July 20th, 2016
Sooooo…. I have applied to Adler School of Psychology to do my MPsy. I have my interview coming up and am hoping to get in! As the first order of business, applicants took a “Thrive and Survive in Graduate School” course which entailed writing an essay.
I chose to write about stress and fertility, as it is very relevant in my life right now. I have attached it here for your reading pleasure! Sorry it’s lengthly, but I believe it’s well worth the read. In the interest of space, I am not including the list of references here, but if you would like to see it, just shoot me an email.
Exploring the Relationship between Stress and Fertility in Women: Implications for Clinical Intervention
“Just relax, and it will happen!” Well meaning friends and family, as well as various health and helping professionals have said this to me over the past six years that my husband and I have been trying to have a baby. However, is this an old wives’ tale or is there actual empirical evidence in support of this? If a woman has various stressors in her life, such as a highly demanding job or a sudden move or a sick parent or a death in the family or looking at advancements in her career, could this impede upon her ability to get pregnant? The purpose of this paper is to explore the complex relationship between stress and fertility in women.
Impact of stress on fertility
From a biological and chemical and perspective, it does seem feasible that stress hormones could interfere with reproductive hormones. Several researchers have noted the role of the stress hormone system called the hypothalamic-pituitary-adrenal (HPA) axis (Coubrough, 1985; Harrison et al., 2005; Negro-Villar, 1993; Sanders and Bruce, 1997). When stressed, the hypothalamus releases corticotropin-releasing factor (CRF), which then stimulates the pituitary gland to release adrenocorticotropin hormone (ACTH), which in turn stimulates the adrenal glands to secrete stress hormones including: cortisol, adrenaline and noradrenaline (Coubrough, 1985; Harrison et al., 2005; Negro-Villar, 1993).
When the adrenal gland releases adrenaline and noradrenaline, part of the flight or flight response is activated and this may interfere with transporting gametes through the fallopian tubes or by altering uterine blood flow (Sanders and Bruce, 1997). Increased CRF and cortisol may also lead to suppression of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are the hormones responsible for ovulation (Coubrough, 1985; Harrison et al., 2005; Negro-Villar, 1993). Without ovulation, there is no egg for the sperm to fertilize. Disruption of ovulation also affects progesterone and estrogen levels, which are partially responsible for the regulation of fallopian tube motility (Harrison et al. 2005). When a stressor takes place, it immediately activates changes in these various hormones, and the body may adapt and distribute metabolic activity away from digestion and reproduction, in order to maintain other vital functions (Harrison et al., 2005; Negro-Villar, 1993).
In animal research, stress can be brought on in various ways, including environmental temperature, light, prolonged noise, isolation, confined spaces and moving locations (Coubrough, 1985). For example, with moving comes the stress of transport and the strangeness of the new environment which alters adrenal function, and was found to ultimately reduce fertility in cattle for up to two months (Coubrough 1985). Coubrough (1985) indicated that “Because of the clear influence of stressors on signal hormones of reproduction, some effect of stress on fertility is inescapable” (p. 155). The degree of the effect of stress would be determined by the intensity and duration of the stress (Coubrough, 1985) as well as the individual’s tolerance of stress (Bethea et al., 2005). Bethea et al. (2005) found in a study of 13 female cynomolgus monkeys that the combination of mild psychosocial stress (moving to unfamiliar surroundings), decreased food and increased activity level lead to a significantly greater release of cortisol, thus decreasing fertility, for stress-sensitive animals compared to high stress-resilient animals.
Cortisol can also impact upon fertility through suppressing the immune system (Sanders and Bruce, 1997), which then causes inflammation in the reproductive organs (Harrison et al., 2005). Immunological changes can impact on the ability of the body to accept foreign substances, such as an embryo (Gallinelli et al., 2001). For example, in a study with 40 women undergoing In Vitro Fertilization (IVF) fertility treatment, Gallinelli et al. (2001) found that prolonged stress was associated with high amounts of activated T cells in peripheral blood (T cells are a lymphocyte that is a subtype of white blood cells that attack infected cells) and a lower implantation rate of the embryo. It could be that the T cells mistakenly saw the embryo as an intruder. Thus, the chain reaction from the stressful event through to the various hormonal and immune system reactions can interfere with fertility.
Excessive stress may cause various reproductive issues in women, namely psychologic amenorrhea (no menses when stressed), pseudocyesis (phantom pregnancy), menstrual dysfunction, early pregnancy failure, (Negro-Villar, 1993), chronic anovulation (ovary not releasing egg) (Coubrough, 1985; Negro-Villar, 1993), delayed ovulation, cystic ovarian degeneration, (Coubrough, 1985), reduced fertilization/ conception rates, spontaneous abortions, (Coubrough, 1985 and Klonoff-Cohen, 2009), no live birth deliveries, low birth infants, multiple gestations, (Klonoff-Cohen, 2009), endometriosis (Harrison et al., 2005), longer natural cycles and poorer response to fertility treatment (Boivin and Schmidt, 2005). For example, Negro-Villar (1993) noted that changes in cortisol levels were found in women who had psychologic amenorrhea, which was more common for women who had stressful lives and occupations, were underweight, single and had a history of drug use.
