Systematic Treatment Enhancement Program for Bipolar Disorder – STEP-BD

The NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is a long-term outpatient study designed to find out which treatments, or combinations of treatments, are most effective for treating episodes of depression and mania and for preventing recurrent episodes in people with bipolar disorder.

1. Q. What was the goal of the STEP-BD depression psychosocial treatment trial and how did it fit into STEP-BD?

The study reported in the April 2007 issue of the Archives of General Psychiatry describes the results of a clinical trial examining the effectiveness of four psychosocial interventions for people with bipolar disorder who are experiencing a depressive episode. The clinical trial was part of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) research program, the largest, federally funded treatment trial ever conducted for bipolar disorder. STEP-BD enabled researchers to explore a range of treatment options related to bipolar disorder, including mood-stabilizing medications, antidepressants, atypical antipsychotic medications, and psychosocial interventions (talk therapies).

Once enrolled in the STEP-BD program, participants aged 15 or older received individualized care from their STEP-BD treatment provider that included the best available treatment options. This approach was called the Best Practice Pathway. Participants in the Best Practice Pathway who were age 18 or older and whose depression did not improve or who experienced a new depressive episode, could enter the randomized clinical trial that examined the effectiveness of different combinations of medication and psychosocial therapy for the depressive phase of bipolar disorder.

In this one-year randomized clinical trial, the goal of the psychosocial study was to determine if receiving intensive (and long-term) treatment with any one of the three psychosocial therapies offered in STEP-BD was more effective in relieving bipolar depression than receiving treatment with a brief, short-term talk therapy intervention.

2. Q. Why is the psychosocial treatment trial important?

Although various treatments currently are available for treating bipolar disorder, including medications and talk therapies, it is not known if psychosocial interventions, when received alongside medication, can help relieve bipolar-related depression and keep patients well in typical, real-world clinical settings. In addition, most previous clinical trials were conducted in single academic centers and included carefully selected groups of research participants who may be different from the people seeking care in everyday practice settings.

In this regard, the psychosocial treatment study in STEP-BD is unique because it included “real world” patients experiencing the early phases of a depressive episode, who were already receiving care for their bipolar disorder as part of STEP-BD. The therapists who delivered care in the psychosocial treatment study received STEP-BD training in the different psychosocial therapies by experts in the field. The training and ongoing supervision was of low intensity, consistent with what is typically available in clinical practice.

3. Q. How were participants selected for inclusion in the psychosocial treatment trial?

While enrolled in the STEP-BD Best Practice Pathway, participants were evaluated for depression at every follow-up visit. These clinic visits recorded and tracked participants’ treatment and assessed their symptoms and clinical status for the duration of participation in the study. If the study participants experienced a depressive episode, they could choose to leave the Best Practice Pathway and enter the randomized portion of STEP-BD; 366 participants did so.

The randomized acute depression study lasted 26 weeks and addressed the question of whether adding an antidepressant medication (buproprion or paroxetine) to an existing mood stabilizing medication is more effective for treating acute bipolar-related depression than adding a placebo pill. All participants in this portion were required to be on a mood stabilizing medication, such as lithium, valproate, carbamazepine or other mood stabilizer approved by the U.S. Food and Drug Administration.

These 366 participants also had the option of participating in the randomized psychosocial treatment study in which they would receive psychosocial treatment in addition to their medication treatment. Of the 366 participants who entered the randomized depression trial, 236 chose to enter the psychosocial portion. In addition, 57 STEP-BD participants who were enrolled in the Best Practice Pathway, but who were not part of the medication portion of the randomized depression trial, chose to enter the psychosocial study as well. Altogether, 293 participants took part in the psychosocial treatment study. Many of those who chose not to participate in the psychosocial portion of the study were already receiving psychotherapy on their own.

4. Q. What psychosocial interventions did participants receive?

Researchers randomly assigned participants to receive either a short-term collaborative care intervention or one of three longer-term intensive therapies that have been shown to help stabilize bipolar symptoms—cognitive-behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), or family-focused treatment (FFT). Collaborative care was considered the “control” intervention, meaning that the outcomes of this therapy were used as a baseline by which to compare the other three intensive therapies. All of these therapies focused on education about the illness, relapse prevention planning, and bipolar illness management interventions, and all but collaborative care consisted of up to 30, 50-minute sessions that took place over nine months.

Collaborative care, which consisted of three, 50-minute sessions over six weeks, provided participants with a workbook, an educational videotape and other information that aimed to help them understand and manage the illness, maintain adherence to medications, and develop a treatment contract geared toward preventing bipolar episodes.

In the CBT intervention group, participants received education about the illness. They learned to challenge negative thoughts or beliefs about bipolar disorder or its associated stressful life circumstances, developed schedules to stay active, and developed strategies to detect and cope with mood swings.

The focus of IPSRT was on attaining and maintaining regular social rhythms (daily routines and sleep/wake cycles) and the relationship of daily activities to mood and levels of social stimulation. IPSRT therapists encouraged participants to keep track of their daily routines (e.g., when they went to sleep, when they woke up, etc.) while working toward establishing stable social rhythms. Patients also worked to resolve key interpersonal problems related to grief, role transitions, interpersonal disputes, or interpersonal skill deficits.

In FFT, participants and their relatives (e.g., spouses and parents) were taught an understanding of bipolar illness, its course, treatment and management. Family members were taught how to recognize early warning signs that might predict an oncoming depressive or manic episode in the person with bipolar illness, and strategies to intervene when these warning signs occurred. Treatment included enhancing communication between the participants and their family members to improve the quality of family interactions, and problem-solving to manage conflicts related to the illness.

