Negative self-views and self-appraisals are commonly associated with depressive symptoms. Individuals with major depression, as well as those with depression related to bipolar, often experience low self-esteem, feelings of worthlessness, and overall negative self-concept while in their depressive states. In contrast to these feelings, high levels of self-esteem, goal attainment, and motivation are often evident preceding or during manic episodes.

But according to the results of a new study led by Hana Pavlickova of the School of Psychology at the University of Wales Bangor, negative self-beliefs can also predict manic episodes in people with bipolar. Pavlickova theorized that the comorbidity of both positive and negative affect might exist during periods of no symptoms and also during periods when symptoms were present. Understanding how this overlap affects each mood state could help determine when manic or depressive episodes might occur and also could provide opportunities for intervention prior to those episodes.

For her study, Pavlickova evaluated 253 participants with bipolar several times over the course of 18 months. She looked at depressive and manic symptoms and how self-esteem, self-appraisals, internalization, externalization, and other behaviors influenced the symptoms.

The results revealed that self-esteem was most strongly associated with both mood states. In particular, low self-esteem was linked to depression and high self-esteem to mania. However, negative self-esteem, although highly predictive of depressive symptoms, also indirectly predicted manic episodes. Pavlickova discovered that although cross-sectional data indicated a direct association between negative self-esteem and depression, longitudinally, negative self-esteem was weakly but clearly associated with mania.

She explains this finding by suggesting that individuals with bipolar may overcompensate for feelings of negative self-worth by actively avoiding any depressive emotions and engaging in high levels of externalizing, which could provoke manic behaviors and symptoms. These results are novel in that they demonstrate the overlapping relationship of negative self-evaluations in bipolar. Pavlickova added, “In terms of clinical implications, the findings accentuate the importance of the therapeutic management of negative self-concept shared by both depression and mania in bipolar disorder.”

Reference:
Pavlickova, H., et al. (2013). Symptom-specific self-referential cognitive processes in bipolar disorder: A longitudinal analysis. Psychological Medicine 43.9 (2013): 1895-907. ProQuest. Web.

I 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?

Many who live with disabilities are burdened by a chronic sense of shame that can be as difficult to live with as the actual disability. Shame is not the same as guilt. Shame is persistent and represents how we feel about ourselves (“I am a shame and disgrace”) rather than how we feel about something we did or did not do (“I feel guilty and embarrassed”).

The term “ashamed” is often used interchangeably with “humiliated.” Shame may be the result of humiliation, but not humility. Humiliation entails stripping a person of his or her sense or worth—of wounding the person’s very being. Humility is more a sense of meekness or equality with others. Dr. Brené Brown has been researching shame and vulnerability for a few years, asking people how they experience shame. Many say it makes them feel small and vulnerable; it includes an almost physical sensation of being kicked in the gut; it takes them to place that feels wounded; and they want to disappear.

How does this happen? How do we begin to feel wounded? Small? Vulnerable? Shamed? Humiliated? It is usually a response to something that happens to us—that is done to us. We are somehow victimized, humiliated, or traumatized by the actions of a person or people who inflict injury upon our sense of self—our very being.

This wounding may be intentional or inadvertent: The shame of a child whose first-grade teacher refused to allow her to go to the bathroom, resulting in an accident in her clothes in front of the whole class. The man who can’t read well enough to complete a job application being verbally harangued by an uncaring receptionist in front of an office full of people. A person in a wheelchair who is “holding up the line” for an elevator when a busy executive is in a hurry. The family with an older autistic child boarding an airplane in advance while others accuse them of making excuses to avoid waiting.

Regardless of the source, this pervasive sense of shame can result in a lifetime of fear, avoidance, and anxiety when faced with issues that trigger similar feelings. The triggers may be subtle and seemingly unconnected, but that feeling of being diminished remains.

For the first-grader who was humiliated by the refusal of her teacher to allow her to go to the bathroom, triggers may transfer to a dislike for authority figures, issues with toileting, or avoidance of school.

The man with difficulty reading who was humiliated by the lack of awareness or disregard of the receptionist may avoid looking for work, find that he is defensive with people working in offices, or resist going to the doctor if it requires filling out forms.

A person in a wheelchair who was humiliated due to holding up the elevator and inconveniencing the busy executive may avoid leaving home, resist taking the safety precautions necessary in a busy location, or feel “less than” people in white-collar jobs.

The family of the child with autism may avoid traveling by plane, become defensive when in need of special treatment, or limit interactions with people waiting in line.

I recommend that those who have feelings of shame learn more about the causes and triggers by getting professional help to address these feelings. Two types of therapy—EFT (emotional freedom technique, aka tapping) and EMDR (eye-movement desensitization reprocessing)—may reduce or eliminate shame reactions.

Are you a “beaten dog”? Rest assured, I’m not calling anyone names here. But have you been kicked around, treated like nothing, and hurt? Do you not feel loved unless you are treated badly? This is what I mean when I say “beaten dog.” If you are offended, maybe some truth is staring you in the face. If you are not offended, I’m glad—and while this may not apply to you, perhaps it does apply to someone you know.

