Mental Health Crisis in America
The Death of Ruth Bader Ginsburg
PLEASE MASTER : Dialectical Behavioral Therapy (DBT)
When you become so preoccupied with food and weight issues that you find it harder and harder to focus on other aspects of your life, it may be an early sign of an eating disorder. Without treatment, eating disorders can take over a person’s life and lead to serious, potentially fatal medical complications. Eating disorders can affect people of any age or gender, but rates are higher among women. Symptoms commonly appear in adolescence and young adulthood.
Eating disorders are a group of related conditions that cause serious emotional and physical problems. Each condition involves extreme food and weight issues; however, each has unique symptoms that separate it from the others.
Anorexia Nervosa. People with anorexia will deny themselves food to the point of self-starvation as they obsesses about weight loss. With anorexia, a person will deny hunger and refuse to eat, practice binge eating and purging behaviors or exercise to the point of exhaustion as they attempts to limit, eliminate or “burn” calories.
The emotional symptoms of anorexia include irritability, social withdrawal, lack of mood or emotion, not able to understand the seriousness of the situation, fear of eating in public and obsessions with food and exercise. Often food rituals are developed or whole categories of food are eliminated from the person’s diet, out of fear of being “fat”.
Anorexia can take a heavy physical toll. Very low food intake and inadequate nutrition causes a person to become very thin. The body is forced to slow down to conserve energy causing irregularities or loss of menstruation, constipation and abdominal pain, irregular heart rhythms, low blood pressure, dehydration and trouble sleeping. Some people with anorexia might also use binge eating and purge behaviors, while others only restrict eating.
Bulimia Nervosa. People living with bulimia will feel out of control when binging on very large amounts of food during short periods of time, and then desperately try to rid themselves of the extra calories using forced vomiting, abusing laxatives or excessive exercise. This becomes a repeating cycle that controls many aspects of the person’s life and has a very negative effect both emotionally and physically. People living with bulimia are usually normal weight or even a bit overweight.
The emotional symptoms of bulimia include low self-esteem overly linked to body image, feelings of being out of control, feeling guilty or shameful about eating and withdrawal from friends and family.
Like anorexia, bulimia will inflict physical damage. The binging and purging can severely harm the parts of the body involved in eating and digesting food, teeth are damaged by frequent vomiting, and acid reflux is common. Excessive purging can cause dehydration that effect the body’s electrolytes and leads to cardiac arrhythmias, heart failure and even death.
Binge Eating Disorder (BED). A person with BED losses control over their eating and eats a very large amount of food in a short period of time. They may also eat large amounts of food even when he isn’t hungry or after he is uncomfortably full. This causes them to feel embarrassed, disgusted, depressed or guilty about their behavior. A person with BED, after an episode of binge eating, does not attempt to purge or exercise excessively like someone living with anorexia or bulimia would. A person with binge eating disorder may be normal weight, overweight or obese.
Eating disorders are very complex conditions, and scientists are still learning about the causes. Although eating disorders all have food and weight issues in common, most experts now believe that eating disorders are caused by people attempting to cope with overwhelming feelings and painful emotions by controlling food. Unfortunately, this will eventually damage a person’s physical and emotional health, self-esteem and sense of control.
Factors that may be involved in developing an eating disorder include:
- Genetics. People with first degree relatives, siblings or parents, with an eating disorder appear to be more at risk of developing an eating disorder, too. This suggests a genetic link. Evidence that the brain chemical, serotonin, is involved also points a contributing genetic and biological factors.
- Environment. Cultural pressures that idealize a particular body type place undue pressure on people to achieve unrealistic standards. Popular culture and media images often tie thinness (for women) or muscularity (for men) to popularity, success, beauty and happiness.
- Peer Pressure. With young people, this can be a very powerful force. Pressure can appear in the form of teasing, bullying or ridicule because of size or weight. A history of physical or sexual abuse can also contribute to some people developing an eating disorder.
- Emotional Health. Perfectionism, impulsive behavior and difficult relationships can all contribute to lowering a person’s self-esteem and make them vulnerable to developing eating disorders.
- Eating disorders affect all types of people. However there are certain risk factors that put some people at greater risk for developing an eating disorder.
- Age. Eating disorders are much more common during teens and early 20s.
- Gender. Women and girls are more likely to have a diagnosed eating disorder. However, it is important to recognize that men and boys may be under-diagnosed due to differences in seeking treatment.
- Family history. Having a parent or sibling with an eating disorder increases the risk.
- Dieting. Dieting taken too far can become an eating disorder.
- Changes. Times of change like going to college, starting a new job, or getting divorced may be a stressor towards developing an eating disorder.
- Vocations and activities. Eating disorders are especially common among gymnasts, runners, wrestlers and dancers.
A person with an eating disorder will have the best recovery outcome if they receive an early diagnosis. If an eating disorder is believed to an issue, a doctor will usually perform a physical examination, conduct an interview and order lab tests. These will help form the diagnosis and check for related medical issues and complications.
In addition, a mental health professional will conduct a psychological evaluation. They may ask questions about eating habits, behaviors and beliefs. There may be questions about a patient’s history of dieting, exercise, bingeing and purging.
Symptoms must meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in order to warrant a diagnosis. Each eating disorder has its own diagnostic criteria that a mental health professional will use to determine which disorder is involved. It is not necessary to have all the criteria for a disorder to benefit from working with a mental health professional on food and eating issues.
Often a person with an eating disorder will have symptoms of another mental health condition that requires treatment. Whenever possible, it is best to identified and address all conditions at the same time. This gives a person comprehensive treatment support that helps insure a lasting recovery.
Each person’s treatment will depend on the type of eating disorder, but generally it will include psychotherapy along with medical monitoring and nutritional counseling. Family-based treatment is especially important for families with children and adolescents because it enlists the families’ help to better insure healthy eating patterns and increases awareness and support.
Many people receive treatment for an eating disorder without needing an intensive treatment setting. However, for some people, an inpatient or residential eating disorder treatment center or partial hospital setting is best when they begin treatment. Others may need hospitalization to treat serious problems caused by poor nutrition or for care if they are very underweight.