5. Q. What do the results from the STEP-BD psychosocial treatment trial tell us about the treatment of bipolar disorder?

The outcome measures that were used to evaluate success of the treatments were “time to recovery” (e.g., how quickly did people get well) and the total amount of time during the study year that participants remained “well” (measured by the probability of being well during any given month). To be considered “well” in the study, participants had to have no more than two symptoms of mild or moderate mania or depression.

Of the 293 STEP-BD participants in the psychosocial treatment study, 59 percent recovered from their depression; 41 percent either did not recover or left the study early.

Over the course of the study year, participants in the intensive psychotherapies (FFT, IPSRT, CBT) had a more successful recovery rate (64 percent) compared to the individuals in the collaborative care group (52 percent). Also, participants in the intensive psychotherapies who recovered did so faster (on average, after about 113 days) than those in the collaborative care group (after about 146 days). Furthermore, the participants in the intensive psychotherapies were one and a half times more likely to remain well during any given month of the study year than those in the collaborative care group.

The study also showed that in each of the four psychosocial treatment groups, participants who were also enrolled in the randomized medication portion of the trial got well faster than those who were not, even though all patients were receiving some type of medication. In addition, recovery time was faster in all four groups for those participants who had family supports available.

Differences among the three intensive psychosocial interventions were not statistically significant, but they are worth noting. Over the yearlong study, 77 percent of participants in the FFT recovered, compared to 65 percent of participants in IPSRT and 60 percent in CBT.

6. Q. What do the results mean for people with bipolar depression and the doctors who provide care for them?

This one-year study showed that, in conjunction with adequate mood stabilizing medications, intensive psychotherapy is more effective in helping people recover from a depressive episode, and stay well over a one-year period, than a brief collaborative care treatment. All three types of intensive psychosocial treatments had comparable benefits.

Overall, psychotherapy appears to be a vital part of the effort to stabilize episodes of depression in bipolar illness. These findings should help clinicians plan treatments for individuals recovering from an episode of bipolar depression.

5 Tips for Parents of Troubled Teens

The teen years already come with a variety of challenges, including seeing many unexpected changes in your teen’s behavior. Although teens can appear to be unpredictable at times, much of their behavior is entirely normal for adolescence. However, some teens may struggle with emotional, psychological, and behavioral concerns, and they may exhibit behavior that is troubling or concerning. For instance, troubled teens might:

  • abuse drugs and alcohol
    engage in risky sexual activity (unprotected sex, promiscuity, etc.)
    harm themselves through cutting or other forms of self-harm
    talk about suicide
    exhibit extreme signs of defiance (frequently skipping school, many fights at home)
    act aggressively toward friends and family
    display a sudden change in peers that also accompanies getting into trouble with the law or at school
    experience rapid mood swings or intense moods such as depression or mania
    parents of troubled teens

It’s important to recognize that all teens are going to display behavior that is different than what you’re used to seeing in them. For instance, you might have always known your child to be talkative, engaging, and helpful around the house. Now your teen barely says a word, spends all of their time in their room, and refuses to help out with chores. Your words of wise guidance is received with a shrug of the shoulders or a roll of the eyes. You’re not sure exactly who your teen is anymore.

Despite these changes, this is normal behavior for adolescence. A troubled teen is often going to exhibit extreme forms of behavior, such as those listed above.

How to Help Troubled Teens
If you’re having a hard time with your teen consider the following ways you can help:

Focus on strengthening the relationship with your teen.

You might know the saying about troubled teens and youth: the ones that are the hardest to love are the ones that need it the most. If you can, spend quality time with your teen every day, even if it’s for 15 minutes. The point is that you want to boost the connection you have with your teen, or create one if there’s not one already there. Teens who feel connected to, accepted, and loved by their parents often display less troubling behavior. To strengthen your relationship with your teen:

  • Tell your teen you love them.
  • Spend some one-on-one time together. Find something you both enjoy doing.
  • Praise your teen whenever possible.
    Express empathy whenever you see your teen struggling with emotions.
  • Show interest in your teen’s life.

Encourage your teen to follow healthy lifestyle habits. It might not solve all the problems, but getting enough sleep, eating well, and exercising can have a great impact on a teen’s emotional stability. Each of these healthy habits affect both the mind and the body, leading to mental clarity and well-being. Talk to your teen about developing a routine for getting good sleep, exercising, and eating well.
Create more structure for your teen.

Along the lines of developing a routine for healthy lifestyle habits, you may need to create more structure in general. Although your teen might at first fight against it, structure often helps troubled teens to feel safe and secure by your parenting. This too can support the parent-child relationship. Structure may include being more firm about your house rules and enforcing them, having clear expectations of your teen and communicating them, as well as having clear rules around drug/alcohol use, curfews, and other boundaries that support your teen’s safety.
Listen to your teen openly and honestly.

One of the primary needs for teens is to be loved and accepted by their parents. Acting out behavior may stem from not feeling heard or understood. Or worse, feeling rejected by their parents. If you are working on strengthening the relationship with your teen, do your best to hear what your teen has to say. Step into your teen’s shoes and empathize with their feelings and thoughts. This is another way to find connection. And it’s through genuine connection that help relationships grow and develop.
Educate yourself on teen development.