If it does apply to you and you can see how this role has affected your life, I want to apologize. No one should feel beaten, abused, and treated so poorly that he or she feels unworthy and believes life is cruel. I hope you seek help in breaking this mind-set and take hold of the reality that you ARE worthy!

Some questions you can ask yourself:

1. When someone is nice to me, do I question it? Do I question that the niceness is sincere?
2. When things are calm and smooth, do I need to throw a fit so that I can verify that I am loved via being yelled at?
3. Do I want or tend to take advantage of a person’s niceness because I believe I can?
4. Do I pick negative, hurtful people to be around?
5. Am I envious of others who are in healthy relationships?
6. Do I want a healthier relationship but believe I can’t have one?
7. Do I believe that this is how things will be for the rest of my life and that nothing—not even me—can change?

To change a self-belief statement or self-perception, admitting the need to change is a must. If you change for someone else, the change may not last long. Identifying how you respond to the above questions is key. Looking at ourselves can be a difficult and painful challenge, but it is where healing begins.

A self-belief statement can be defined as how you view who you are, how your “world” is, and how things (positive or negative) happen/happened to you. When someone is brought up in a negative, abusive, and painful environment, a negative self-belief is formed. The self-belief statement can be changed, but it can be difficult and takes time.

To change a negative self-belief statement:

1. Identify and be aware of your negative self-belief statement. As Dr. Phil says, you can’t change what you don’t acknowledge.
2. Self-examine your thoughts and mind-set, and take responsibility for why your belief statement is negative.
3. Acknowledge what you can and can’t change. Example: You can’t change what happened to you growing up, but you can change how you respond and whether the past controls you.
4. Grieve. You lost out on a healthier childhood, the unspoken expectation that the adults in your life would be there to help you grow. Let go of the pain. Mourn. Cry.
5. Forgive. It’s a hard thing to do. Forgiveness is for YOU, not for them. To lose the power that the past has over you, forgiveness is key. Forgive shortcomings, failures, pain, whatever. Let go. Forgive yourself for not being perfect. When you forgive, you’ll feel less weight on your shoulders and be able to move on a little easier. Forgiveness is a part of a cleansing process, allowing healing to begin.
6. Redefine yourself—who you want to be, how you want to be, the type of people you want to be around, etc. Your personality may not totally change, but you can choose to be happier, to not let the same roadblocks stand in your way, and to have healthier relationships. You can choose to be a person who is not going to allow yourself to be kicked around anymore. Find what is good in your life; maximize those things while minimizing your weaknesses.
7. Be at peace with yourself. Self-acceptance is a great accomplishment. No one can do this for you. When you love and accept you, other people will see that and be drawn to it. Self-acceptance allows your inner beauty to shine.

This is a process. It’s not always easy. Personal growth is not a straight journey. It has lumps, bumps, breaks, and is topsy-turvy. But if you are moving toward health, you will get there.

Recent research continues to support the connection between shyness and relationship challenges, with studies showing that shyness is “negatively associated with concurrent marital satisfaction” and linked to “declines in marital satisfaction” over time. While shyness may seem like a minor personality trait, emerging evidence suggests it can significantly impact romantic relationships and overall partnership satisfaction.

According to a landmark study by Sarah L. Tackett of the School of Family Life at Brigham Young University, shyness can indeed affect relationship dynamics. Her research examined how shyness affected self-esteem and relationship satisfaction in a sample of 14,807 romantic couples. While this foundational research from 2013 provided important insights, more recent studies have expanded our understanding of how personality traits like shyness influence romantic partnerships.

For the study, Tackett asked each partner to rate the other on levels of shyness. Then, each partner was to rate their own shyness and self-esteem. Finally, each partner was asked to rate their overall level of relationship satisfaction.

The results revealed that perceived shyness of one partner was directly predictive of that same partner’s low self-esteem and low relationship satisfaction. In other words, if a husband saw his wife as shy, the wife reported low levels of self-esteem and satisfaction with the relationship. The same pattern emerged when women perceived their partners as shy.

More recent research from 2021-2023 confirms these findings, showing that “shyness is negatively correlated with self-esteem” and that shy individuals often struggle with self-presentation, which can impact relationship dynamics. A comprehensive study of 1,020 women found that “shyness turned out to be negatively correlated with global self-esteem” and showed negative correlations with personal power, lovability, and relationship competencies.

These results show that shyness can create a path for unhappy relationships. Researchers believe there are many reasons for this trajectory:

Communication Challenges: Perhaps shy individuals are uncomfortable voicing their opinions and find it easier to accept an unsatisfying relationship than to pursue a new, more rewarding one. Recent studies confirm that “trait introversion was significantly associated with communication apprehension, including group discussion, meetings, and interpersonal” communication.

Self-Esteem Impact: It’s important to distinguish between normal shyness and social anxiety disorder, which “usually starts during childhood or adolescence and may resemble extreme shyness” but requires professional attention.