From a behavioural perspective, stress can influence lifestyle habits and unhealthy coping strategies which can also have an impact on infertility. For example, eating disorders (under-eating or over-eating), overly intense exercise, (Negro-Vilar, 1993), caffeine intake, alcohol consumption (Klonoff-Cohen, 2009; Louis et al., 2011) and cigarette smoking (Louis et al., 2011). Louis et al. (2011) found that the highest mean caffeine (coffee, tea, pop, chocolate) consumption was in women who experienced pregnancy losses and Klonoff-Cohen (2009) found that caffeine had an impact on miscarriages, not achieving pregnancy and infant gestational age. It appears important, then, to use effective healthy coping strategies to manage stress and achieve well-being, to improve the chances of having full term healthy baby.
From a psychological perspective, stress can affect general mood which can in turn impact upon infertility. Psychologic distress has generally been recognized as a contributing factor to infertility (Negro-Vilar, 1993). For example, Barry et al. (2011) found that women with polycystic ovarian syndrome (PCOS) had significantly more difficulty coping with stress, were more neurotic, had more anger symptoms, withheld feelings of anger, and experienced more anxiety and depression than a control group of women with infertility problems that were not related to PCOS. Even when controlling for symptoms of PCOS with matched group comparisons, neuroticism and anger still remained higher in the PCOS group.
There was also a prospective study done by Sanders and Bruce (1997) that examined stress level and mood over several months for 13 women in the general community who were trying to conceive. The researchers collected samples to measure hormone levels (noradrenaline, adrenaline, and cortisol) and administered various questionnaires to assess psychosocial stress (State-Trait Anxiety Inventory and Bi-polar Profile of Mood States [POMS]) and lifestyle (sleep, work satisfaction, tiredness with work, time pressure, leisure time, and feelings of being hassled). Hassles were defined as irritants from minor annoyances to fairly major problems, pressures or difficulties.
The women reported significantly better mood states (more composed, agreeable, elated, confident, energetic, clear-headed), less anxiety and felt significantly less hassled during the month of conception compared to their previous non-conception (infertile) cycles. However, there was no significant difference in hormone secretions between the conception and non-conception cycles. There was also little relationship found between psychological mood and hormones during infertile cycles, aside from a negative association between noradrenaline and composed-anxious and clear-headed- confused scales of the POMS. In other words, during the infertile months, the higher the noradrenaline level, the less composed and clear-headed they were. During the conception cycle, there was a significant negative association between noradrenaline and the composed-anxious, agreeable-hostile and energetic-tired POMS scales. In other words, the month that women were successful in conceiving a baby, the higher the noradrenaline level, the less composed, agreeable and energetic they were.
There was also a trend for the women to find their work less mentally tiring and to get more adequate sleep during the conception cycle, although this relationship was not significant. Stress does appear to influence fertility in women, and the mechanism by which this occurs could be due to biological effects of stress on the quality or production of gametes, or on the subsequent fertilization, implantation or maintenance the pregnancy (Sanders and Bruce, 1997). It is important to capture data on not only hormones or the immune system, but also on psychological levels of distress.
There is inconsistent evidence in the literature of the impact of distress on fertility. Boivin et al. (2011) found that women’s emotional distress did not impact upon fertility. They performed a meta-analysis which included 14 studies of women who had undergone one cycle of a fertility treatment. Those 14 studies sampled a total of 3583 women in 10 different countries. The pretreatment emotional distress level, including depression and anxiety, before fertility treatment was not found to have an impact on achieving pregnancy. They only included studies that tested for anxiety and depression as a measure of emotional distress because they were reliably related to stress induced activation of the HPA axis. Boivin et al. (2011) pointed out that fertility rates are often highest in countries with harsh conditions such as war, famine and poverty, and so the hypothalamic-pituitary-gonadotrophin axis has likely evolved to guard against activation of the stress response in the HPA axis. They concluded that women and doctors should be reassured that emotional distress, whether caused by fertility issues or whether caused by other life events, would not compromise the chance of achieving pregnancy.
Impact of infertility on stress
It appears that stress could potentially have an impact on infertility through chemistry, biology, behaviour and/or psychology/mood, although the results are inconsistent. Alternatively, could infertility itself actually cause the stress? For women who experience more social pressure for motherhood, they viewed an infertility diagnosis as more stressful (Miles et al., 2009). In their study examining predictors of distress in infertile women, Miles et al. (2009) received personal statements from 56 participants, where they wrote about their experiences with infertility. They found that 55% of those women reported stress, anxiety and depression, and 27% wrote that infertility was “the most painful experience in their life” (p. 249). In addition, 12% expressed frustration with the lack of appropriate counselling services for those experiencing infertility treatment.
Not only is the diagnosis of infertility in and of itself stressful, but so are invasive infertility procedures such as IVF (Klonoff-Cohen, 2009). Greil et al. (2011) conducted a two wave national study comparing 266 infertile women who did and did not receive fertility treatments, in an effort to disentangle the effects of infertility treatment versus experiencing infertility on fertility-specific distress. The group with the highest increase in fertility-specific distress was the group that had fertility treatment at both waves and still did not have a child. The researchers found that infertility treatment itself is associated with levels of distress that are over and above those associated with the state of being infertile (Greil et al., 2011).
