be able to get tax benefits, but you can still combine your lives in a way that works for both of you.

References:

1. Aleccia, J. (2013, April 4). “The new normal”: Cohabitation on the rise, study finds. NBC News. Retrieved from http://www.nbcnews.com/health/new-normal-cohabitation-rise-study-finds-1C9208429?franchiseSlug=healthmain
2. Roberts, S. (2013, April 9). Against marriage: A ring does not define a relationship. The XX Factor. Retrieved from http://www.slate.com/blogs/xx_factor/2013/04/09/the_case_against_marriage_a_ring_doesn_t_define_a_relationship.html
3. Schwyzer, H. (2011, February 16). Why some men don’t want to get married. Alternet. Retrieved from http://www.alternet.org/story/149941/why_some_men_don’t_want_to_get_married

Premature termination with people in therapy happens with both seasoned and newly licensed therapists. In a study that talked about the therapeutic relationship and psychotherapy outcome, it shows that 20 to 57 percent of people in therapy do not return after the initial session (Lambert). Another 37 to 45 percent only attend therapy a total of two times (Schwartz). Sometimes these people leave without warning, but sometimes they do give some signs they won’t be returning, even if they do not directly explain them. Some will contact the therapists by email, will leave phone messages, or simply will not show up for their appointments. These people may come back much later, or not all. Many will also find a new therapist when they want to resume their therapy work.

There can be many reasons for this. I have had some people and personal contacts share some of their reasons with me. Here are some common reasons I’ve heard:

The ‘Can of Worms’

People realize therapy opened a bigger “can of worms” than they were prepared to handle. They say hindsight vision is 20/20. I wrote in my previous article, Helpful Tips to Make Therapy Most Effective for You, that one of the things to keep in mind during therapy is what you want to achieve or gain in therapy. Sometimes we don’t always know, even when we are posed that question. We can identify that we are struggling in some area of our life, or we are in some pain either emotionally or mentally, and we want some relief. We find the therapist we have a good connection with, make the appointment, and go in for our sessions.

Sometimes, we never know what to expect. Some have really good results; others have light-bulb moments with increased insight. Some, however, are taken aback by the depth of therapy, and they realized they didn’t want to go further at that time. One particularly candid response I heard from someone in this position was, “it was just too hard and painful at the time, and I just didn’t want to see what else was there.”

Subconscious Resistance

I don’t often hear people in therapy say, “I don’t think I’m ready to continue with this issue.” Sometimes other reasons come up, which is known as resistance. Therapy can provide wonderful possibilities, benefits, and outcomes, but occasionally we still resist the experience. This may be because of fear of success, failure, feeling overwhelmed by truth, fear of the unknown, or simply overwhelming emotions.

Therapeutic Breach

Misunderstandings, miscommunications, and impasses can often happen between therapists and people in therapy during the treatment duration. In the study mentioned earlier, the top reason people dropped out of therapy after the initial session was dissatisfaction with the therapist, or the feeling that the therapist didn’t really “get” them. There can be both competent and unprofessional behaviors found in all professions, and this is holds true in the therapy world. Further, even with the best training and the heart to serve people, the best therapists are not omnipotent, nor will they be perfect in their approach.

Many interventions are chosen according to what the person in therapy presents. Some will make unintentional mistakes or misunderstand what people meant. Therapy is not like getting a medical exam. There is no therapeutic equivalent to getting blood drawn, waiting for it to be studied, then receiving a detailed evaluation and report. The journey of healing through therapy must be a collaborative effort to be effective. If or when a therapeutic breach happens, a person may choose to drop out prematurely, or avoid the elephant in the room—the elephant being that there’s something hindering your therapeutic growth; you can feel it’s there but you are not able to talk about it. Alternatively, the person in treatment and therapist could have a dialogue, which can offer the most constructive growth for both parties. Often, however, it’s difficult to initiate that dialogue.