Limited Shared Experiences: When couples can engage in activities together, they can share the joy of those experiences. If one partner is introverted

Current research indicates that shyness “correlates with defensive styles of self-presentation” and “implies lower relationship satisfaction,” supporting the original study’s conclusions. However, newer studies also show that “individuals who had secure relationship attachments realized a buffering effect between shyness and well-being,” suggesting that “relationships can both minimize and maximize the negative effects of shyness”.

The research sheds light on some of the challenges couples with differing personality styles may face, but also points toward solutions. Recent therapeutic research shows that “integrative behavioral couple therapy (IBCT)” can help “improve constructive communication patterns and mitigate destructive ones in couples,” particularly benefiting “dyadic cohesion, affection, dyadic satisfaction, and dyadic consensus”.

For couples dealing with shyness-related relationship challenges, it’s important to understand that personality traits like shyness exist on a spectrum and can be addressed through therapy and communication strategies. Professional support can help partners understand each other’s needs and develop effective coping strategies.

*This information is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.*

Tackett, Sarah L.; Nelson, Larry J.; and Busby, Dean M. Shyness and relationship satisfaction: Evaluating the associations between shyness, self-esteem, and relationship satisfaction in couples. American Journal of Family Therapy. Jan/Feb2013, Vol. 41 Issue 1, p34-45. 12p. 1 Diagram, 1 Chart. DOI: 10.1080/01926187.2011.641864.

References:

1. Tackett, Sarah L.; Nelson, Larry J.; and Busby, Dean M. Shyness and relationship satisfaction: Evaluating the associations between shyness, self-esteem, and relationship satisfaction in couples. American Journal of Family Therapy. Jan/Feb2013, Vol. 41 Issue 1, p34-45. 12p. 1 Diagram, 1 Chart. DOI: 10.1080/01926187.2011.641864.
2. Baker, L., & McNulty, J. K. (2010). Shyness and marriage: Does shyness shape even established relationships? Journal of Personality and Social Psychology, 98(6), 1048-1066. https://pubmed.ncbi.nlm.nih.gov/20363900/
3. Battle, N., & White, G. (2024). Intimate Introverts: Influence of Introversion on Self-Disclosure and Emotional Intimacy in Close Friendships. Journal of Mental Health and Social Behavior, 6(1), 188. https://gexinonline.com/uploads/articles/article-jmhsb-188.pdf
4. Bober, A., Gajewska, E., Czaprowska, A., Świątek, A. H., & Szcześniak, M. (2022). Impact of Shyness on Self-Esteem: The Mediating Effect of Self-Presentation. International Journal of Environmental Research and Public Health, 19(1), 230. https://pmc.ncbi.nlm.nih.gov/articles/PMC8744881/
5. Mandal, E. (2023). Shyness and self-esteem in women. The role of likeability, personal power, lovability, and self-worth conditioned by others’ approval. Current Issues in Personality Psychology, 11(4), 310–318. https://pmc.ncbi.nlm.nih.gov/articles/PMC10699290/
6. National Institute of Mental Health. (2024). Social Anxiety Disorder: What You Need to Know. U.S. Department of Health and Human Services. https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness
7. Rowsell, H. C., & Coplan, R. J. (2013). Exploring links between shyness, romantic relationship quality, and well-being. Canadian Journal of Behavioural Science, 45(4), 287-295.
8. Tackett, S. L., Nelson, L. J., & Busby, D. M. (2013). Shyness and relationship satisfaction: Evaluating the associations between shyness, self-esteem, and relationship satisfaction in couples. American Journal of Family Therapy, 41(1), 34-45.
9. Research team. (2023). Effects of integrative behavioral couple therapy on communication patterns and marital adjustment. Journal of Education and Health Promotion, 13, 280. https://pmc.ncbi.nlm.nih.gov/articles/PMC11414875/

Don’t wait for trouble to set in when it comes to the enriching elements of your life, such as sensuality and sexuality. Often, we are draining ourselves of the essence in our sexual, erotic selves through seemingly small, inconsequential thought and behavioral patterns.

This article addresses some of the most common drains to our sexual energy. I encourage you to use it as an awareness-raising exercise and to begin to investigate your own energy drains. In response to what you learn from your own self-reflection and investigations, you may begin to compile and act on antidotes to your drains.