Support groups, nutrition counseling and medications are also helpful to some individuals.
Psychotherapy should be provided by a mental health professional with experience in treating eating disorders. Because of the complexity, therapy needs to address both the symptoms and a person’s psychological, interpersonal and cultural influences which contributed to the disorder.
Cognitive behavioral therapy (CBT) is often successfully used in the treatment of eating disorders because it helps people understand the relationship between their thoughts, feelings and behaviors. CBT that is developed for the treatment of bulimia is very effective at changing the binge-purge behaviors and eating attitudes.
Wellness and Nutrition Counseling involves professionals helping a patient return to a normal weight. Dietitians and other health care providers can help change old habits and beliefs about food, dieting and exercise with healthy nutrition and eating information and planning. Sometimes planning and monitoring responsibilities are shared with mental health professionals or family members.
Although you may realize that your behaviors are destructive it may be difficult to control them. Treatment can teach you ways to cope. Here are some examples:
Lifestyle. It’s important to begin making changes in your life and remove the reminders and stop negative behaviors associated with the disorder. Resist the impulse to check yourself in the mirror frequently or weight your several times a day. Fight the urge to diet or skip meals.
Steer Clear of troublesome reminders. Identify the triggers–a certain place, challenging situations, some friends-for old behaviors or symptoms and prepare a plan to deal with them.
Accept yourself. Your healthy weight is your ideal weight. Don’t be tricked by ultra-thin models and actresses. Look for healthy role models. Focus on activities and interests that make you feel good about yourself.
Partner with your health care providers. Develop trust and communicate openly. Give your healthcare provider the information they need to help you recover. Don’t skip therapy sessions, and be consistent with meal plans. Ask about vitamin and mineral supplements and which type of exercise, if any, is appropriate for strengthening and rebuilding your body.
Complementary therapies. Alternative and complementary therapies and medicines can have negative or positives effects. Always discuss with your health care providers anything you would like to add to your treatment plan. Weight loss supplements, diuretics, laxatives or herbal remedies are commonly unregulated, and often misused. Other treatments generally considered safe and helpful, including acupuncture, massage, yoga, chamomile tea and biofeedback.
Learn all you can. Read self-help books that offer practical, credible advice. Research helpful topics online, but don’t visit websites that promote dangerous eating habits or showcase very thin, unhealthy bodies, as it could trigger a relapse. For men with eating disorders, check out the National Association for Males with Eating Disorders (N.A.M.E.D.).
Find emotional support from others recovering from an eating disorder. Share your thoughts, fears and questions with other people who have dealt with an eating disorder. Connect with others on online message boards or peer-support groups like NAMI Connection Recovery Support Groups.
If you live with a mental health condition, learn more about managing your mental health and finding the support you need.
Supporting Your Family Member Or Friend
Discuss your concerns. If you have concerns about a friend or family member and suspect an eating disorder may be the reason, learn about the different disorders, symptoms and warning signs. When you are knowledgeable, talking with them in a loving and non-confrontational way about your concerns is best. Tell the person you care.
Suggest they see a doctor, counselor or other health professional. This may be tricky, as your loved one may not want to admit or even realize there is a problem, but sometimes seeing a professional who is knowledgeable about eating disorders is the first step in recovery.
Avoid the traps. Conflicts and battles are hurtful. If a person is not ready to acknowledge a problem, you can be a supportive friend. Avoid placing blame, guilt or shame on them about behaviors or attitudes related to the eating disorder. Remember that giving simple solutions minimizes the courage and strength a person needs to recover from an eating disorder.
Be a good role model. Reflect on your attitudes and actions. Do you maintain sensible eating and exercise habits? Also, focus on the other person’s successes, accomplishments or personality.
Parenting. Having a child with an eating disorder places significant responsibility on parents, making them active partners in treatment planning and implementation. Your family needs to feel comfortable and confident in the professional’s approach and abilities, and in discussing the disorder. Finding a mental health professional with experience treating young people or children with eating disorders and their families is important.
Find emotional support. Family support groups provide people with a chance to share thoughts, fears and questions with other people who are in similar situations and understand.
Eating disorders are some of the most challenging mental illnesses and are serous, life-threatening conditions. Affecting one in 20 people during their lifetime, eating disorders frequently occur in people with other mental illnesses, including depression, anxiety disorders and substance abuse issues and as with other mental illnesses, early identification and early intervention are keys to recovery.
NAMI joins NEDA this week in support of the aim to ultimately prevent eating disorders while reducing the stigma surrounding these conditions and improving access to treatment.
NAMI recently spoke with Andrea Vazzana, Ph.D., a clinical psychologist and eating disorders specialist, to learn more about eating disorders and how to help a friend or loved one living with one of these conditions.
NAMI: What is the current prevalence of eating disorders in America?
Vazzana: Overall, over 10 percent of young women currently meet criteria of one of the eating disorders, anorexia nervosa, bulimia nervosa or eating disorder NOS (not otherwise specified). The new Diagnostic and Statistical Manual (DSM5), set to publish in May this year, includes binge eating disorder as a mental illness. Men can also live with eating disorders. While the prevalence of men to women was previously thought to be a ratio of 1-to-10, it is now believed that the ratio is closer to 1-to-6, meaning that six times more women than men have the condition. Although not as common in men, it is important to recognize that more men are now being treated for these mental illnesses.
Some believe that eating disorders are more prevalent in women because of what is called the “thin-ideal”. Biology and environment are both contributors to this condition, and researchers have found that the cultural pressure to equate thinness with beauty, as well as some sports that encourage low body fat and thinness, are factors. It is not always the ideal cultural “think” to equate thinness in men and therefore that social factor is often removed. Still, there are some sports and cultures where being thin is idealized and therefore a contributor.
What are the types of eating disorders and are there any recent changes in prevalence and conditions?
Vazzana: Eating disorders NOS, will be changing with the new DSM, to be published in May. The criteria and diagnosis will change. Binge eating will be a full-blown disorder all on its own. Binge eating disorder is similar to bulimia in that it includes the binging, but not the purging, aspect of the condition.