Eugster and Vingerhoets (1999) conducted a review of IVF research in the context of psychological state. They found that couples who entered into IVF treatment were generally well adjusted. The experience of waiting for the outcome of the treatment and the news of an unsuccessful IVF treatment were the most stressful for both men and women. During the IVF treatment, patients were commonly anxious and depressed, and after an unsuccessful IVF treatment, they were often sad, depressed and angry. Psychosocial factors, such as ineffective coping strategies, depression and/ or anxiety were associated with lower pregnancy rates with IVF treatment (Eugster and Vingerhoets, 1999).
Personally, I know first hand that the IVF treatment experience is stressful. It involves daily hormone injections of potent fertility drugs to stimulate the production of eggs making my ovaries feel like two uncomfortable tennis balls in your abdomen, painful progesterone oil needles administered into muscle, frequent visits to the infertility clinic for blood work and external and invasive internal ultrasounds, surgical transvaginal ultrasonography procedure (Boivin et al., 2011) to extract the eggs, fertilization of the eggs in the laboratory with the sperm, waiting impatiently for the embryos to develop, seeing embryos dying every day and hoping that the rest survive to the blastocyst stage (day 5 of development), another procedure to transfer the embryo(s) into the uterus, and finally the dreaded waiting for two to three weeks to find out whether our prayers have been answered. This is a stressful series of events which would all be absolutely worth it if the result is in our favour, but is devastating when it is not. Indeed, Boivin et al. (2011) found in a meta-analysis that there was significantly more distress in women who found out that they did not get pregnant compared to women who did get pregnant.
Klonoff-Cohen (2009) found that women who were concerned about the medical aspects of the IVF procedure by itself, such as side effects, surgery, anesthesia or pain, had 20% fewer oocytes (eggs) retrieved and 19% fewer oocytes fertilized. Further, women who were very concerned about missing work for the procedure had 30% fewer oocytes fertilized and those even moderately concerned about missing work had 2.83 times the risk of not achieving a pregnancy at all.
Another very recent study by Gana and Jakubowski (2016) found that infertility-related stress significantly predicted both emotional distress and, interestingly, marital distress. The effect was stronger for emotional distress, particularly life domains which included social, marital and sexual areas of the person’s life that are affected by infertility (Gana and Jakubowski, 2016). It is plausible, therefore, that the diagnosis and subsequent treatment can itself contribute to the stress endured during the fertility journey.
Interaction of stress and fertility
Another alternative is that perhaps there is a reciprocal causation/ reciprocal determinism (Bandura, 1978) interaction, where daily chronic stress impacts upon infertility but also infertility increases daily chronic stress. According to Bandura’s (1978) model of reciprocal determinism, behaviour, cognitions and the external environment all interact with each other in such a way that each of these components interact with each other and influence each other. In applying this model, stress does not independently cause infertility and infertility does not independently cause stress. Rather, Bandura (1978) argues that personal and environmental factors do not function independently, but indeed determine each other. It is through actions that people produce environmental conditions that affect their behaviour in a reciprocal way. The experiences generated by behaviour also in part determine what people think, expect and do, which then affect their subsequent behaviour (Bandura 1978).
In application to fertility, the actions or behaviours can be over-working or under-eating or moving locations or drinking coffee that affects stress levels in a reciprocal fashion. The experience of infertility generated by the behaviour then determine self-perceptions, such as ruminating over the personal failure of being infertile (Gana and Jakubowski, 2016), and affect subsequent behaviour, which could look like seeking out fertility treatment. The experience of seeking out fertility treatment then has an interactive relationship that makes the person more stressed, which further impacts upon the infertility issues.
Wright et al. (1989) conducted a review of the research on psychosocial distress and infertility. In the 30 publications that they examined, they found that overall, patients diagnosed and treated in infertility clinics showed significantly higher psychosocial distress compared to control groups. However, it was difficult for them to conclude the exact nature of the relationship, namely whether psychosocial issues trigger infertility or infertility triggers psychosocial distress or whether there was an interactive causal relationship between infertility and psychosocial distress. More longitudinal research is required in order to make definitive conclusions (Wright et al., 1989).
The interactive causal relation can also include the couples’ marital relationship in the fertility process, as an external factor. Gana and Jakubowska (2016) found that there was an interaction between emotional distress and marital dissatisfaction in fertility. The more emotional distress people experience, the more dissatisfied in their marriage they were, and the more marital dissatisfaction they experience, the more emotionally distressed they were. This is in line with Bandura’s (1978) model of reciprocal determinism.
Further research is required in order to fully understand the exact relationship between stress and fertility. It is difficult to draw definitive conclusions due to the wide variation in study methods and measures of outcome, for example, in measures of emotional distress. The Spielberger State-Trait Anxiety Inventory has been the most commonly used tool (Boivin et al., 2011), but perhaps that is not specific enough to assess problems of infertility (Greil et al., 2011). In fact, there have been tools designed to measure infertility distress, such as the Fertility Problem Inventory (Newton et al., 1999). The Fertility Problem Inventory encompasses five dimensions: social concern, sexual concern, relationship concern, rejection of a childfree lifestyle, and need for parenthood.