• The great storyteller: Being in your head too much creates performance anxiety and, sometimes, perfectionism. Telling yourself that your skills aren’t up to par, or wondering if your lover’s last lover was better or more interesting than you in the sex department, will keep you from fully engaging all your senses and fully being your erotic self. If you are telling yourself that sexual engagement with another (or yourself) has to look like candles and a quiet house, you are engaging in a false story and draining your sexual energy. You may have authored a story that is keeping you hostage.
• Swinging for the fences: When we engage in all-or-nothing thinking, we miss out on opportunities to replenish our sexual energy. No time for a long-lasting lovemaking encounter? Do not forgo a wonderful, engaged, 30-second kiss or a good, ol’-fashioned make-out session. The dog needs to be walked, there are bills to be paid, and you have phone calls to return, but give yourself time and space to indulge in some physical contact before tackling the rest of life. Trust me, it is far more enjoyable putting sexual energy replenishment at the top of your to-do list than skipping the kiss because you don’t have time for a full lovemaking session. When we assume sexual engagement must be a “home run” every time, we are draining ourselves and missing the opportunity to replenish our sexual energy.
• Relying on the goodness of others: Relying on your partner(s) to replenish your sexual energy by initiating or expressing interest is enemy No. 1. Your strength and sexual energy, including self-esteem, self-care, self-love, and empowerment, are all too often thought to be somebody else’s job. When we as individuals fulfill our own needs, we embark on a new way of relating to ourselves and others. To feel good about ourselves outside of the bedroom is essential to feeling good in the bedroom.
• Glory days: It’s particularly draining to ourselves, relationships, and sexual energy when we dwell on “better times” in our relationship. Within a longstanding relationship, we tend to think back to when we first met our partner and lament the times we couldn’t keep our hands off each other. One of the greatest gifts we have as humans is relating and relationships. Yes, it tends to be that the closer we get to our intimate partner, the flame can be dampened, however the fuel to that fire is drained only by focusing on “how it used to be.” In Patricia Love’s book, The Truth about Love: The Highs, the Lows, and How You Can Make It Last Forever, she shares with readers the predictable stages of “better times” and a more enriching, emotionally intimate relationship, which is often coupled with less “firework” sex. It is essential to understand the ebb and flow of sexual energy.
• Keeping score: Unresolved resentment and conflict, and not voicing our own needs, drains our sexual energy. Gatekeeping, policing, and “giving to get” drains the sexual energy from us and our relationships. Our sexuality is not a weapon or a reward system. When we engage in this thinking and pattern of interacting with our lovers, we drain the essence of our sexual selves.

So, what stories are you telling yourself? What habits need a little tweaking in order to replenish your sexual energy? I encourage you to monitor your own thinking and behavior patterns, and note what drains you and what replenishes you. Enjoy!

Sexism is overtly exhibited in nearly every aspect of modern society. Women and adolescent girls, in particular, are especially likely to experience the deleterious effects of sexism. Whether it is a model in a magazine, an actress on television, or a mannequin in a store window, images of how women should look, dress, act, and even react are everywhere. Adhering to society’s unrealistic and often varied models of the ideal woman makes it difficult for women to find and accept their own identities and bodies. In fact, the sexist beliefs associated with women, both negative and positive, have been linked to numerous physical and mental health issues for women, including depression, anxiety, binging, purging, and anorexia. Young women are also heavily influenced by the opinions and judgments of those closest to them, including their family members, friends, and coworkers. Understanding how the beliefs of others and internalization of those beliefs affects a woman’s body image is necessary in order to help women overcome any challenges related to self-worth, self-esteem, and positive self-image.

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Debra L. Oswald of the Department of Psychology at Marquette University in Wisconsin wanted to explore the negative and positive (hostile and benevolent) sexist attitudes toward young women and how these attitudes affected their beliefs about their own body images. In one study, Oswald assessed how a father’s benevolent sexist beliefs, those that positively affirmed the traditional female role and appearance, shaped daughters’ self-image. In a second study, Oswald looked at how subtle and overt hostile sexism affected self-image. She found that overall, hostile sexism from peers, friends, and family members led to negative body esteem. However, hostile sexism from parents did not. Oswald also discovered that a father’s benevolent sexism was directly linked to positive body esteem in daughters. This finding is concerning because it suggests that although young women may feel good about themselves when they conform to traditional female roles, when they step out of those roles, they may be met with hostile sexism which could decrease their sense of self-esteem and negatively affect body image. The results of this study also imply that sexism contributes greatly to a woman’s physical and mental self-image. “We hope this research highlights the complexity of these cultural beliefs and encourages researchers and clinicians to take this wider cultural context into consideration when examining and treating women’s body esteem issues,” said Oswald.

Reference:

1. Oswald, Debra L., Stephen L. Franzoi, and Katherine A. Frost. Experiencing sexism and young women’s body esteem. Journal of Social & Clinical Psychology 31.10 (2012): 1112-137. Print.

Women have many roles. They are sisters, friends, daughters, mothers, and wives. And most women are employed in some capacity, with or without pay. Whether they work at home—raising children and running the house—or they enter the workforce as an employee, most women work. For young women, the transition from student to worker can be challenging. Equally difficult can be the reentry into the workforce for women who return to a job after having stayed home to raise children. How a woman approaches these transitions can affect not only her success in this pursuit, but also her self-esteem and well-being.

David Weiss of the Department of Psychology at the University of Zurich in Switzerland looked at two specific factors in women’s work-related aspirations. First, he looked at how openness influenced the experience. Second, he gauged how women’s gender ideology affected outcome. Weiss conducted a study that followed 61 young women as they left high school and began careers. He then looked at more than 800 women’s transitions from school or parenthood to work. Weiss found that the women who were lower in openness embraced traditional female gender roles, while those with more openness embraced nontraditional gender roles.