What are the most common co-occurring disorders (mental health conditions)?
The most common is depression and dysthymia, what some consider a less-severe but often longer lasting condition than depression. Half to three-fourths of those with eating disorders meet the criteria for depression in their lifetime, and there is a direct relationship to malnourishment and depression.
In addition to depression, the other most common co-occurring conditions are anxiety disorders, specifically social phobias and, with people living with anorexia, OCD, which impacts about 25 percent of individuals with this condition.
Substance abuse, particularly alcohol abuse, is co-occurring in about 5 percent of people living with anorexia and from 25-40 percent of people living with bulimia.
Personality disorders are also common co-occurring conditions, particularly for people living with bulimia.
What are current treatment options available and what are likely outcomes?
Recovery from eating disorders is possible. The right treatment choice depends on the type of eating disorder, but treatment approaches are often similar for the various conditions, and coordination of care between mental health care providers, nutritionists and medical professionals is important, depending on the individual’s treatment plan. Nutritional guidance, as well as individual and family counseling, is an important treatment options to consider.
The best rates of recovery for people living with bulimia involve cognitive behavioral therapy (CBT) where the focus is often on normalizing weight and eating behaviors and challenging distorted thinking patterns that are usually associated with this condition. One of the goals is to interrupt the thought pattern that leads to individuals evaluating themselves in terms of shape and weight. Individual therapy is often another key to recovery.
The best rates of recovery for people living with anorexia include treatment plans that incorporate family-based therapy, often the Maudsley Method, which is often used for adolescents and children with Anorexia still living at home. This intervention involves parent coaching to encourage feeding their children to help restore their weight—eating meals with them and encouraging eating. With anorexia, it is important that the individual restore their weight as soon as possible; the longer they are in a danger zone of thinness and malnutrition, the worse the outcome. Early intervention is key; people living with anorexia (about 5 percent) have the highest probability for mortality, including death by suicide.
In addition to psychotherapies, medications, specifically, selective serotonin reuptake inhibitors, SSRIs, a type of antidepressant medication, are sometimes used in patients that are responding to CBT as an adjunct therapy.
What myths are the most common and what stereotypes exist that create barriers to understanding and treatment?
The myths surrounding eating disorders are vast and include myths primarily around race, age and social economics.
When people think of anorexia, they often mistakenly think of young, white, high social status females. This is not the case. There are 5-10 million people in America who have eating disorders, and one out of 6 are men, who more deeply experience the negative aspects of stereotypes and have unique barriers to treatment and acceptance.
We also know that eating disorders do not just affect white women. The rates are as common in young Hispanic and Native American women as they are in Caucasian women. With African American and Asian American women, however, there does seem to be a lower prevalence, with the exception of pre-adolescent African American girls. With Caucasian girls, the prevalence is lower and rates increase with puberty and continue to increase as into early adulthood.
Age is another myth; eating disorders do not just affect teens and young adults. More and more are being diagnosed for the first time in middle age. And unless effectively treated, eating disorders will last into adulthood for many.
How can someone help a friend or loved one who may have or one who is living with an eating disorder? How should they/could they intervene if needed and how can the provide support?
Regarding intervention, the key to remember is that the earlier the better. In terms of identifying a problem, it is important to know that it is common to have body dissatisfaction. Most women are more critical. However, when they go beyond dissatisfaction and they are harshly critical and disparaging of their bodies, and when there is noticeable evidence of over-thinness and over concern about food and weight, there may be a problem.
Some people mistakenly wait to intervene, thinking that the individual may grow out of their condition. The best thing to do is to let them know about your concern. You have observed behavior—talking poorly about their body, other signs—and you just want to be honest. Saying something like, “I have noticed these things and I am concerned about your health,” without being judgmental, can be the most natural first step. Because individuals living with eating disorders are generally already self-critical, it is important to so separate the illness from the individual. Try not to focus comments on appearance but rather focus comments on health by expressing concerns and the need for further medical evaluation. Recognizing that people with eating disorders often consider being thin with success, being persistent and consistent while avoiding criticism and comments on thinness, is important.
After an individual is in treatment for an eating disorder, one of the best things a family member or parent can do is to get family-based treatment or therapy. During meals, families and friends should try not to be angry even if they see their friend or loved one struggling with eating. Working to avoid impatience can be challenging, but neutral and supportive reassurance offer the best outcomes.
It is important that friends and family strive to avoid commenting on appearance. Avoid comments like, “You’re gaining some weight, that looks great!” Compliment other things, perhaps superficial aspects of clothing, conversations, other activities and contributions, but avoid mentions of size or appearance if possible.
What do you think is the most important thing for people to know about eating disorders?
The importance of intervening early! Treatment works best the earlier you can begin it. The longer the condition persists, the more deadly it becomes with more physical complications to manage.
Andrea Vazzana, Ph.D.,is a clinical assistant professor of child and adolescent psychiatry at the NYU School ofMedicine and a licensed psychologist at the Child Study Center.
When Cathy Moen’s son, Elijah, was in first grade, he was diagnosed with attention deficit hyperactivity disorder. She took him to the pediatrician, who put him on medication and suggested therapy.
The medication part was easy. But getting him therapy proved more difficult — not because Moen couldn’t find a therapist or didn’t have insurance, but because of logistics.
The appointments were always during the day, and between her work schedule and the traffic, it was nearly impossible for them to make it.
But she soon learned Elijah was able to see a therapist in his Bloomington school. More than 15 years ago, Minneapolis Public Schools helped pioneer a national model of bringing community mental health care directly to its students. Today, most of the public schools in Minneapolis — more than 50 of them — have a therapist on site, and many other districts, like Elijah’s, have followed suit.
These days, Elijah’s therapist simply walks down the hall and pulls him from class.
“This is like a godsend,” said Moen.
The family’s health insurance pays for the care the same way it would if the student were being seen in the clinic. The school program was designed so that no student in need will be turned away for lack of insurance.