It’s important to know that adolescence is a stage onto itself – it is unlike childhood and adulthood. The needs of a teen are unique. Teens want their independence but require the same security that children do. Meanwhile, teens do their best to walk this tightrope toward adulthood. This is a challenging stage of life, and it demands certain types of parenting. Furthermore, the teen brain is still developing, which can cause teens to be more emotional and impulsive versus logical and rational. A fuller understanding of adolescence can support you in responding to the needs of your teen.
Help Your Teen Manage Their Anger
Many troubled teens exhibit anger and often find themselves in trouble because of it. Because of the consequences that come with expressing anger inappropriately, you can help your teen learn how to manage their anger, in addition to the suggestions provided above. Unfortunately, the consequences to not being able to control anger can include damaging relationships at home, school, and work. In extreme cases, failing to appropriately manage anger can lead to violence, legal problems, suspension/expulsion from school, and other problems. It’s important for parents or caregivers to teach their teens how to manage their anger and use coping tools for facing intense emotions in a healthy way. This is particularly true for parents of troubled teens, who may struggle with anger and may have a hard time expressing this emotion appropriately.

Teens who struggle with anger:

often simply lack the tools to appropriately express their anger.
can learn how to acknowledge anger but not respond to it
can learn how to express their anger in a healthy way
can learn to redirect their anger towards a positive cause
If you are a parent of a troubled teen who often displays anger or aggression, you might teach your teen to:

Develop effective coping skills. Talk to your teen about specific choices they can make in the moment. You might come up with a list together so that your teen has options to choose from. These might include breathing, walking away, thinking of the consequences, or talking to someone.
Develop control over angry responses. You can let your teen know that this will take practice. Anger is a very quick emotion and can come on suddenly. It takes time to learn to have control over anger. However, letting your teen know that it’s possible can be a first step.
Increase frustration tolerance. Sometimes anger or frustration doesn’t need to be followed up by an action. In other words, slowly your teen can learn to tolerate the anger inside (by learning to express it in a healthy way) versus exploding with an angry response.
Improve problem-solving strategies. To help avoid triggers, you can teach your teen to strategies that help solve problems. This in turn can help your teen feel empowered. (Often, feeling disempowered is the root cause of anger.)
Replace aggressive behavior with assertive behavior. Talk to your teen about the differences between passive, aggressive, and assertive behavior. This can also give your teen more choices in terms of how they respond to an anger-provoking moment.
These are suggestions for helping troubled teens with anger, emotional ups-and-downs, and defiance. However, if any of the above suggestions are not entirely effective, it is best to seek the support of a mental health professional.

Self-esteem: How to Help Boys

Adolescence and Teenage years are hard on kids – whether they are boys or girls. It happens equally as well and there is no winner when it comes to low self esteem.

According to latest research in the field of self esteem in kids, the difference in scores on tests of self-esteem among teenage boys and girls is very small. The girls do have self-esteem issues during adolescence. But so do the boys. Adolescence years are equally hard on kids – whether they are boys or girls.

Do Good to Feel Good

If one wants to feel good about self, then he/she has to do something good to feel good about. Doing real and worthwhile things make a person have a positive self esteem and makes him always look upon himself positively. You need to start developing a helpfulness culture in the family where all members help in doing things of one another or may be for people outside home. If you are staying near an elderly neighbor, start with shovelling their walk or mowing their lawn. Get involved in different charitable activities as a family. Raising money for a for a good generic cause also makes a family feel good about themselves. This goes a long way in establishing positive sense of feeling for boys and makes them know that they have earned their positivity.

You should be ready to welcome your son’s friends anytime for doing something fun. Open up your home for the boys to have good time. He will start having confidence on his mother and himself.

Top tips on the boys self-esteem

1. Always set Boundaries and Rules to Follow

Teenagers also needs rules and boundaries just like younger children. Set rules, set expectations that fits your family values and explain them the importance of following them. Make them understood that you expect the rules to be followed regularly and what will follow if it isn’t followed. This makes the boys know that they are values and brings a self-esteem boost for them.

2 Do not Praise too much – be generous

Praising and acknowledging the acts and deeds of children always go as a sure way of building self confidence in children. Tell positive things to your your teens say specific praise. Do not forget to praise them for their efforts since this is what matters and not the results. Let your son know how much you are pleased looking at how hard he has been trying. Always be sincere with your praise since teens after some time will know whether the praises are genuine or not – defeating the whole purpose of praising and pumping them up.

3. Be Supportive During a Conflict

Boys sometimes end up being in middle of a conflict at either school or among friends or team members. Always listen to them and their story before being judgemental about them. The conflicts which they face seems silly to us, but they are very serious for them. Because of teenage years and hormonal changes happening in them. Create a habit and support your child in good and bad equally. Do not budge from taking stand for your child if needed. If they starting feeling that they have a parent to lean on who loves and accepts them is a great confidence booster for them.

How to Deal with a Critical Mom?

There are many ways to look at the mother daughter relation. I is different than mother son relation and father son relation. Mothers are protective, sensitive and critical about the way they treat and love their daughters. So why the relation is so fraught as compared to the one between mothers and sons? The real reason is that boys tend to demand and strive for more separation to find their own identities as compared to girls which gives boys and mother’s relations a sense of separation, whereas the girls tend to come closer and becomes more like their mothers as they grow up – increasing the competition and hidden conflicts. Girls strive to develop a sense of self like their mother rather than against their mothers which causes all the difference of being so critical. It can make the communication with mom more and more frustrating since competition creeps in.

Mom’s are not mean when you find them awake all night or believe so that they are awake. The mothers do not pester their daughters unnecessarily. They are expressing their love and concern, but the way is what it is. You need to train yourself to see what is inside as compared to what is coming outside – nit-picking, criticism, and all those things you don’t like.