Those women who were more open demonstrated high levels of self-efficacy and well-being. Women who were less open fared poorly when they tried to step out into nontraditional female roles. “Taken together, the present research suggests that endorsing an ideology that provides strong behavioral guidelines can help women low in openness to master the challenges of a developmental transition,” Weiss said. He added that for women who approach career choices with an open mind, working within the confines of traditional gender expectations can have negative effects on self-esteem, well-being, and overall work-related success.

Reference:
Weiss, David, Alexandra M. Freund, and Bettina S. Wiese. Mastering developmental transitions in young and middle adulthood: The interplay of openness to experience and traditional gender ideology on women’s self-efficacy and subjective well-being. Developmental Psychology 48.6 (2012): 1774-784. Print.

My friend and colleague, Linda Poelzl, has been working as a professional surrogate partner for 17 years. As a local writer commented a few weeks ago after meeting both of us, what this means is frequently misunderstood.

Sometimes I think “sex” is the most powerful and misleading word in the English language! Call Linda a sex surrogate and people start imagining her writhing in coitus.  Call me a sex therapist and local readers post, “How sicko and disgusting that we have a sex therapist here in San Luis Obispo County!” on their Facebook walls.

Our local weekly (the New Times) was particularly excited to arrange an interview with Linda and me because of the flood of positive publicity surrounding The Sessions, a new film based on actual experiences in the late 1980s when surrogate partner Cheryl Cohen Greene worked with polio-disabled journalist and poet Mark O’Brien.

In the trailer, there is one scene in which two astonished hotel workers watch a nervous and paralyzed O’Brien being loaded into an elevator on a stretcher. When one of them asks why they’re taking him upstairs, the other explains that he has an appointment with a “sex therapist,” a misnomer that has Linda and other surrogates feeling frustrated.

“The public doesn’t comprehend that you and I work together to help people heal!” she says. Where my work as a therapist is psychological, Linda’s is physical, employing exercises focused on intimacy, body image, relaxation, and the giving and receiving of touch or “sensate focus.” Sexual intercourse occasionally does occur, but it is a minor part of her work.

Common presenting issues for men include rapid ejaculation, delayed ejaculation, and very often, simple inexperience—one of Linda’s current clients is a 32-year-old virgin. “He’s never, until recently, held hands, kissed a girl, had sex,” Linda says. “He’s a gorgeous guy! There are a lot of people around who are silently suffering.”

Some people refuse to differentiate what Linda does from prostitution, she explains. What they don’t comprehend is that she never works alone. After each session, she relates her impressions to me, which enables me to better assist clients through many challenges toward sexual healing.

I, in turn, communicate with Linda after each talk session in my office, and the three of us usually meet together to conclude the surrogate’s involvement. Legitimate surrogate partners always work in tandem with therapists who have an ongoing established relationship with the client they refer.

I was introduced to Linda by Cohen Greene herself, and we’ve worked together for much of this year. Her approach is gradual, with the first sessions devoted to getting acquainted, discussing issues, and building rapport. “I’m going to touch you, and you’re just going to relax and feel and enjoy it, and then we’ll check in at the end …”

“And that’s usually like hands and face and maybe a foot rub—the first couple sessions are with clothes on, usually,” Linda says. “And sometimes if the client is ready and I’m ready, we might take clothes off in the third session … to do an exercise called ‘Body Image’ … it’s more about being comfortable with each other nude before we get into being sexual …

“We answer questions. I talk about condoms and safe sex. Then we usually get into bed … and I ask them about their bodies, and how they like to be pleasured. After that, it pretty much gets into whatever their problem is. If they have rapid ejaculation, we do exercises to work on control and awareness. A lot of times people think it’s all about intercourse, and it’s not. That’s a small part. Usually by the time they’re ready to do a lot of that, they don’t really need me anymore.”

If the client is able to form a bond with the surrogate, this means the person is capable of falling in love with future partners “out in the real world.” After finishing work with the surrogate partner, the client generally continues ongoing intimacy work with me as “talk therapy.”

It’s natural intimacy work, pure and simple. Many people yearn for the physical experience, the orgasm, without the relationship, without the intimacy. One without the other never satisfies in the end. So the work that Linda does, in conjunction with the work that I do, is invaluable.

I’ve been thinking about grief, mourning, and loss a lot lately. It shows up as a theme in my work as a psychotherapist all the time. I’ve also been studying the literature on methods of providing grief counseling and grief therapy. What I realize is that my sub-specialty in this area is not limited to working with individuals who have experienced the death of a loved one. It is more far-reaching than that. Judith Viorst wrote a wonderful book, Necessary Losses: The Loves, Illusions, Dependencies, and Impossible Expectations That All of Us Have to Give Up in Order to Grow, in the mid-1980s in which she described the losses we experience along the life cycle. It’s a must-read for people who are unfamiliar with it.