It would also be helpful for future studies to include more data on men (Boivin and Schmidt, 2005; Negro-Vilar, 1993) and couples (Gana and Jakubowska, 2016). Limited research on men shows that stress for men is also related to infertility issues, namely poor semen quality (count, motility, morphology) (Boivin and Schmidt, 2005; Negro-Vilar, 1993), impotence, ejaculatory disorders and decreased serum lutinizing hormone and testosterone (Negro-Vilar, 1993). Men’s lifestyle habits can also have an impact on fertility. For instance, Klonoff-Cohen (2009) found that men’s alcohol use was associated with spontaneous miscarriages and not achieving a live birth.
Although there is no conclusive empirical evidence as yet to demonstrate that reducing stress leads to higher take home baby rates (Boivin, 2003), there is mounting evidence to show that less stress is conducive to better fertility (Campagne, 2006). Given this information, it may be worth it to make attempts to reduce stress or learn to cope better with stress before even starting fertility treatments (Campagne, 2006). Doing so may make the fertility treatment no longer necessary or reduce the number of treatment cycles required before pregnancy is achieved, or it may prepare the couple for an initial failure of treatment if it comes to that (Campagne, 2006).
There are numerous infertility interventions available which have shown very positive results in lowering stress, such as acupuncture (Balk et al., 2010), Integrative Body-Mind-Spirit (I-BMS) therapy (Chan et al., 2012), art therapy (Hughes, 2010), expressive writing (Matthiesen et al., 2012), group therapy (Domar et al., 2000), hypnosis (Levitas et al., 2006) and even clown therapy (medical clown visits after an embryo transfer) (Friedler et al., 2011). Some of these have demonstrated success in improving pregnancy rates. For example, acupuncture for 57 women undergoing IVF treatment resulted in a 64.7% pregnancy rate compared to 42.5% who achieved pregnancy without acupuncture (Balk et al., 2010).
Chan et al. (2012) outlines a full I-BMS program for women in their first IVF treatment. They have four group sessions for I-BMS that involve education on the interconnectedness of body, mind and spirit, along with acceptance, forgiveness, self-love, letting go of high IVF expectations and growing through pain and personal transformation. Using a randomized controlled study of 339 women, they taught treatment participants mindfulness (living in the moment) and relaxation skills such as guided imagery and meditation. Although there was no significant difference found in biological outcomes (pregnancy) between the intervention group and control group, they did find that compared to baseline for the treatment group, they had significant decreases in trait anxiety, lower levels of physical distress, and disorientation. They reported being more tranquil and had significant increases in marital satisfaction. They also saw childbearing as less important compared to the control group. In other words, they were more accepting of the outcome in the event that no pregnancy was achieved. Disorientation (lack of vitality and loss of direction) could occur in women who see having a child as their next life goal and may feel blocked and incapable of moving forward if they are not able to conceive (Chan et al., 2012). To address this, the intervention group was encouraged to re-evaluate their life goals, focusing on personal fulfillment and broadening their perspectives, regardless of whether or not they become pregnant. These types of programs would be helpful for women and couples going through fertility treatment, even if the result is better overall well-being and not achieving pregnancy.
Boivin (2003) compared psychosocial interventions in infertility, and found that when compared to counselling interventions, educational interventions resulted in twice as many positive changes across various measures including negative affect, interpersonal functioning and pregnancy. The most successful interventions lasted for six to 12 weeks, had a follow-up period of at least six months, and had strong educational and skills training and/or group format that emphasized medical knowledge and learning stress management and coping techniques (Boivin, 2003). Infertility education may increase understanding of the implications of infertility for the couples’ psychological health and help to eliminate the social stigma attached to childless families (Ridenour et al., 2009).
It would be helpful for clinical interventions to include the couple. Boivin and Schmidt (2005) found that higher marital stress, higher personal stress, older age and more years struggling with infertility were each associated with poorer fertility treatment outcome. Thus, strains on the marital relationship that are caused by fertility issues, could interfere with the success of the fertility treatment, and could actually make couples discontinue with treatment (Boivin and Schmidt, 2005). Boivin and Schmidt (2005) found that women who had more marital distress required more treatment cycles to conceive a child than women who had less marital distress.
Women require a supportive marital relationship to help them adjust to infertility diagnosis and to infertility treatment, especially if the treatment fails (Boivin and Schmidt, 2005). Experiencing the infertility journey together can either strengthen the couple or create a strain in the relationship. Peterson et al. (2003) found that couples who perceived an equal level of social infertility stress reported greater marital adjustment in comparison to couples who perceived the stress differently. High congruence, or agreement, between partners in relation to the stresses that they experience help them to successfully manage the impact of those stressful life events (Peterson et al., 2003). Thus, if couples view the infertility journey in the same way, then they are more likely to be stronger as a couple as a result.
Ridenour et al. (2009) developed an Infertility Resilience Model (IRM) that encompasses the individual, the couple, and external factors that influence resilience to infertility-related stress. The model provides research-based guidelines for assessing a couples’ level of resilience in relation to infertility. In the IRM, external or environmental influences (such as duration of infertility, culture, social support, etc.) affect each person, which forms the individual perception, and the collective perception or the congruence within the couple creates the couples’ resiliency. Protective factors for the couple could include the quality of the relationship that the couple had before infertility, communication skills, access to information and access to infertility treatments. Individual protective factors could include mental health and religion or spirituality. Ultimately resilience results in acceptance of infertility regardless of infertility treatment outcomes or external influences (Ridenour et al., 2009).