The Minneapolis program has also provided a road map for schools across the country as more administrators realize that mental health is as important to students’ future success as academics. Studies have shown that students are more likely to show up for appointments when the therapists are on-site.
More and more states are making mental health care in schools a priority. At least two states have recently passed laws that require schools to teach mental health. And more are considering it.
But the benefit of having a therapist on-site goes beyond just getting students to see a therapist. In Minneapolis, it’s also helped make mental health a school-wide priority — and helped get counselors, teachers and others more involved, said Mark Sander, who helped start the district program.
“Those teachers start learning more and more [about mental health],” said Sander, who directs school mental health for the district and the county.
He said as they learn more about mental health, teachers are feeling like, “‘OK, I get it. And now, you know, I’ve got this other student who’s not diagnosed with anxiety but has some of those anxiety features. And now I know how to better support them.”
At South High School in Minneapolis, the therapists sit in the school clinic, the same one where students go if they feel sick during the day or to get a physical so they can play sports.
The issues the students bring to the therapist run the gamut from stress about grades and colleges to anxiety related to a bad situation at home.
Farah Hussein is a therapist at South. She said it’s hard being a teenager, and she tries to help.
“There’s a lot of conversations about, ‘Who am I? Where do I fit in the world? Where do I belong?’ and just a lot of distress in exploring that,” she said.
All of this has important implications for the students’ well-being beyond just their mental health.
Sharon Hoover, who co-directs the National Center for School Mental Health at the University of Maryland School of Medicine, said more schools are collecting data on outcomes of in-school mental health programs, and the results are clear.
“They are more likely to have good attendance and to graduate and to get improved grades. We even have documentation of having better standardized test scores when you put universal systems in place like classroom-wide social emotional learning,” she said, all of which makes for happier, better adjusted students.
Cathy Moen, the mother whose son, Elijah, is in therapy in school, said she doesn’t know if it’s the medicine, or the therapy, or just that he’s growing up, but she — and his teachers — are already seeing a difference.
At the same time, it can be hard to know if the worries and racing heart you experience at the thought of, say, meeting new people, is run-of-the-mill stress, or if you’re actually experiencing some level of anxiety and could benefit from seeing a professional.
“I can’t tell you how many people I see who say, ‘I don’t know if I should be coming in here,’” clinical psychologist Robert Duff, Ph.D., author of Hardcore Self Help: F**k Anxiety., tells SELF. “On a broad scale, [talking about anxiety] is positive, but I don’t blame anyone for the confusion.”
Figuring out how serious your anxiety is can be tough because anxiety is a normal and essential part of being a human.
“Anxiety is a reaction to a situation we perceive as stressful or dangerous,” Monique Reynolds, Ph.D., licensed clinical psychologist at the Center for Anxiety & Behavioral Change in Rockville, Maryland, tells SELF. This produces a stress response in your body—specifically, your brain’s hypothalamus triggers your sympathetic nervous system to release norepinephrine (aka adrenaline) and cortisol (a stress hormone) to get you out of harm’s way.
This is actually a good thing when there is a real threat of danger present. “A major part of our brain’s job is to keep us alive, and fear and anxiety are a big part of that,” Reynolds says. For example, the anxiety you would feel at seeing a truck hurtling towards you would make you move from its way more quickly.
But if you have anxiety, that stress response can kick in when it shouldn’t. “You feel very much the way you do when in a dangerous situation…[but] there’s no real danger there,” Duff says. Instead of being helpful, this misfiring of your fight or flight reaction can hinder you.
While a little anxiety can also help you to perform at an optimal level under stress, giving you a burst of adrenaline and hyper-focus to finish a business proposal before deadline or nail that dance number at a performance, living in a constant heightened state of anxiety can be distracting at best and debilitating at worst. When anxious thoughts are interfering with your life and causing you significant distress, that isn’t something you should just chalk up to nerves and push through. That’s something you can get help with.
Anxiety is the most prevalent mental illness in the United States, and it comes in various forms.
Anxiety affects about 40 million American adults each year, according to the Anxiety and Depression Association of America (ADAA). But it’s not as cut-and-dry as saying that anxiety is simply when you feel nervous all the time. This mental health condition comes in many forms.
Generalized anxiety disorder (GAD) is characterized by having excessive worries and fears for months, according to the National Institute of Mental Health (NIMH). Per the ADAA, GAD affects 6.8 million U.S. adults each year. Panic disorder involves spontaneous bouts of debilitating fear known as panic attacks, along with intense worry about when the next attack will come, according to the NIMH. Per the ADAA, it affects 6 million American adults each year. Social anxiety disorder (also known as social phobia) happens when you have a marked fear of social situations in which you might be judged or rejected, as well as avoiding these situations or experiencing symptoms like nausea, trembling, or sweating as a result.
Then there are other issues that are closely related to anxiety, like obsessive-compulsive disorder, which involves intrusive thoughts and urges, and posttraumatic stress disorder, which happens when people have a prolonged stress response to harrowing situations.
These are just some of the various anxiety and anxiety-adjacent disorders out there. That these issues can present in myriad ways can make it even harder to know if what you’re experiencing is anxiety that could benefit from outside help.
“Some people feel they can control their anxiety, some feel it’s something they ‘should’ be able to manage, some feel shame, some fear they might be ‘crazy,’ and others downplay how much their anxiety is impacting them,” Reynolds says.
If anxiety interferes with your daily life—whatever that might look like to you—that’s reason enough to see a mental health professional.
“When your world starts to become limited because of anxiety, that is a good signal that it’s time to seek treatment,” Reynolds says. “What is it doing to your life, your relationships, your sleep, health, work, and ability to learn and pursue things that are important to you?”
This “functional impairment,” as Reynolds calls it, can show up in different ways in different people. Is anxiety making you avoid doing things with loved ones because you’re too nervous to go outside? Do you skip school or work out of fear of what people may think of you? Can you not get enough sleep because you’re up all night worrying about the next day? Is your anxiety over certain tasks, like paying bills, leading to procrastination so extreme it comes with consequences, like getting your lights turned off?