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I would venture to say that most of the work we as psychotherapists and spiritual counselors do is about coping with loss. We help our clients grieve about their losses, whether it’s loss of youth, money, job, socioeconomic status, or friends. They need to be helped to grieve the loss of hopes and dreams. They even grieve the loss of fantasies and illusions, although much of this happens unconsciously. In this case, our job as psychotherapists and counselors is to help them recognize that they are in mourning and provide tools to cope. The idea is that grief takes up a lot of psychic space in our beings, and it is only by coming to terms with our losses that we create room for the new.

The focus of this article is how many people typically grieve. The ways—which are not healthy—include:

• deny
• become anxious or depressed, or a combination of both
• engage in risk-taking behavior such as drinking excessively and driving, compulsive spending, and sexually acting out
• become an abuser, a victim, or a combination of the two
• over-eat or under-eat, and other “overs” and “unders”
• become controlling
• hoard

These are just a few of the many ways people attempt to fill the space loss creates in their psyches and spirits. With methods such as these, the loss is not completely grieved or grieved at all. The feelings may even become worse, leading to a cycle of self-harming behavior.

So what predisposes someone to engage in the self-harming and ultimately unsatisfying behavior described above? There can be many factors, including low self-esteem, a history of untreated anxiety and depression, an inability to express feelings—especially difficult ones such as anger—and the lack of a support system. There are also more complex reasons involving one’s family of origin, including trauma in early childhood and the absence of a secure connection with early caregivers.

This sense of emptiness and lack of safety makes loss intolerable rather than simply painful, and it is this inability to tolerate it that leads to the behavior described above.

In addition to these internal factors, society in general and specific cultures in particular make grieving difficult. Part of this stems from our lack of recognition of the universality of loss, i.e., as something that permeates all aspects of life and isn’t just about death. In addition, we have become a culture of short-term fixes—the “just-get-over-it-and-move-on” philosophy. This puts pressure on individuals to minimize their sense of loss.

Finally, there is the over-arching reason grief is given short shrift. It makes many, if not most, people uncomfortable because it touches unhealed grief in themselves.

Next month, I will discuss some effective and healing ways to cope with grief and loss.

When parents view their child’s “problematic” behavior, attitudes, or troubles as a reflection of them, it can be a terrible blow to the ego. For parents with positive self-feelings, anger, hurt, and disappointment can occur when they don’t see themselves reflected in their children. (“My child should be just like me.”) For parents who do not feel very good about themselves, seeing a child as being “just like me” can feel devastating. Parents who lack self-esteem often feel like their child’s problems are their fault. Their inability to differentiate themselves from their children can also result in guilt and painful feelings of responsibility that are often overstated and inaccurate. Many parents who struggle with the idea that their child is a reflection of them (for better and worse) have not separated from their children. These parents tend to feel some responsibility for their child’s situation. Most often they believe that, either in their early behavior with their children or in their biological contribution (or both), they have profoundly affected their child’s life and character.

“Peter” came to his therapy session in a rage about “Adam,” his 25-year-old son. He had just come from his son’s apartment and was disgusted about the dirt and disarray he encountered: “What is the matter with that kid? He’s such a slob. There is stuff everywhere. It feels so chaotic! I have the same feeling when I think about how he gets drunk with his friends on the weekend. He’s a mess!”

When I asked Peter what made him so angry about this, he began to express remorse about being so enraged. Choking up, he said, “I guess I’m really hurt. I feel like Adam is being disrespectful to me. He knows I hate his messes and his drinking behavior. I feel like he’s on a terrible path of disorganization and disaster. I keep asking myself, ‘How did he turn out this way?’ ”

I asked Peter what he thought about why Adam was like this. “I don’t really know,” Peter said. “But I honestly believe it’s my fault. You know I was a terrible workaholic during Adam’s first 10 years. I neglected him when he was growing up. Then I think, if I was a workaholic, will he be an alcoholic? I know I made him this way. I’m a mess of a father.” Peter was tortured by his painful feelings and disappointment that his son hadn’t turned into the ideal adult that Peter wished he could be.

Over time, as we explored Peter’s feelings, it became apparent that he put all the responsibility for the person Adam was at age 25 on himself. He found it very difficult to see Adam as a separate individual with his own reasons for behaving the way he did. Slowly, Peter was able to consider that his influence hadn’t only been negative and that he wasn’t the only influence on Adam’s development. Adam’s mother was nurturing; Adam had many friends growing up. Peter could even recall some teachers who were influential in Adam’s life. He acknowledged, for example, that a high school teacher had encouraged Adam to stay with his music, and Peter admitted that Adam was a successful musician.

“I guess I haven’t focused enough on Adam’s successes, just on the ways I see him as a failure and blame myself,” Peter said. “Sometimes I still think that maybe Adam is punishing me when he messes up in ways he knows I hate. I guess I really have to admit that it isn’t all about me. Adam is a different person from me. It’s just hard to be OK with that. But I do want to get there. I know that would be best for our relationship.”

Peter is slowly beginning to separate from Adam and experience Adam’s successes and failures as more about Adam than him. He is also beginning to take Adam’s character and behavior less personally. Giving up the idea that “it was all my fault” makes space for Peter to see Adam as a separate individual.