Giving Feedback

Healing in therapy is not just about getting results and meeting goals; it is also about the process of the therapeutic relationship. It is about how things unfold as you are exploring issues with your therapist. Therefore, sometimes constructive feedback is needed from people in therapy to minimize impasses and misunderstandings. This proactive approach can itself be a reflection of significant growth. For example, let’s say this person has relational difficulties, such as discussing vulnerable feelings. This is a wonderful opportunity to practice giving constructive feedback, which the person can then apply to other relationships. A competent therapist will often be very receptive to constructive feedback at any time during the sessions.

Readiness for therapy often comes at a point where people experience greater pain and discomfort by remaining personally stagnant than by initiating small adjustments in life to feel better in the long run. While there is no exact time frame for those lasting changes to occur, that readiness provides that platform for real growth to occur. The key is consistency. Premature termination sometimes cuts that opportunity short, despite improvements thus far in therapy sessions. Therapy, no matter the duration, is not a pass-or-fail experience, but rather an opportunity for positive growth with the right therapist.

References:

1. Lambert, M., J. & Barley, D., E. (2001). Research Summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy, 38, 4, 357-361.
2. Schwartz, Bernard, PhD and Flowers, John, PhD. (2010). How therapists fail: Why too many clients drop out of therapy prematurely. Impact Publishers.

In my work with adult survivors of sexual assault, I am beginning to notice a pattern of behavior that I have termed “wounded attachment.” The impact of childhood sexual assault has reverberating effects on almost every facet of survivors’ livelihood, from relationships with family, friends, partners, spouses, and children to their jobs, finances, faith, etc. It is as if sexual assault redefines one’s pattern of and trajectory in life.

Sexual assault is the act of forcing, enticing, intimidating, or coercing another person to engage in a sexual activity, from fondling to coitus, when the other person is unwilling or unable (as is the case of one who is underage, drugged, or unconscious). Imagine yourself as a child, seeing the world through a child’s eyes, and then being introduced to a violent act—an act that serves to not only damage one’s physical body and mental/cognitive mind-set, but also disrupt one’s spiritual being.

This one act for some—repeated acts of violence for others—does untold amounts of damage to one’s psyche. Yet the resilience I’ve witnessed from many who choose to live their lives after the violence is remarkable. Unfortunately, for many the damage is such that many are unaware of how it has skewed their way of looking at the world. This sometimes is displayed in the relationships subsequent to the sexual assault.

Far too often, survivors believe that once the assault ends, it is done and they don’t need to talk about it. Yet the choices made, the decisions not made, and the relationships that come afterward tell a different story. Wounded attachment is an insidious component that I have seen repeatedly in my work with adult survivors of childhood sexual assault. What is wounded attachment? It’s the unconscious way of being attracted or attached to someone or something that reminds the survivor of or reinforces the wound/trauma, or in this case the sexual assault. At its core, it’s the way in which survivors subconsciously seek out relationships that reinforce the wounded aspect of themselves.

[fat_widget_left]Sometimes it is displayed in the choice of employment/work. For example, survivors may find themselves working at a job that belittles them, makes them feel worthless, or where they feel like they have to make everyone else happy at the expense of their own happiness, thereby reinforcing their wounded concept of self. Another example is when a survivor is continually engaged in romantic relationships that serve to reinforce the wounded parts of self.

As a child, depending on when the assault occurred and the developmental stage in which it occurred, the person seeks to please the adult and gain affection, attention, nurturing, love, trust, etc. A child who has been sexually assaulted blurs that idea of love, nurturing, trust, attention, and affection, and begins to believe that the only way to receive love, attention, etc., is to please the “assaulter.” This remains in effect as the child matures into adulthood.

Although the assault is no longer occurring, if the child did not receive any type of counseling, intervention, or effective treatment to process and repair the damage to the mind, body, and psyche, then this adult is continuing to live out the wounds experienced as a child. As such, the adult becomes caught in a cycle of relationships that reinforce the wounded attachments. Awareness of this plays a crucial role in helping adult survivors of sexual assault move toward recovery, resiliency, and healing.