Keep tabs on whether you’re blowing up at people, too. Anger and irritability can sometimes be a sign of anxiety. “We often forget that fight or flight includes ‘fight,’” Reynolds says. “If you have a shorter fuse or are always on edge for triggers, it could be related to anxiety.”
So, too, could physical issues. “We think of ourselves as these disembodied heads floating around,” Reynolds says. “We forget that there is a big feedback loop between the nervous system and the body.” Every part of you, from your head to your stomach to your feet, has nerves to regulate important processes, which is why your sympathetic nervous system’s stress response can be so far-reaching. You even have an entire nervous system reserved for gastrointestinal function, known as your enteric nervous system, which may help explain why there’s such a strong link between issues like irritable bowel syndrome and anxiety.
Constant fatigue can also kick in if your anxiety is in overdrive. “The physical reaction to anxiety, by nature, is supposed to be short-term. The body is supposed to come back down to baseline,” Duff says. “But a prolonged period of anxiety depletes your resources and exhausts you.”
“If your anxiety is bothering you and you are suffering, you deserve to get help,” Duff says. That’s true whether or not you think your anxiety is serious, whether or not you think you meet diagnostic criteria you read online, and whether or not your friends and family treat your anxiety with the weight it deserves. And if your anxiety is getting to the point where you’re worried for your safety, call 9-1-1 or the National Suicide Prevention Lifeline (it’s available 24 hours a day, seven days a week at 1-800-273-8255), or go to the emergency room, Reynolds says.
Seeing a therapist can be anxiety-inducing on its own, but it’s worth it. Here are a few ways to make it easier.
Knowing what to expect at your first therapy session may make the experience less scary. Although every professional is different, you’re likely to get a lot of questions at the first visit. Ultimately, your psychologist or therapist’s goal is to learn what troubles you’re having so that they can create a plan to help you build the skills you need to address your anxiety.
They’ll also want to figure out which kind of therapy best matches your needs. Different forms, like cognitive behavioral therapy, which aims to help people change negative thought patterns, work for different people.
Since the cost of therapy can be prohibitive, know that there are resources to help you find affordable treatment, like the National Alliance on Mental Health’s HelpLine at 1-800-950-6264. The HelpLine is available Monday through Friday, from 10 A.M. to 6 P.M., and you can explain your specific situation to the staffer or volunteer who answers. They may be able to refer you to local organizations that offer more affordable treatment. You can also try the Substance Abuse and Mental Health Services Administration (SAMHSA) treatment locator tool, which can help you find mental health providers who take various forms of insurance, offer payment assistance, or use a sliding scale. Resources like GoodTherapy also allow you to limit search results to therapists who use sliding scales.
And don’t stress about meeting some arbitrary threshold of anxiety for your appointment to be worth the effort. “Somebody with anxiety [may] think there is a risk to seeing someone. ‘If I go and don’t have an anxiety disorder, there’s something bad about that,’” Duff says. “That’s not true. If you are suffering and seeing some of these signs, that’s enough.”
It may be that all you need is a few sessions, or you may meet weekly for months or years based on your goals. Your psychologist or therapist might decide medication would help you live your healthiest, happiest life, or just having someone to talk to might work for you. Also, if you decide you’re not really into the person you’re seeing but you still want help, there’s absolutely nothing wrong with trying someone else, Duff says.
Ask yourself what kind of life you want to live and what’s holding you back from achieving it, Reynolds says, adding, “If there’s anything related to fear and anxiety, it’s a great sign that maybe you need support around those things.”
Have you ever felt hesitant about approaching someone you met eyes with? Or felt nervous talking to someone you’re interested in? Or felt a knot in your stomach while finding the courage to ask someone on a date? Most likely, you’ve experienced at least one—or maybe all—of these feelings, because anxiety and dating are a difficult pair to separate.
Dating enhances several of our deepest fears: rejection, being judged, getting emotionally wounded. It can be challenging to overcome these fears and put yourself out there. In fact, our dating culture has shaped itself aroundthese fears in an attempt to make the process of dating “easier.” But in many ways, this evolution has made dating more complicated and anxiety-inducing than ever. Take, for example:
Meeting People Online
Many online websites and apps have been created so people can screen potential suitors before ever having to physically meet them. For those who engage in online dating, there is a multitude of new concerns to contend with: Is this person real or are they just “catfishing” (using a fake profile)? How are they going to perceive me based on my profile? What questions can I ask to get to know them? This is all before the anxiety of actually meeting the person.
Knowing “The Rules”
It has become the norm to refrain from showing too much interest in someone you’re getting to know. This standard has produced a set of unspoken “rules” for any person engaging in modern dating culture. Some of these rules include:
- Don’t double text (i.e. send an additional text before the person responds to your first text). This makes you seem too eager.
- Don’t call someone. This will likely be met with distaste and confusion because phone calls are essentially obsolete.
- Don’t respond immediately to a text message. This makes it seem like you were sitting around waiting for them to text you.
- Don’t “like” any old posts or photos on their social media. Otherwise, they will know you were “Facebook stalking” them, or intently monitoring or looking through their Facebook updates or history.
- Don’t let them see you typing for too long on systems that show the other person when you are typing a message (e.g. iMessage, Facebook Messenger, etc.). Then they will know you were putting a lot of thought into saying the perfect thing.
If someone breaks these rules, they are typically perceived as desperate and unattractive. So if we like someone, we have to bury it away. It’s almost a competition of who can be less interested. How can our pride be hurt if our attitude is: “Oh I wasn’t really that into you anyway”?
Dealing With “Trendy” Rejections
The way people reject those they are casually dating is constantly changing based on what’s “in.” For a while, the trend was “ghosting,” or abruptly ignoring the person on every channel of communication. This causes the person rejected to anxiously wonder when the other person will respond and what they did so wrong. Similarly, there is also the “slow fade,” which is the same thing, except more drawn-out.
As if those trends weren’t bad enough, there’s a new one coined “breadcrumbing,” which is not being interested in someone, but continuing to lead them on. People who do this are trying to keep a person interested while they seek out other options.
How Can We Make This Easier?