“Rose,” another client, began to talk about her 10-year-old daughter, “Jessica,” in our therapy sessions.  Rose was obsessed with worry that Jessica, who had learning disabilities, would never have a successful life. She said with some sadness: “Her brain is damaged. How will she ever be OK?”

“What do you mean, ‘Her brain is damaged’?” I asked.

“You know that we had her tested and she has so much trouble focusing and organizing her thoughts,” she responded.

“Yes, I know she has some learning disabilities, but seeing her as ‘a person with a damaged brain’ seems a rather extreme way of defining your daughter,” I said.

“I sort of know what you’re saying is true,” she said. “But you know I had learning disabilities as a kid. No one identified them; no one did anything about it. I still struggle at work and in my life in general with being focused and organized. I get so depressed and anxious when I forget things or don’t get stuff done like I promise my husband or my boss. I know my brain is messed up, and Jessica is just like me. Why would I think her fate is going to be any different?”

Rose had a very strong belief that biology was determining her future as well as her daughter’s. She was reluctant to consider that her daughter’s life could take a different path from hers. She had a difficult time thinking about Jessica as a separate person with her own unique characteristics. I reminded her that she and her husband had been addressing Jessica’s learning problems and getting help for her. I also pointed out that this was very different from her own experience growing up. I emphasized that there are many influences other than biology that influence a person’s development. I also asked Rose to tell me anything she could think of about Jessica’s accomplishments. We both listened to the list Rose came up with: “Great piano player, really good artist, hula-hoop champion, kind person, good swimmer, and I guess other stuff, too.” Rose reluctantly acknowledged, “Yes, I suppose her brain works OK in some ways.”

Rose and I spent a lot of time talking not only about Jessica, but also about Rose’s negative sense of self. It was harder for her to take seriously that she has her own accomplishments. It was even more difficult to consider that Jessica was like her in some ways and not others. (Rose is a terrible artist and swimmer!) Our work has centered on Rose’s struggle to experience herself in positive ways and on seeing Jessica as a separate, differentiated individual. We have also been talking about how painful it is to see your child have areas of deficit, and even worse when you feel you are the cause. Helping Rose to talk about her impaired sense of self and its development has allowed her to make distinctions between her own experience and Jessica’s. I have tried to help Rose consider that while there could be some biology at work in regard to Jessica’s learning disabilities, so much more than being “just like me” is involved in what makes Jessica who she is.

We are familiar with parents feeling great pride in how they played a role in their children’s successes. But when parents boast incessantly about their children’s accomplishments to the extent it doesn’t feel like typical parental pleasure, we typically consider them to be narcissistic. For Peter and Rose, their great dismay in what they perceived as their children’s deficits, problems, and failures was also narcissistic.

The term narcissism comes from the Greek myth of Narcissus, in which Narcissus falls in love with his own reflection in a pool. The notion of reflection is pertinent to the experiences of Peter and Rose. Rather than experiencing narcissistic pleasure, these distraught parents experienced a narcissistic wound. They couldn’t tolerate the pain of looking into the pool (i.e., at their child who also represents the parent) and seeing something that is not “beautiful” reflected back. When they looked at their children, they saw a reflection of themselves. It was intolerable that the reflection they saw was “a mess” or had a “damaged brain.” It was not “beautiful.”

These parents are responding narcissistically, and they have not differentiated themselves from their children. One has to wonder how parents, who view their children as reflections of themselves, may have influenced their child’s separation/individuation process. As parents become more aware that their beliefs that their children are or are supposed to be “just like them” are assumptions, they will be in a better position to examine those beliefs. As a result, parents will experience less pain, and their children will be helped to develop into separate, unique individuals.

A client recently described how thrilling it was to take her daughter to see the Broadway musical Annie.  She recalled that her mother took her to see it when she was a child, and it had been an indelibly wonderful experience. Now she had the pleasure of providing the same thrill for her daughter. I thought how special it was for my client to share this with her daughter and how lucky my client was that her daughter had the same feelings about the experience. It also reminded me that so many parents who want to provide what they believe to be all the right things for their children are not always met with such good feelings.

I recalled another client whose desire to recreate his delight for his son was dashed when he took him to the rodeo and was met with the response, “This is stupid.” In spite of their most nurturing and positive intentions, parents may find that their wishes and rules for their children are met with rejection. This can create painful feelings, including insult, hurt, anger, and disappointment. “Drew,” a 42-year-old client, was in a prolonged struggle with his 8-year-old daughter about piano lessons she adamantly refused to take. He told me, “When I was a kid, I refused to continue piano lessons after a few months. My parents never insisted I continue. I’m not going to let that happen to my daughter. She isn’t old enough to know what she wants or what the consequences of her actions will be.”

As Drew and I explored his feelings, it became clear that he not only felt disappointed, he felt rejected by his daughter. “It feels like she is telling me, ‘Get out of here, you don’t know what’s good for me,’ ” he said. I responded: “I can see how upset you are about this, but I wonder what it is that makes you feel so personally rejected. Is it possible that your daughter is different from you?” Drew’s first response was, “She’s my daughter and she is like me. I just know this is very important for her to do. When I was a child, I didn’t know I was making a terrible mistake. My parents should have known and pushed me to continue.”