How to handle Critical and Meddling Moms

There are many examples where a highly critical mom has been driving crazy people till their own old years. Like one of the person in her 70’s said that her mom criticise her for her skinny legs, non-feminine appearance, body hairs, etc. such that it is haunting her till today everyday. Her mom still in her 90’s tell her daughter to become more sexy and appealing by becoming feminine rather that doing the things like she is doing. Quite a pain, if you put yourself in the daughters shoes who has been suffering due to ever critical mom since last 7 decades.

Here are some of the things which you can do to handle the situation:

1. Focus on things you can change rather than on what you can’t change like your mom and her behaviour. You cannot just have any control on your mother and her emotional blabber. Just accept and think you are responsible for your happiness.
2. Do try to understand that the parents criticism is not about you but about some of their inner feelings which lost during the course of years. The problem of why they are criticizing lies in you parent’s own self-contempt. They should first learn to accept and love themselves and here you go – they will become better and less criticizing.
3. They think you are their extension and do the same self check with you as well. They do not consider you as a separate person rather a part of themselves hence so critical.
4. Parent cannot always be right. They have their own say, but since you are an adult, you can also think and decide on your own. Parents still jhave the same perception about you since you are the same kids for them forever. So relax and take fun in their opinion rather than slogging and sweating out due to their viewpoint.
5. Be assertive with your parent. You are not required to be defensive and make excuses. Be polite and say “I don’t appreciate this”. This can channelize the inner content and the anger outburst is not expelled on to other non-deserving relations like your child or spouse.
6. The more time you spend with people who bring positive energy in you the more are the chances that the critical comments from your mother will fade away. Just balance the time you spend with positive people and negative people. You will be fine. This balance will bring you peace and joy.

Helping your Perfectionist Child Find Balance

The current world is highly competitive and challenging for a youngster and children especially. The tough college admissions process, jobs scenes, ever increasing toughness in doing business are all driving people crazy and unmanageable. These problems in today’s culture of high stakes are not solved until we become a perfectionist. But the problem does not end here. Being a perfectionist is proven to interfere a lot with the child’s ability to achieve goals and shape their futures. In fact, they often struggle with depression, anxiety, and low self-esteem.

Perfectionist kids can be divided into two categories – one as underachievers and second as overachievers. The first one tend to be paralysed by their perfectionism and could not make decision or try new things because they are too afraid to fail. Overachievers always relentlessly try new things and perform them perfectly.

When the achievers achieved something, they set the goals higher and higher. the realisation of being perfect does not come easy and although it comes, it becomes more and more difficult to choose between being perfect and the most effective strategy for getting things done.

Here are top signs of a Perfectionist child
Check on these questions for your child and find if they are overachievers or underachievers.

1. Are they Fear failure?
2. Do they believe that doing mistakes is not good?
3. Do your child feel comfortable with criticism or disapproval?
4. Thinks that if he gets C, it is end of world for him or her.
5. Have some solid rules of his/her own to abide with?

Ways to Support a Perfectionist Child

1. Teach your children to focus the efforts and process instead of results and outcome. Explain them that the journey is equally important as the goal.
2. Help your kids understand the meaning of learning from mistakes. The perspective should be mistakes are learning opportunities.
3. Challenge your child’s definition and standards for success. Explain that the world will not end because the result was not perfect.
4. If you see anxiety in them for something, talk with them about the efforts, outcome, etc. Check for their expectations and make them set realistic goals.
5. Ask your child what they are afraid of and what is the worst which can happen. This way, you will be able to understand your child’s expectations and fear.
6. Help them prioritise the tasks which will help them focus only on those which are well worth focusing and spending energy on. You will remove many of the tasks from their perfection list by this simple exercise – greatly reducing their burden.

Get rid of the negative self-talk

You can be your own worst enemy. Negative critical messages you say to yourself can rev up your stress, hold you back, and take you down!

Negative self-talk are messages like:

  • “You’re stupid.”
  • “You can’t do anything right!”
  • “You’re ugly.”
  • “What a loser.”
  • “You’ll never amount to anything.”

The messages in your head may be generated from low self-esteem or be repeats of messages voiced by flawed parents.

All too often, parents who don’t deal with their own shortcomings put them onto their children.

If you were repeatedly put down by a parent or other important adult—that was their stuff, not yours.

I noticed that I would say “You’re stupid” whenever I was disappointed in something I thought or did.

That message had haunted me for years but letting myself hear it clearly led me to being able to banish it from my inner repertoire.

In bringing the message up from my subconscious to my conscious in such a clear way I knew immediately where the message came from. My mother sent me that message in a myriad of ways including saying “You’re so stupid!”

I also realized “I’m not stupid.” This was mom’s stuff. She had her attributes but she had an 8th grade education and—as she would say about other people but not herself—she was not the sharpest knife in the drawer.  Mom overcompensated for her own ignored inadequate feelings by putting me down.

I developed a system for countering the message.

I came up with a list of evidence that I’m not stupid.

Whenever I heard “You’re stupid” in my head, I would say to myself “Reality check.” Then I would recount the list of evidence that I’m not stupid.

Eventually, I didn’t need to use all the items on my evidence list before I would feel myself snap out of feeling inadequate.

A short time later, I didn’t need the list anymore. Just saying “Reality check” would undo the “You’re stupid” message.

And soon, “You’re stupid” went away.

I had been rid of the “You’re stupid” message for over 20 years when one of my sisters told me she too had been haunted by “You’re stupid.”

I said to her “You too?” to express my surprise.  And she replied “With our mother, how could you not.”