With all these challenges (and more), it’s important to maintain your mental health when trying to connect with someone. And it’s important to remember that dating isn’t hopeless—even if you experience a mental health condition that makes it even harder. Here are a few things you can do to reduce your anxiety while dating:
❤️ Accept Yourself First
As cliché as it sounds, it is essential to love yourself and be happy with who you are before you add another person to the mix. A lot of dating anxiety happens because of insecurities within ourselves. Learning to be content and fulfilled while single before looking for a relationship is extremely helpful towards dating in a healthy way. When your happiness isn’t dependent on your search, you won’t put as much pressure on the situation or feel as anxious about every person you meet.
“Your relationship with yourself sets the tone for every other relationship you have.” – Robert Holden
❤️ Be You Always
Once you have accepted yourself, you will feel comfortable being open and honest about who you are. You will respect yourself and won’t waste your time playing the usual games to pique someone’s interest. If someone doesn’t like you or the fact that you are open with your feelings, then they’re not the type of person you should be with anyways.
❤️ Dismiss Exaggerated Thoughts
Thoughts that rev up anxious thoughts need to be either ignored or thought through in a logical way. For example: “I’ll be alone forever” is not a rational thought. Yes, you may have to wait to find someone, but most likely, you will not be alone for the entirety of your life. Being able to recognize that a thought is exaggerated can be helpful in minimizing your anxiety.
❤️ Know It’s Okay to Feel Anxious
It’s okay to feel nervous, awkward and uncomfortable when first meeting someone. And it’s also okay to tell them that when you meet them—chances are they feel the same way. After all, it’s human nature to feel nervous at the prospect of finding a partner.
Laura Greenstein is a communications coordinator at NAMI.
By Rebecca Matthes,
When we enter into long-term relationships—and certainly marriages—we may keep in our mind a list of the things we’d like to get from (and, one hopes, are willing to give to) a partner. Recent research suggests certain gestures are especially important for fostering satisfaction and are closely associated with couples’ long-term success. Collectively, these can be thought of as a Relationship Bill of Rights.
“Expectations are essential, and if you’re not expecting good stuff, then you very likely won’t get it,” says social psychology professor Eli Finkel, who directs the Relationships and Motivation Lab at Northwestern University and is the author of The All-Or-Nothing Marriage. “We should be honest with ourselves about what things are essential for us to get through the marriage, focus on those things, and let the other things go.”
This goal, he says, shouldn’t be put aside when couples face conflict, because every partner has the right to disagree—and to be imperfect. “It’s constructive to think of difficulties not only as unpleasant circumstances to be endured but also as opportunities to learn about each other and deepen the relationship,” Finkel says. “I’m optimistic about people’s ability to make progress on problems.” But he notes that resolution is more likely if partners’ beliefs about relationships are not based on the theory that people must find the one and only individual who’s perfect for them. The idea that any given partner is “meant to be”—or not—can make someone more likely to discard a relationship when hard times hit, convinced that the search for an ideal mate needs to continue elsewhere.
The following rights have consistently been found to form a baseline that gives couples the best chance of going the distance.
You have the right to your partner’s attention.
Your partner’s attention is likely to improve your satisfaction with a relationship, whether it’s spontaneous—like an unexpected afternoon text that makes you smile—or in response to your requests. A 2017 study on relationship experiences published in the Journal of Personality and Social Psychology found that on the days when their partners had supported them or said something that made them feel loved, people reported higher relationship quality.
Couples often show attention to each other in the little things they do. Jennyvi Dizon, 37, a fashion designer in New York City, is touched every time her husband of 15 years picks up a treat for her at the grocery store or remembers that she needs almond milk for her breakfast. “He says it’s his job to remember,” she says. “He really believes in the saying, ‘Happy wife, happy life.'” In return, she makes a point of tucking him in when he goes to bed every night, though she herself often doesn’t go to sleep until a few hours later.
How to get it: If your partner is kind, but not naturally attentive, it may help to explain the sort of attention you need and then to give positive feedback when you get it. And if busy schedules conspire to keep you from each other, engineer some together time. As Finkel explains, “Spouses who spend more time together engaged in actual conversation tend to be happier than those who spend less. And spouses who pursue more leisure activities together—including outdoor activities, sports, card games, and travel—are at reduced risk of divorce.”
Proposed amendment: The arrival of a child typically causes couples to take a short-term happiness hit because their attention is diverted from each other to the new addition; newborns in particular tend to be quite vocal about their own rights. New parents spend less time talking or doing activities together, and their relationship satisfaction declines as a result, making this a time to be even more conscious of finding or making moments to focus on each other.
You have the right to a partner who will try to work out your differences.
All long-term relationships encounter sore spots and conflicts. Ignoring these problems won’t make them go away, even if partners do so because they sincerely don’t want to pick a fight. “No relationship can thrive when the two parties hold in frustrations that need to be shared and resolved,” says Leon Seltzer, a clinical psychologist in Del Mar, California. “When couples stop trying to work out their differences and revert to passivity to keep the peace, they hold more and more inside of them and their alienation grows. The frustrations tend to leak out through sarcastic, taunting remarks, thinly veiled criticisms, or increasing inattention to the other’s needs.”
Addressing problems as they arise improves spouses’ psychological well-being and ratings of marital quality, especially for women. One study of 205 married couples found that wives who believed that their husbands did more emotional work were more satisfied with their relationships.
Once differences are out in the open, even those that might have seemed irreconcilable in one’s imagination can often be addressed with a compromise or a conscious agreement to disagree. “You can learn to validate the hardcore differences that exist—and will always exist—between you and your mate,” Seltzer says. Consider a scenario in which one partner is far more extraverted than the other. Rather than sitting at home seething, or endlessly haranguing a husband or wife who doesn’t want to go out, partners who open a conversation might discover that their mate really doesn’t mind if they sometimes socialize without them.