Ridenour et al. (2009) created a sample assessment questionnaire based on the IRM, that would be helpful for clinicians in working with couples. Sample items from this questionnaire include: “Do you feel pressure when friends and acquaintances become pregnant?”, “Is it wise to make a decision if your partner still has reservations?” and “How do you see your relationship if you were unable to have children?” (Appendix A, p. 47-48). A thorough assessment would allow the therapist to understand the individual circumstances and how these may affect couple interactions.
In closing, I feel blessed to have what I call “My Preconception Dream Team”, working with us to help us to achieve our goal of parenthood. We have a nutritionist, bio-energetic practitioner, naturopathic doctor who uses acupuncture, a massage therapist who is also a doula, a psychologist who is familiar with fertility issues and of course our fertility doctor. They do mainly work with me, but they have helped my husband as well. They help to make sure that my hormone levels are in their proper balance, we are taking the appropriate vitamins and supplements, we’re taking time to de-stress, we’re eating healthy foods that help with fertility, we have an open space to talk about our fertility journey and we are taking the appropriate medical measures. Reflecting upon all of the above research, I feel very lucky to have a husband who I feel congruent with as we continue to proceed along this fertility journey. I feel ever hopeful, that despite my highly demanding job, pending move, sick parent, recent death in the family and applying to an incredible graduate school, that we are resilient, and our dreams of being parents will come true. Together, we continue to remain hopeful, and whatever the outcome, we will accept it and embrace it.
May 15th, 2016
Hello Couple Wellness Peeps!
So we have our Environmental Wellness workshop coming June 5th! (The day after my birthday, I may add!). We have two amazing experts coming- a Feng Shui expert and a Professional Organizer.
Monique Steele, our Professional Organizer, sent me some amazing tips in anticipation of our workshop, and I thought I’d share them as a guest blog post here.
Here’s what Monique has to say about organizing your space!
Categorize. Organize your office into categories, placing like items together. By doing this, your office will become more functional. For example, look in your mail drawer next time you need stamps.
Stickies (sticky notes, tabs, stickers, etc.)
Tools (straight cutter, staple, staple remover, hole puncher)
Budget (checkbook, calculator, bill calendar)
Writing Tools (markers, pens, pencils)
Mail (envelopes, stamps, address labels)
Labeling (labeler and label tape)
Purge Paper. It’s easy to let papers pile up in your home office. Get control of the clutter before it takes over your space. Go through every piece of paper in your office by using the System of Three: shred/toss it, file it or take action from it. File your important paperwork in a color-coded filing system.
Utilize Wall Space. This is often the one step people miss when organizing their office. Use your wall space to hang filing systems, calendars, whiteboards, shelving and more. There is so much more space available when you go vertical.
Never lose (or sort!) socks again.
Get each family member a mesh lingerie bag and ask them to fill it with their dirty socks. Run the bag through washer and dryer then place each family member’s lingerie bag in their clothing pile to put away. With this trick, you can forget sorting, folding, or leaving a stray sock in the dryer.
Simplify linen storage.
Store folded sheet sets inside a pillowcase and you’ll never have to guess if that fitted sheet works on the queen- or king-sized bed again.
When in doubt, try a tray.
Sometimes it only takes the power of suggestion to make you a bit neater. A well-placed tray might be just the hint you need to keep things in order, and appears tidy even if its contents are in disarray. Keep a serving tray in your home office to collect papers and keep supplies organized. It’s perfect for clearing extra space quickly and adds a pretty touch to what can be a dull spot.
Assign specific living quarters to everything you own. Put things where they work for you: vitamins by the juice glasses, coat hooks in the garage next to the car.
Whenever you run across anything empty, ripped, the wrong size or never used, immediately toss it in the trash or a charity box.
Thanks for your amazing tips Monique!!
Readers, enjoy and have fun organizing your space!
May 8th, 2016
It’s Mother’s Day today!
A day charged with expectations and obligations. A day meant to honour our mothers and show her our appreciation for her carrying us in her womb for nine months. A day for brunch, manis and pedis and afternoon tea. A day for flowers and balloons and mushy cards.
Not every person can celebrate Mother’s Day in this way. What if your mother would rather you help out in their backyard than go for brunch (like mine!!). What if your relationship with your mother is complicated and you haven’t spoken to her in years? What if you were adopted and you never met your birth mother?
Mother’s day is not just for birth mothers. It is for foster mothers, adoptive mothers, furry mommy mothers. It could even be for that neighbour or close family friend who you always got good advise from.
Mother’s day, much like Valentine’s day, should be celebrated every day. Showing our appreciation for that person throughout the year. It is to celebrate that one person, whoever it was, who was there for you through thick and thin. That person who wiped your snotty nose when you were sick, who listened to you when you had a bad day at school, who nagged at you to clean up your room.
So whoever that special person was to you, show them you care today and that you’re thinking of them.
Happy Mother’s Day!!