To get rid of negative self-talk take these steps:

  1. Begin to notice it. Pay attention to what you say to yourself. Rather than push it away, bring it up to full awareness and hear the message clearly. Possibly write it down so you’ve really got it.
  1. Counter the message. The phrase “Reality Check” worked for me as a signal to counter the message. That may work for you too. Whether or not you use that signal, you want to challenge the message and provide yourself with evidence to the contrary. It may be helpful to write out the evidence.
  1. Replace negative with positive. Possibly replace the negative message with its positive counterpart. “You’re stupid” can be replaced with “You’re not stupid” “You’re smart” “You can do this” “Academics aren’t your thing but there’s more to smart than school grades” or something else that empowers you.


Reflect on whether you have any negative self-talk.

Where did that message come from?

How has the message gotten in your way?

Use the steps to practice riding yourself of the counterproductive message.

Donald Trump and the Narcissistic Illusion of Grandiosity

Donald Trump has grown an empire of wealth and power, but is it enough? He admits that it isn’t the money that motivates him (The Art of the Deal, 1987). What drives narcissists are their fears of feeling weak, vulnerable, or inferior. Consequently, for male narcissists in particular, achieving power is their highest value at any cost. Trump is “certain about what he wants and sets out to get it, no holds barred” (Trump on Trump).

There is great disparity between what narcissists show the world and what goes on inside. Despite their big egos, they’re frightened and fragile just the opposite of their grandiose, powerful façade. They must work hard to keep up their image, not only for others, but for themselves. In fact, their immodesty and exaggerated self-importance are commensurate with their hidden shame. Shame is paradoxical in that it hides behind false pride. Its defenses of arrogance and contempt, envy and aggression, and denial and projection all serve to inflate and compensate for a weak, immature self. Like all bullies, the greater their defensive aggression, the greater is their insecurity.

Shame fuels their needs for admiration, attention, and respect. “If I get my name in the paper, if people pay attention, that’s what matters” (Donald Trump: Master Apprentice, 2005). Trump wants “total recognition” as when “Nigerians on the street corners who don’t speak a word of English, say, ‘Trump! Trump!’” (New Yorker, May 19, 1997). Praise and success never fill a narcissist’s inner emptiness, nor compensate for deep-seated feelings of inadequacy.

To gain recognition and validation of their worth, narcissists brag and exaggerate the truth. They imagine themselves to be more special – more desirable, more intelligent, more powerful, more invincible – than others. “Some people would say I’m very, very, very intelligent” (Fortune, April 3, 2000). “My I.Q. is one of the highest!” (Twitter, May 8, 2013). “All the women on ‘The Apprentice’ flirted with me  – consciously or unconsciously” (How to Get Rich, 2004). “It’s very hard for them to attack me on looks, because I’m so good-looking” (NBC’s “Meet the Press,” Aug. 9, 2015). Trump announced his grandiose, unrealistic ambitions to Scott Pelley to force businesses to close foreign plants, to compel the Chinese to devalue their currency, and to build a cheap, impenetrable wall paid for by Mexico. (Estimates are $28 billion a year.)

It’s all or nothing with narcissists. For Donald Trump, there are winners, like himself (TrumpNation: The Art of Being The Donald, 2005), and losers, and he “doesn’t like to lose” (New York Times, Aug. 7, 1983). “Show me someone without an ego, and I’ll show you a loser” (Facebook, Dec. 9, 2013). Trump must stay on top and thrives on the challenge. “You learn that you’re either the toughest, meanest piece of [expletive] in the world or you just crawl into a corner … Guys that I thought were tough were nothin’” (New York magazine, Aug. 15, 1994).

Losing, failing, being second aren’t options. “Life to me is a psychological game, a series of challenges you either meet or don’t” (Playboy, March 1990). He “lies awake at night and thinks and plots” (New York magazine, Nov. 9, 1992). These high stakes make for vicious competitiveness, where offense is the best defense. “Sometimes, part of making a deal is denigrating your competition” (The Art of the Deal, 1987).

Narcissists have a “my way or the highway” attitude and don’t like to hear no. Others’ limits make them feel powerless as they did as a child, which is very frightening. They can throw a childlike tantrum when others don’t comply. When their imagined omnipotence and control is challenged, they manipulate to get what they want and may punish you or make you feel guilty for turning them down.

By projecting their aggression outward, the world appears hostile and dangerous. “The world is a pretty vicious place” (Esquire, January 2004). People who are seen “as out for themselves” (Playboy, March 1990) become adversaries to defeat or control. To keep safe, they push others away, fending off threats and humiliation, and they do so aggressively. Women “are far worse than men, far more aggressive … ” (The Art of the Comeback, 1997). “You have to treat ’em like [expletive]” (New York magazine, Nov. 9, 1992). Nevertheless, narcissists are exquisitely sensitive to any sign of disrespect or imagined slight that threatens their self-concept. When Trump says, “The rich have a very low threshold for pain” (New York magazine, Feb. 11, 1985), he includes himself.

Trump learned to attack from his father, who “taught me to keep my guard up” (Esquire, January 2004). When attacked, narcissists retaliate to reverse feelings of humiliation and restore their pride. “If someone screws you, screw them back. When somebody hurts you, just go after them as viciously and as violently as you can” (How to Get Rich, 2004). “If somebody tries to push me around, he’s going to pay a price. Those people don’t come back for seconds. I don’t like being pushed around or taken advantage of” (Playboy, March 1990).