Monica and Melvin Pullen, both 42, of Lititz, Pennsylvania, had been married for about four years, and were expecting their first child, when they bought their first home with the understanding that both would continue to work. However, once their daughter arrived, “I knew immediately that I didn’t want to return to work,” Monica says. But she kept it to herself. After about six months, the family started to feel the financial strain. Finally, she confessed her feelings. “He was fine with my staying home; we would just need to downsize.” As they prepared to do that, a new job came along for Melvin that allowed them to get by without needing to move. Still, Monica says, “the experience taught us to be upfront, open, and honest about what we want, regardless of the outcome.”
How to get it: “The party that initiates the discussion must do so with tact, diplomacy, and restraint—and the willingness to respect the other’s reluctance to engage on a topic that might make them feel very vulnerable,” Seltzer says. If your partner is prone to conflict avoidance or stonewalling, you may need to maneuver around those defense mechanisms: “I know this topic makes you uncomfortable, and that’s the last thing I want, but I think pushing it under the rug is keeping us from being closer. Can we talk about this in a way that helps us both understand why it’s so button-pushing? I want us to be closer and more trusting of each other.”
The discussion should help each of you better understand the other’s needs—and you’re both entitled to a partner who will validate your position, even if they don’t agree with it. “Resolution doesn’t always take the form of one person having to change their views or behavior,” Seltzer says. “It’s empathic understanding that minimizes the conflict.”
Proposed amendment: In some cases, as a couple ages, confronting problems head-on can actually lose some of its positive effect and even turn counterproductive. A 2015 study published in the Journal of Family Psychology suggests that for older wives, more marital “work” is associated with decreased satisfaction with their union. A research team led by Jakob Jensen of East Carolina University proposed that as we age, our marital priorities shift away from conflict resolution and toward maximizing the emotional rewards of maintaining a relationship.
You have the right to a partner who’ll share the load.
This is a right well worth defending, in part because it appears to deliver significant benefits to both partners.
The stark division of household labor that was nearly ubiquitous in households of the past is less common today, with both outside earnings and domestic responsibilities more likely to be shared by partners. A 2018 study, published in Socius and led by Daniel Carlson of the University of Utah, compared national data from the early 1990s and 2006 and found that contemporary couples shared more household tasks than did couples in even the recent past, and that this advantaged many aspects of their relationships, starting with their sex lives. “Sharing housework is associated with greater feelings of fairness, teamwork, and overall relationship quality,” Carlson says. “In particular, feelings of teamwork—communication, cooperation, and shared vision—are important to sexual intimacy.” These feelings foster a partnership based on reciprocity and mutual gratification, he has found, improving a relationship’s quality and lowering the risk of its dissolution.
It isn’t necessary that couples split the work precisely in two, research finds—which is fortunate, because most couples still do not do so. In about 31 percent of families with two parents working full-time, women still handle more household chores and responsibilities; 59 percent report that they share them equally. And in more than half of these families, women continue to do more to handle children’s schedules and activities, according to 2015 data from the Pew Research Center. But Carlson’s work still shows measurable benefits to a couple’s sex life as long as neither partner does more than 65 percent of the domestic work. Partners tend to be satisfied with relationships in which the work is divided, not necessarily equally, Carlson says, but in a way they both feel is fair.
How to get it: Discuss your expectations with your partner. “I would even recommend writing down the tasks that you have and coming up with a plan to divide them and then track their completion,” Carlson says. “Partners—men especially—often don’t see that they are not contributing to the degree they promise, so having something concrete to point to can be helpful.”
“We had a lot of fights about housework,” says Anna Aquino, 40, of Canal Winchester, Ohio. “The majority of it wouldn’t get done or would fall to me. Because I work from home, I understand I can have more to do, but I would get frustrated, and my husband would get annoyed when things weren’t done. It didn’t seem fair to anyone.” The couple finally agreed to post a chore chart on the fridge. “It saves a load of fights,” she says. The day-to-day chores aren’t split down the middle, since Aquino’s husband works more outside the home, but she says both partners are happier now because “it’s pretty fair all around and everyone agreed to it.”
Proposed amendment: When it comes to sharing domestic responsibilities, couples don’t need to aim for a specific target, but should work to find the breakdown that serves their relationship best. “You could have a good relationship with someone doing 100 percent of the household work,” Finkel says. Your partner might actually love cooking, cleaning up, and caring for kids or pets, while you feel more fulfilled by work and hobbies. “If a couple sees that as fair,” Carlson says, “they certainly can be happy.”
You have the right to honesty about sex.
What are partners entitled to in the bedroom? The answer will vary from couple to couple, but the research finds that it’s not necessarily the presence or absence of sexual activity, a specific schedule or frequency, or even the pleasure derived from it that is most associated with relationship satisfaction. What matters is that both partners’ expectations, whatever they are, are met. That’s why two people can sincerely find satisfaction in a sexless relationship: If neither expects sex, nor seeks it, its absence doesn’t affect how they feel about each other. But sexual expectations can and do change over time, and it’s crucial for a couple’s satisfaction that partners communicate shifts in both their desire and their capability.
“It’s the disparity in partner preferences, whether for frequency or type of stimulation, that can potentially result in the greatest unhappiness,” says sex and marital therapist Michael A. Perelman, a professor of psychiatry at Weill Cornell Medicine in New York City. When such a disparity exists, “communication and compromise skills become critical to mutual satisfaction.” Both partners need to be upfront about their expectations and help their partner understand them. From this place, a mutually agreeable plan can be drafted. If never-uttered sexual concerns are leading one partner to question his or her place in the relationship, the other partner has the right to hear about it, no matter how awkward the ensuing conversation may be.
How to get it: Find a comfortable time to talk about the issues, Perelman advises. For some, it might be while relaxing in bed, a setting that can lead to openness and intimacy; for others, he says, such a conversation will best be broached over a glass of wine or a cup of coffee, “in any comfortable place that affords privacy.” Try a gentle opener: “I have a few thoughts about our sex life I’d like to discuss, if that works for you.”
Proposed amendment: Partners should never criticize each other during sexual activity (unless something is uncomfortable or painful). If you’re hesitant to start a conversation, you might unilaterally consult a sex therapist first. “Even if only one person in the couple seeks assistance, it’s highly likely that some relief can be found,” Perelman says.
You have the right to affection.