April 22nd, 2016
It’s official! I have recently joined TranQool, which is an on-line video counselling platform. Tonight, they interviewed me for a promotional video. Here is a sneak peak of the questions:
1 Can you please introduce yourself? (your name, where you live, where you went to school and whatever else you wanted to say)
Hi, I’m Melissa Johari, and I live and work in Etobicoke, Ontario. I have my Psychology degree from Western and I have my Masters of Social Work from Laurier. I am a Registered Social Worker specializing in couples counselling, with a particular focus on premarital counselling.
2 Why did you become a therapist?
I became a therapist to help people. That is my passion in life. I love seeing positive growth and change in the clients that I work with. I especially love helping couples to maintain or regain closeness in their relationship.
3 What kinds of problems do you help your patients with?
I have additional training in Hypnotherapy, Emotionally Focussed Therapy (which helps couples identify their negative cycles), Prep-Enrich (a premarital counselling program) and Theraplay (attachment work between children/youth and their caregivers).
So, I help my clients with self-esteem, stress, depression, anxiety, relationship issues and life transition issues like changing jobs, getting married, experiencing loss, moving or having a new baby.
4 How long have you been doing this for?
I have been a Social Worker for 12 years as of just last week, and I have had my private practise for 4 years now.
5 Can you share one of your favourite stories about how you helped a person? (totally understand that we need to keep the person’s information private but maybe you can phrase it in a way that he/she is not identifiable)
I really enjoyed working with a teen girl with anger issues. Really understanding her frustrations, empathizing, and having her mom participate in some sessions with us too, helped them both to see that underneath the anger was stress and anxiety around her school performance. They told me that I helped not only with the youth’s angry outbursts, but also with her relationship with her mother.
6 Do you remember the first time you paused and said to yourself, “I just helped someone change their life”
A client I was seeing had some relational problems with her daughter, and I helped her to understand the issue from her daughter’s point of view and helped her to accept that what was happening was not solely her fault and not in her control. Coming to that point of awareness and acceptance was a transitional moment for her.
7 In your opinion, what are the top three benefits of doing therapy?
The top three benefits of therapy are:
1/ having a neutral and non-judgemental place to go with someone who is actually trained to listen empathically.
2/ obtaining that guidance and direction in life when things just seem overwhelming and difficult
3/ being able to learn tools, skills and strategies that you can take with you and apply throughout life. For example, learning life skills such as having healthy boundaries.
8 What are the benefits of CBT for mood disorders like anxiety?
CBT helps people to be able to self-reflect on what is happening in the inner mind. To become mindful of the words that we say to ourselves, and to identify patterns in how our thoughts relate to our feelings/emotions which relate to our behaviour. Drawing attention to the negative words we say to ourselves helps us to open our awareness of it and allows us to observe what is happening. We can then learn to use positive words and words of affirmation to be able to replace the worry or sadness or self-doubts. Giving ourselves these positive verbal reminders helps us to cope throughout the day. We can also take action and do things that help us to feel like a confident, positive, and relaxed person. Think about what brings us joy and happiness, and make a point of making that a priority in our lives, as a coping strategy. Does taking your dog out for a walk in the park bring you to the here and now and make you feel happy and relaxed? Amazing, make a point of doing that more. Slowly allowing yourself to open up and appreciate the little things in life, taking notice of things around you. Those are some benefits of CBT.
9 How would you say CBT and the skills you learn while doing CBT stay with you?
Recognizing negative self-talk that we all tend to do every day, and replacing it with positive self-talk.
10 I have always (publicly) said that therapy and CBT changed my life, it gave me the skills to challenge my negative thoughts and better know myself. What’s your advice for someone who’s never done therapy and is contemplating it?
It can’t hurt. The worst case scenario is that it doesn’t help. The best case scenario is that it does. It’s really up to you to take the first step. It’s a journey, and booking that first appointment does take courage.
11 Why do you think people should use TranQool ?
I joined TranQool because it was a convenient, accessible way for clients to be able to seek services. With people’s busy schedules now a days, it definitely helps in bringing people together. TranQool is convenient and affordable to seek therapeutic resources, from the comfort of your own home.
March 28th, 2016
Podcast Interview/ Blog Post
March 28, 2016
Sperry Bilyea, from the Thrive In My Life Podcast, saw my profile in Etobicoke’s Women of Merit magazine, and asked me to be a guest on her podcast. We also met before that time at a networking meeting called Happy Healthy Women, where I am involved as a trailblazer. Sperry also has a Thrive Summit coming on April 4th which looks really interesting: www.thrivetogether.ca
Sperry and I will be doing our podcast interview later today, and I thought I would write this blog to help me prepare for it!
Here are her questions and how I plan to answer them:
1. What is one of your favourite go to metrics you use to measure success goals?
I have to admit that I am biased in loving “My Personal Monthly Wellness Goals” sheet. I use it to track my own personal wellness goals in all eight areas of wellness, and I also use it with participants at my monthly wellness workshops. The eight wellness areas according to my Relational Wellness Wheel are: Physical, Emotional, Social, Vocational, Sexual, Environmental, Financial and Spiritual. With this metric, you create a goal in each area of wellness and then tasks for how you will achieve each goal. Each month, you then review your progress and create new monthly goals. Join us at our monthly workshops so that you can use the monthly wellness goals sheet with us!