He told Scott Pelley that his father was “a tough cookie” — a strict, “no-nonsense kind of guy” (Playboy, March 1990). There are many ways parents can shame their children and instill the belief that they’re not worthy of love. Scolding feelings and needs or emphasizing high expectations convey conditional, tough love, which makes a child feel unaccepted for who they are. Sadly, the implication is that without success (or for a female narcissist, often beauty), no one would care about me. “Let’s say I was worth $10. People would say, ‘Who the [expletive] are you?’” (Washington Post, July 12, 2015). Instead, they must earn their parents’ acceptance. Ted Levine, Trump’s high school roommate, described the kind of pressure to excel that the boys were under. “He had to be better than his father. We were sent here to be the best of the best, and we knew what our job was.”

To compensate for insecurity and shame, narcissists feel superior, often expressed with disdain or contempt. Arrogance and putdowns bolster their egos by projecting the devalued parts of themselves onto others. Trump has disparagingly and publicly labeled various people a “dog,” “bimbo,” “dummy,” “grotesque,” “losers,” or “morons.” Narcissists’ invectives are made worse by their lack of empathy, which enables them to see people as two-dimensional objects to meet their needs. “It really doesn’t matter what they write as long as you’ve got a young and beautiful piece of [expletive]” (Esquire, 1991). Objectifying others demonstrates how insensitively they were treated growing up.

“Not the quarry, but the chase; not the trophy, but the race” inspires Trump. “The same assets that excite me in the chase, often, once they are acquired, leave me bored. For me … the important thing is the getting, not the having” (Surviving at the Top, 1990). Conquest and winning reaffirm a narcissist’s power. “It’s all in the hunt and once you get it, it loses some of its energy. I think competitive, successful men feel that way about women”.

Victory also bolsters unexpressed feelings of insufficiency. Trump so hinted, saying, “Oftentimes when I was sleeping with one of the top women in the world I would say to myself, thinking about me as a boy from Queens, ‘Can you believe what I am getting?’” (Think Big: Make it Happen in Business and Life, 2008).

However, power and love don’t easily coexist. “Intimacy requires vulnerability, letting down one’s guard and being authentic to get close emotionally — all signs of weakness that are frightening and abhorrent to a narcissist. Rather than give up power and control, which risk exposure of their false persona, many narcissists have short relationships or are distancers when more than sex is anticipated”

Love relationships are about connecting — something herculean for a narcissist. “For me, business comes easier than relationships” (Esquire, January 2004). “I’m married to my business. It’s been a marriage of love. So, for a woman, frankly, it’s not easy in terms of relationships” (New York magazine, Dec. 13, 2004). “I was bored when she (Marla) was walking down the aisle. I kept thinking: What the hell am I doing here? I was so deep into my business stuff. I couldn’t think of anything else”.

Science of Personality of Donald Trump

The fate of any organization is largely a function of that organization’s leadership. The “organization” of the United States is no exception to this rule. While he leads in the polls for the Republican party candidacy, it seems only appropriate that we understand and think about the type of leader Donald Trump would be for the United States.

I do not know Mr. Trump personally and I have never had the opportunity to assess his personality professionally (though I’d be happy to do so if he were willing). Thus, my views are based purely on watching his behavior. His personality is captured by his reputation, which is the sum of his behavior, and organized by a standard set of themes as follows.

We can look at both sides of Mr. Trump’s personality. The Bright Side (how he typically behaves when he’s at his best) and the Dark Side (how he typically behaves when he lets down his guard).

Beginning with the Bright Side we can expect Mr. Trump to be:

  • Highly Adjusted. Mr. Trump seems not at all anxious or nervous. He will appear calm under pressure, won’t take criticism personally, and is quite pleased with himself as a person. The downside is that he will be reluctant to listen to feedback — especially negative feedback — from others.
  • Highly Ambitious. Mr. Trump seems competitive, wants to win, and wants to be in charge. He will be concerned about results and getting things done. On the downside, he may tend to compete with those who are actually on his team and potentially alienate his staff if he does.
  • Highly Sociable. Mr. Trump likes to entertain, to be the center of attention, and to talk…a lot. The obvious downside is that he can be unwilling to listen, overbearing, and shoot off at the mouth without thinking.
  • Low on Interpersonal Sensitivity. Mr. Trump is direct, doesn’t shy away from confrontation, or really care much about peoples’ feelings. The upside is that he is willing to let people go when needed (e.g., “You’re Fired”). The downside is that he is hostile and alienates others.
  • Low on Prudence. Mr. Trump doesn’t care much for rules and tends to avoid them. He is independent minded and seems unconcerned with details. The positive side is that he will be quick to make decisions and to make things happen.
  • Highly Inquisitive. Mr. Trump has a lot of ideas and a big imagination. He’ll have all sorts of ideas for solving problems, but he may have problems implementing them and can be a bit unpredictable.

On the Dark Side we can expect Mr Trump to be:

  • Highly Bold. This is Mr. Trump’s most defining characteristic. He seems unusually self-confident, and shows feelings of grandiosity and entitlement. These individuals tend to make a good first impression, but are difficult to work with because they feel entitled to special treatment, ignore their critics, and intimidate others. He’ll tend to overestimate his capabilities.
  • Highly Mischievous. Mr. Trump seems charming, interesting, and daring. He enjoys taking risks, pushing the limits, and seems to thrive on excitement. Such people are hard to work with because they are impulsive, downplay their mistakes, take ill-advised risks, and have no regrets.
  • Highly Colourful. Mr. Trump seems quick, fun, and socially skilled. He loves making use of his celebrity and having his accomplishments recognised. He’s very good at calling attention to himself. Such people are hard to work with because they are self-promoting, over committed, and easily angered.
  • Low on Diligence. See Prudence above, but multiply everything by two.
  • Low on Dutifulness. Mr. Trump likes to defy the status quo, doesn’t care about pleasing others, and is quick to make decisions. He won’t take orders (or advice) from many people (if anyone).