Sexual passion may wax or wane over time in any long-term relationship, but it’s important that affection carry on. “Giving and receiving affection is associated with feelings of pleasure, acceptance, happiness or contentment, and a sense of being loved or cared for,” says Anita Vangelisti, a communications professor at the University of Texas at Austin who has studied affection’s effects, specifically in the early years of marriage. She has found that hearing “I love you,” and receiving physical affection outside of sexual intercourse, among other behaviors, predicts higher marital satisfaction for both men and women.
While expressions of affection typically become a little less frequent over time, she says, “partners who maintain relatively high levels tend to be happier.” Research on the physiology of affection has also shown that giving and receiving it are associated with the release of oxytocin, as well as the regulation of stress hormones throughout the day, enhancing well-being and enabling each partner to manage stress more successfully.
How to get it: “Ask for it,” Vangelisti says. You can start by giving more affection to your partner. “Once your partner sees you giving them more affection, they may reciprocate.” You can try to arrange more opportunities for affection by planning relaxed time together. “If one or both of you are always busy and rushing around, it’s more difficult to give and receive affection.”
And don’t fear that “manufacturing” affectionate behaviors, or the opportunities for them, will strip them of their power. Research by Brittany Jakubiak of Syracuse University and Brooke Feeney of Carnegie Mellon University has shown that people felt more secure and trusting in a relationship, and more confident that it would endure, after a partner held their hand or threw an arm around their shoulder, even if they were told that the partner had been instructed to show them affection.
Proposed amendment: Be clear about the type of affection you seek and make sure you and your partner both understand how you each define the term. If they think they’re showing affection by taking your car to get washed, while you want hugs and a whispered “I love you,” that’s the kind of misunderstanding that can erode satisfaction with a relationship.
You have the right to the benefit of the doubt.
Relationships flourish when couples attribute the best of intentions to each other all the time. This means that, yes, your partner really should view you through rose-colored glasses, idealizing you in normal circumstances and forgiving you relatively easily when you fall short. “A little bit of positive illusion is better,” Finkel says. “It’s easy to go down rabbit holes of perceived slights, but if we have a general view that our partner is loving and at core a decent person—maybe even more decent than they really are—then when we do have difficulties, we’re better at overcoming them. Some amount of self-delusion is linked to better relationship quality.”
Relationship satisfaction typically starts falling immediately after a couple says “I do,” but many studies have pointed toward a prescription for sustaining it. In just one recent example, Sandra Murray of the University at Buffalo found that partners who continue to idealize their spouse, even somewhat unrealistically, experience less decline in satisfaction with the marriage over three years than people who cannot maintain the same belief.
How to get it: “We have a lot of latitude in how we perceive our partner’s behavior,” Finkel says. If you show up late to an important event, your partner could label you inconsiderate—or remember that you’ve been overwhelmed at work but are still trying to get everything done. If you or your partner tend more toward reflexively blaming the other, try thinking about the situation from the perspective of a neutral third party who wants the best for both of you. “It gets us out of our myopia and gives us a broader perspective,” Finkel says. Implementing some psychological distance can help you and your partner feel less angry about conflicts and should strengthen the relationship over time.
Proposed amendment: Beware of the doormat effect. “We have studies showing that if someone is highly forgiving, with no amends made, or if a partner is always difficult, forgiveness may still have beneficial consequences, but it undermines the aggrieved party’s self-respect,” Finkel says. If a problem festers over time, the relationship is likely to suffer. Minor flaws or occasional missteps can be sugarcoated, but more serious issues must be addressed and ideally resolved.
“It’s a shared responsibility,” Finkel says. Partners need to own up to hurtful things they’ve done and express regret, even if they don’t fully believe they are in the wrong. For the hurt partner, there’s a lot of benefit in both hearing an apology and seeing amends. It can help you both put infractions in the past. “Let them be speed bumps, rather than barricades.”
You have the right to gratitude.
Partners who are grateful for each other, studies have shown, feel more satisfied in their relationships. And even when just one partner feels gratitude—whether on an existential level or for simpler things like being brought a favorite drink—both benefit. Amie Gordon of the University of California, San Francisco calls it a cycle of gratitude. “If you start doing nice things, and your partner picks up on it and feels appreciated, it should inspire their own good feelings,” she says. Gratitude can increase people’s motivation to stay in, and improve, a relationship, and make them more likely to engage in more considerate behaviors, like better listening and sacrificing for their partner. Gordon’s research has shown that more grateful people are likelier to maintain long-term relationships.
A recent study in Social Psychological and Personality Science suggests it’s the feeling of gratitude that makes a difference, not the acts that engender it. Researchers found that people are equally likely to notice a partner’s sacrifice as not, and they are just as likely to see a sacrifice where there is none as they are to correctly note its absence. No matter: When a person believes a partner has sacrificed for them, accurately or not, the benefits of gratitude accrue. And when they fail to detect a sacrifice, their partner feels less satisfied.
How to get it: Your partner is not obligated to keep a gratitude journal or meditate with you on life’s blessings. So how to elicit it? You can prime a partner’s expressions of gratitude by showing your appreciation for them. “If you feel unappreciated or taken for granted, try doing some of the things you wish they would do for you,” Gordon suggests. “It’s a nice way to jumpstart gratitude in a reasonably well-functioning relationship.” If you’re having trouble accessing your own gratitude, think about what life was like before you were with your partner. That can help counter hedonic adaptation—or becoming accustomed to, and perhaps less appreciative of, the benefits they bring to you. When showing your own gratitude, make it personal. “It’s not just, ‘Hey, thanks for taking out the trash.’ Say, ‘You know how much I hate it; you’re so thoughtful for doing the thing that I hate.’ You’re not just thanking them for the act,” Gordon says, “but for the person they are. It bumps it up a notch.”
Proposed amendment: Gratitude shouldn’t be used to gloss over problems such as emotional abuse. “It’s not healthy to try to feel gratitude because, hey, this person didn’t yell at me today, or get mad when they usually do,” Gordon says. No one should use gratitude to prop up a relationship that they should be exiting.