2. How many hours of sleep per night?
Sleep is very important. We spoke about that at our February wellness workshop that was on Physical Wellness. Getting sufficient sleep – between six to eight hours- is associated with better outcomes physically and emotionally. I try to go to bed between 10pm and 11pm, and get up at about 6am.
3. What book or favourite app would you recommend to others?
In my counselling work with couples, I often recommend two books over and over again. Those are:
The 5 Love Languages, by Gary Chapman
Hold Me Tight, by Dr. Sue Johnson
The 5 Love Languages helps couples understand that how they express love may not be how their partner best perceives love. For example, if a husband sends flowers to his wife as a gesture of love, it might feel nice for her, but if her love language is Quality Time and not Receiving Gifts, then she would likely feel more loved if he were to arrange a weekend getaway together.
In Hold Me Tight, Dr. Johnson talks about how to identify negative cycles in the relationship and how to take a step back to stop the cycle from continuing.
In terms of an app, I just became an approved video therapist with TranQool. Although meeting in person is always better, this on-line counselling is helpful to those who may have difficulty getting to a therapist’s office. TranQool has a useful mood tracker tool called the “Daily Emotional Tracker” (DET). That is helpful for the client and therapist to better understand where the person’s mood falls and see any patterns that may emerge.
4. Is there a leader, CEO or person that you are following right now on a regular basis?
I love Brene Brown. I have all her books- Daring Greatly, The Gifts of Imperfection, and Rising Strong. I love how she encourages us to be authentic and genuine, and how it is a strength to be vulnerable. Those are important messages, and ones I greatly believe in. I follow her on Facebook and often like and share her meme’s.
I also enjoy following The Happy Wives Club on Facebook. They often have encouraging and heartwarming meme’s that remind me to appreciate my husband every day.
5. Is there a project, charity or community you are passionate about?
Yes, the monthly wellness workshops that I’m running right now is raising money for Holiday Helpers. It is a charity that helps families in need in the GTA at Christmas-time, with food, a Christmas tree, winter wear and gifts. It is a great organization that grows bigger and bigger every year. They are in their 20th year now.
I also enjoy volunteering at a retirement home with my dog, Gilli. She is a therapy dog with St. John Ambulance, and we have been going to the same retirement home for four years. I often have Gilli with me at my office too, and the clients love having her there. She knows when they are upset and she makes them feel better.
Bonus Tip: What is one tip you would give your audience to thrive?
Aim at achieving balance in life in all areas of wellness- Physical, Emotional, Social, Vocational, Sexual, Environmental, Financial and Spiritual. That doesn’t mean being perfect in all areas, but it means being mindful and aware when there is an imbalance, so that you can take steps to regain that balance. I offer monthly wellness workshops, where each month has a special focus on one area of wellness with speakers, small group activities and an opportunity to review and write out your personal monthly goals. Feel free to check out my events page to see when the next workshop is coming!
March 1st, 2016
March is the Emotional Wellness Workshop for the New Year: New You! Workshop series. I have Dr. Talia, a naturopathic doctor, coming to talk about “5 Ways to Achieve Emotional Wellness”. I am so excited to hear her words of wisdom of how to manage stress and achieve balance in life.
In the meantime, I asked her to provide five general tips for wellness from a naturopathic doctor’s perspective. Here is what she said:
1) Take your stress seriously. Limit work and screen time, meditate, make time for self-care, journal, get social, get enough sleep.
2) Don’t settle for subpar supplements. Not all fish oils are created equal! Talk to a healthcare professional about brands, types and dosing.
3) Love your gut. Taking care of your digestion might reduce your need for skincare treatments, creams, anti-depressants, painkillers, anti-inflammatory medications, etc. Talk to your naturopathic doctor about how to start healing your digestive system.
4) Practice the art of forest bathing. The Japanese practice of “Shinrin Yoku”, or getting outside into natural settings, has research-proven benefits on stress reduction and mental and emotional health.
5) Eat your leafy greens. Aim for 2 cups a day of kale, spinach, broccoli, bok-choy, etc. If someone could capture all the health benefits of leafy green vegetables into a pill, they’d probably never have to work another day in their life!
Thank-you Talia! For more information on my upcoming Wellness Workshops, please visit my Events page.
January 25th, 2016
10 Steps to Achieving Your Goals – Blog
Happy 2016!! With a new year upon us, what does it seem like everyone is doing? Setting New Year’s resolutions! What sadly happens to the vast majority who do this? Those resolutions are long forgotten by the end of the month, if not sooner.
Just look around at gyms- the first few weeks of January they are packed. Then people get busy and preoccupied with other demands, and end up paying for a gym membership that they are not even using. Then they try to pull a Chandler and “quit the gym” (Friends, anybody?).
What if we were to approach your goals and ambitions in a different way? In a holistic way, looking at every area of wellness! What if you had a monthly check-in, with other people you are accountable to, and professionals who are there to help support you in achieving your dreams? What if you had all that for free? Sound too good to be true? Well, it’s not. It’s real, and it starts on January 10! There are only a few spots left, so be sure to register today! https://www.eventbrite.com/e/new-year-new-you-tickets-19570181941
In the meantime, here are 10 steps to achieving your biggest dreams and ambitions and make 2016 your best year yet!