In summary, what we can expect from Mr. Trump is what we have already seen and know about his reputation. What does this mean for the United States? People tend to vote for leaders in their own image. Thus, the personality of Mr. Trump also highlights the characteristics of those who will likely support and vote for him. As such, Mr. Trump’s popularity in the polls also serves as an indicator of our current American culture.

How Does Mindfulness Reduce Troubling Thoughts?

“I’ve got such a mess between my ears, like dishes in the sink. Stuff I don’t believe just tumbles in so I don’t have room to think”- David Wilcox (Empty Out the Inside of My Head)

This common experience is one that leaves in its wake, distress and is a fertile breeding ground for depression. What are some of the troubling thoughts that fill up your symbolic sink?

  • I’m a failure.
  • I’m not smart enough to go to college.
  • No one loves me.
  • I’m too much or not enough to be in a healthy relationship.
  • I don’t matter and have no purpose.
  • I’ll never get it right.
  • Everyone else is happy, except me.
  • I don’t deserve to have what I want.

As a therapist working with clients in an outpatient addiction and recovery practice, I recall a poignant and powerful statement from a single father of three teenagers. He was insistent that they clean up the kitchen after preparing meals, reminding them, “The sink is for washing dishes and not storing dishes.”  How often do we store the dishes that represent the disturbing beliefs we hold so that they, like literal dinnerware accumulate stuck-on stuff? Imagine instead, running soapy water over them and allowing the remains to go down the drain.

Another potent metaphor is that of a glass half filled with water. You can hold it still for only so long and then your arm begins to shake and with it, the liquid within. A few minutes more and the tremors may increase as the water sloshes over the edge, drenching your arm and the floor. It is only when you still your hand and the glass that it remains contained. So it is with our over active brains. That is where mindfulness becomes a helpful tool.

“Focusing on the here and now helps individuals become aware of their negative thoughts, acknowledge them without judgment and realize they’re not accurate reflections of reality,” says William Marchand, M.D., in his informative book entitled Depression and Bipolar Disorder: Your Guide to Recovery. Marchand is a psychiatrist who specializes in mindfulness as a therapeutic tool.

He adds, “When we practice mindfulness, we experience these difficult thoughts and emotions. But we experience them as an observer – rather than being washed away by the never-ending torrent of cognitions and feelings that flood our minds. By becoming moment-to-moment observers of our thought process, we learn to just watch the deluge without getting carried away in the current.”

Still Waters Run Deep

According to Jon Kabat-Zinn, PhD, author of Wherever You Go, There You Are, and the founder of Mindfulness-Based Stress Reduction (MBSR) “The best way to capture moments is to pay attention. This is how we cultivate mindfulness. Mindfulness means being awake. It means knowing what you are doing.”

So, how can we become mindful, instead of mind-filled to overflowing?

  • Remind yourself when pulled into the past which is generally where depressing thoughts are formulated, “I am here and now, not there and then.”
  • As simplistic as that might sound, consider how often throughout the day, particularly when in the midst of stress inducing circumstances, you hold your breath.
  • Observe what is around you. Remember the childhood game, “I spy with my little eye”? You can adapt it to, “I spy with my mindful eye,” and then state what you see around you.
  • Engage in object awareness. Hold a flower, stone or strawberry in your hand and experience it with all of your senses. Attempt to describe it as if to someone who has never seen it before.
  • Full sensory eating. Pick a favorite treat and smell, see, taste, touch and hear it in silence.
  • Wash the dishes or fold clothing with total attention to what you are doing.
  • Take a walk. This too can be meditative as you focus on each step as a distinct movement. A labyrinth can be an effective tool to assist in slowing your movement.

Mourning my Mom

Christmas day 2013 is when it all began. My very small family’s holidays were centred on Mom and her brilliance in the kitchen. On this day, she was scurrying around to get things prepared for us and fell down in the bedroom, her feet became tangled in the bedspread. She laughed when she told us the story.

From that day on she complained “a pulled muscle in her back.” She started physical therapy soon after but never seemed to kick the pain in her back. March came and her new affliction began: constant nausea. None of us knew it was related. Her pulled muscle and nausea were more than likely caused by her enlarged liver which was full of cancer and had spread from her lung.

Death came for my mom 6 days after she was officially diagnosed with lung cancer. From the beginning of the 6 days, she was very weak from being unable to eat much for the previous 6 weeks. She went from fully aware (still bossing my dad and me around) to unaware of things beyond her bed within that time frame.

We, as human beings, are guaranteed a grieving process unique from all others. Coping with loss is ultimately a deeply personal and singular experience. Nobody can help you go through it more easily or understand all the emotions that you’re going through. The best thing you can do is to allow yourself to feel or lean in to the grief as it comes over you. Resisting it only will prolong the natural process of healing.

Easier said than done. If you are anything like me, you don’t indulge in the pain, you run from pain. I typically dull my discomfort with my obsession to work, alcohol, and food …anything to pull the focus from what really hurts. However, I am a therapist and hopefully somewhat self-aware, so this is what brings me to writing this blurb. I am leaning into my pain by sharing my experiences with you, hoping that you who are grieving can KNOW that this is temporary, and you will heal from this pain, but it won’t be easy.