It took a lot of talking for Drew to become aware of his many disappointments about the ways his parents had been involved in his life when he was a child. He began to consider that he might not need to protect his daughter from this disappointment. He recognized that his daughter might, like him, regret not learning the piano, but forcing her to take lessons could easily turn her away from the piano. He realized that her experience and development was and will be different from his and she is a different person with her own thoughts and feelings. After all, she has different parents than he did. The more Drew could understand his daughter’s need to differentiate from him, the easier it was not to feel so rejected and hurt.

When parents assert their desires for their children, it is not unusual for them to be met with expressions of different or opposing wants and needs. Pushing back against what parents want is a necessary part of a child’s development. For a healthy sense of self to grow, children need to differentiate from their parents and become unique, separate, individual selves. This doesn’t mean children are totally different from or always in opposition to their parents. It does mean children need to develop minds of their own. Having one’s own mind is about being able to think about your needs and wants without being overly influenced by others. Ideally, the wishes of others are considered, but ultimately one makes his or her own life choices. Obviously, the degree of autonomy for a 4-year-old differs from that of a 13-year-old and again for a 20-year-old. When children are not given the space to differentiate from their parents and don’t develop a self that is confident and strong, they will not have developed the autonomy to make life choices and get what they want as they enter full adulthood.

At age 53, “Anne” was struggling with her teenage son, “Noah.” She came to therapy expressing feelings of anger and insult from their encounters. She explained that he fought her at every turn about anything she asked of him: cleaning his room, doing household chores, getting his college applications completed.  “I don’t believe how he treats me,” she said. “He says things like, ‘Leave me alone and mind your own business.’ Is that any way to speak to your mother? I feel so hurt and insulted. Doesn’t he know I only want what’s best for him?” In great distress, Anne added, “He has become a terrible person. He is so mean and inconsiderate. He seems like a completely different person than the son I felt loved me a year ago.”

As we talked, Anne described how when she was growing up she never went against her parents. When we explored her past and present relationships, Anne began to wonder if her early experiences being compliant are related to her difficulty asserting herself as an adult. She described how difficult it is for her to disagree with her husband and how she doesn’t always feel so good about herself. She realized that it wasn’t just with her son that she felt so badly treated. “I guess I don’t feel very powerful,” she said. “I have a lot of trouble believing that what I think and feel is OK. I always followed the rules with my parents. Maybe I didn’t develop what Noah needs to do—be someone who feels OK asserting himself when there is opposition.” Many parents with teenagers experience difficult feelings in their parent-teenager relationships. For Anne, the feelings of insult and rejection were intolerable. Even worse for her was the terrible shame she felt about her negative feelings toward her son: “I’m the terrible person. Mothers shouldn’t feel this way.”

How to handle this kind of situation with teenagers is controversial. Furthermore, how any parent hears what a child says is open to interpretation and may be related to how the parent differentiated from his or her own parents. While Anne felt insulted and hurt, another parent in these circumstances might shrug and think, “When will these awful teenage years pass?” On one end of the continuum of parental response, parents might believe that a child of any age should never be permitted to say anything that is hurtful, disrespectful, or angry to a parent. At the other end of the response continuum, parents might accept any expression their child makes without intervening. An extreme example might be if a teenager said, “You’re an awful parent, you have no business having children,” and a parent made no protest about being treated that way. On this far end of the continuum, the lack of a parental response to push against doesn’t provide the child with the feeling that there is a strong parental self to separate from. If there is no other out there to individuate from, it becomes difficult for a child to develop a sense of who he or she is and the ability to be autonomous. The child is left wondering, “Who am I?” Potentially more problematic, the child may be left with a feeling of powerlessness. He or she has not been given the experience of successfully asserting his or her developing self in the world.

There is a lot of room along this continuum for parents to develop responses that feel comfortable to them while allowing some room for their children to develop their unique selves. It helps if parents let their children know what behaviors are acceptable. For instance, telling a child, “You can’t talk to me that way” is not the same as saying, “You can’t be angry at me,” or “You are hurting my feelings.”

When children respond to parents in disappointing or unacceptable ways, it is important that parents stop and consider how they will meet that response. Each situation requires thought. Sometimes, interfering with the child’s wishes or experiences provides an opportunity for the child to push back against the parent and feel a sense of his or her developing self. At other times, supporting the child’s differentiation provides the child with a sense of confidence and recognition of his or her developing self. No matter the age of the child, parents who are curious and interested in why there is disparity or opposition are communicating their openness to more than one way of behaving and/or feeling. This openness to difference helps children develop into self-confident, autonomous adults. Moreover, parents are less likely to repeat the dynamics of their own childhoods if they consider their children’s behavior from a developmental perspective. They will be in a better position to not take things so personally and will feel less hurt, insulted, or disrespected by their children.