There wasn’t much time to for me to deny it, but my mom had a couple of days to do so. On the Wednesday before the Oncologist appointment, my mom, dad, and I went to the emergency room of a local hospital because my mom’s doctor noted her yellow color and wanted some tests. After eight hours of caring for my dad who has many more health issues (wheelchair bound) than my mom at this time and my mom who is so weak she has to be in a wheelchair of her own, we were told, “You have cancer, but we can’t tell you how bad it is or in what organ it lies.” Two days later, we were at the Oncologist, and before we went in, my mom said, “We don’t know if I really have cancer.” I just nodded. But I knew it. I just didn’t know how bad it was. In talking with my dad, he says she never mentioned cancer or her dying on the hour and a half back home drive from the hospital. They spent the next day living the way they had for 50 years, except for the physical weakness in my mother and the ever presence of their only daughter moving in to take care of things. The next day is when it all changed forever; hospice came.


My mom’s anger was never voiced because she instantly became too weak to talk. When I looked in her eyes, I didn’t see anger, I saw “This is not what I expected; I don’t want to leave my family. I am disappointed. This will kill your brother.” Although I had little time to be angry for all the things that needed to be done for someone in hospice care and the other very unhealthy parent witnessing the ordeal, I found time to be angry with the initial physician she saw. It took him 6 weeks to send her for tests. My mom was uncomfortable, weak, and couldn’t eat much for 6 weeks because the doctor (or so I thought) was an idiot and “just a country doctor who didn’t care about my mom.” She was terminal, and I knew that 6 weeks would not have saved her, but I was still angry at him, and shortly after her death I convinced my dad to change doctors all together.

In the 6 days, before she died, I cleaned the house (it was in disarray because she had been sick for a month prior to this), my brother and I took care of my mom and dad’s personal care, laundry and linens, bought the groceries and prepared the meals, dealt with hospice, dealt with the visiting community members, paid the bills, located bank accounts and wills, and you name it. Who had time to be angry? There wasn’t much time to be angry and what would I be angry about? I guess I could be mad at her for smoking since she was 15.

In retrospect, I haven’t really been angry. I continue to grieve my mom’s death and my dad’s current dying process, but calling it anger never really nails it. I mean, isn’t this the natural order of things? Parents get older, they die, and you live life without them. This statement does NOT make it any easier for the person grieving. And the next person who tells me that…GRRRRR.


Bargaining is the normal reaction to feelings of helplessness and vulnerability and is often a need to regain control. For some control-freaks like me, this will be a more difficult stage because there is NOTHING you can do about saving your mom from death. Nothing. Secretly, my mom may have made a deal with God to postpone the inevitable. But probably not, my mom probably did not bargain with God in her last days. She had said to me many times before on days when her COPD had gotten the best of her, “I’ve done this to myself.” So I don’t think that bargaining with God for more time with her family was on her mind. Regret maybe.

My mom and I had a complicated relationship. So this phase has done a number on me in many different ways. This phase showed up as:

If only I had tried to be a better person toward her…given her a break on whatever we disagreed upon.
If only she had had another “better” doctor who would have treated her more effectively.
If only I had not been so wrapped up in my career, I would have paid more attention to her and got her the help she needed much sooner.
My heart is broken because I never could agree to disagree on what we didn’t see alike. I just want one more day with my mom to apologize or to make it up to her. I will never know if she forgave me or knew how much she meant to me or knew how much the holidays will NEVER be the same without her.


Again, it wasn’t obvious that my mom was experiencing depression because it happened so quickly. I am not convinced my mom ever truly believed she would die so soon. Depression has been mine to bare. There were so many things to do and get done that my depression lingered backstage for several weeks, and came center stage a good two or three months after her death, and remains there. My depression has more to do with the change my little family has undergone and what it continues to go through due to my mother’s death and father’s illnesses. The concept of the finality of your family members leaving is pretty tough. You will never say another word to your mom, you will never get the joy out of buying her a gift, you will never be comforted by her chicken soup when you are ill, and you will never be able to apologize about not being the perfect daughter, and soon enough your father will be gone forever as well. Some get through this with prescriptions; some weather it out…but it ALWAYS comes in one way or another.


The only words uttered by my mother in her last day was, “I want peace.” I believe that this was her voiced stage of Acceptance. This stage is marked by withdrawal and calm and a tightening of the visual aperture. Loved ones that are terminally ill or aging appear to go through a final period of withdrawal. She in her last day, appeared to be unaware of things occurring beyond her bed.

This stage is not afforded to everyone. I have not reached it as of yet, and she died 8 months ago. Of course, I have accepted I have spoken my last word to my mother and of course, I have accepted that my father is not on this earth for very much longer; however, I haven’t accepted it without a lot of emotion, and I am all but calm. I continue to lean into the pain every single day, and yes, I numb my pain with food and work, and calm still has not come.

When you experience grief, it is best to experience it with others (if it is a healthy support group). I share mine with my ever supportive husband, grief stricken brother, a couple of dear friends, and a group of intelligent and compassionate therapists (yes, therapists have therapists.) I believe I am doing it in the healthiest way I can…less numbing of the pain, and more leaning into it. But here I am in the final edits of this article, and I am weeping like she died yesterday. I miss her.

There will never be another holiday with her, and we will miss her huge spectacular turkey and dressing and delicious pies, her charm and sarcastic whit and beautiful voice and spirit. We are the lucky ones though; we got to meet her, even be born from her. She mothered us with all of her might. The holidays will still come, but they will never be the same. Eventually we will get through them and remember how lucky we are to have had her in our lives for almost 50 years. If you turn to God in this time, this is the scripture that gets me through the darkest of days. Psalm 3:3 “But you, O LORD, are a shield about me, my glory, and the lifter of my head.”

Wendy J. Poole