- Get fired up! Get excited about your aspirations. Find inspiration to your soul. What do you want in life? Look at every area of your life- physical, spiritual, emotional, environmental, vocational, financial, sexual and social. This is where my Relational Wellness Wheel comes in, which I cover in my New Year: New You! workshop. Dream big and follow your passion. “Every day, take one step towards your goal, and one day you will wake up to find that you have achieved it” (this was an anonymous quote that got me through university). Your personal goals are important and worthy of your attention.
- Set goals using the SMART goal technique- Specific, Meaningful (some say Measurable), Action (some say Attainable or Achievable), Realistic (some say Relevant) and Timely. Be precise. For example, rather than saying I want to lose weight, I can say “I want to lose 10 pounds”. Why is this goal important to you? For example, “I want to lose 10 pounds to look better in my bikini”. What steps/resources do you need to achieve it? For example, “I will work out three times a week in order to lose 10 pounds and look better in my bikini”. How do you know that you can achieve your goal? For example, by prioritizing it, “I will prioritize working out three times a week in order to lose 10 pounds and look better in my bikini”. When is your deadline? For example, “I will prioritize working out three times a week in order to lose 10 pounds and look better in my bikini by June 1, 2016”. Now that’s a SMART goal!
- Share your vision! Share your goals with someone important in your life. This helps you to be accountable to someone, and encourages support. Share with those who you know will cheer you on through your journey. Better yet, share your goals with others who have similar goals to you, so that you can support each other in your mutual accomplishments.
- Write it down, write it down, write it down! When you write down your goals or create a vision board, it helps you to really focus on what it is you want. You are then able to ultimately manifest that vision that you have created for yourself. Think about how your life will be different once you achieve this goal- how will you feel, how will you act, how would it benefit you or those around you.
- Make a plan. Figure out the HOW. How are you going to get to your goal? Imagine yourself at the end of the year, having achieved what you wanted, and think of what it took to get there. Break it down into smaller, simpler, more easily achievable chunks. For example, if I want to lose 10 pounds by June 1, 2016, then I need to lose 1-2 pounds every month between now and then.
- Obliterate obstacles. Break down the barriers that stand in the way between you and your goal. What are some potential road blocks that you anticipate and how would you overcome them? Sometimes your biggest obstacle is YOU! Have faith that you are capable of achieving your goals. Don’t let any fears get in the way- fear of failure, fear of success, fear of judgement, etc. This is your life and you can make the choice to make it great.
- Prioritize. If this particular goal is something that you are really serious about, then make it a priority in your life. No excuses. I know I’m guilty of this myself, saying I’m too busy to work out. Well, guess what? Three weeks ago, I hired a personal trainer, and I have made it a priority in my schedule to meet with her every week, and to work out in between sessions with her. All things are possible. Also, you may have several different goals- figure out what you want to make as a priority goal to focus on. With too many competing goals, it can get overwhelming to try to juggle them all at once.
- Review your progress. Every single month, review the progress that you have made. Where should you be at each interval in order to achieve your goal my your ultimate deadline date? What has worked? What has not? How can you tweak your approach to get better results? Achieving your ultimate goal requires regular fine tuning and re-focusing on an ongoing basis.
- Hard work and determination is key! Nothing that is worth it comes easily. It takes effort and sheer will power. Keep going strong, and you will get there. Don’t give up! If you experience some bumps along the road, it’s ok. It will only provide you with further experience and make you resilient. Continue along your path.
- Think positive, feel positive, be positive. Whether you believe in karma or the Law of Attraction or are aware of the premise of Cognitive Behavioural Therapy or self-fulfilling prophecy, positive thinking goes a long way. How you think impacts on how you feel, which impacts on how you act. In turn, how you act impacts on how you feel and how you think. For example, if your self-talk is berating, such as “I suck, I can’t believe I did that. What a screw up I am”, you will feel self-defeated and will likely continue to make mistakes. However, if your self-talk is empowering, such as “Man, I really took a mis-step there, but I did the best I could at the time. I’ll do better next time”, that allows you to take ownership of what went wrong, without the self-blame or labelling yourself as a screw up. Recognize your strengths and progress every step of the way. Explore positive affirmations to help give you inspiration and avoid negative thinking. You could even write down a mantra on a card that you can keep handy for easy reference. I have positive affirmation cards that you can fill in with your own personal affirmation. Just send me a quick email, and I would be glad to send you one.
I would be happy to help you develop and work on your own personal goals. If you would like a free 15 minute telephone consultation, feel free to contact me. Wishing you much success for 2016! Create an amazing year!
January 25th, 2016
Our Physical Wellness workshop is coming up soon! Only two weeks away, and space is filling up fast! Please register through:
We have two amazing speakers- Anna Lubaszka, a holistic nutritionist, and Giuliana Carbone, a personal trainer. Together, they will share their insights and helpful advice in how to achieve physical wellness when we meet in February! In the meantime, they have been kind enough to give us some teasers in regards to nutrition and fitness.
Here are 5 nutrition tips from Anna:
1. Hydrate well & hydrate often. Our body is over 70% water and most of us are not drinking enough water. Carry a large water bottle with you to stay hydrated throughout the day. Fill it with filtered water and a large squeeze of fresh lemon juice as this will alkalize the water and make it even better for your body.
2. Eat foods in their most natural state, unprocessed. For example instead of snacking on cheese and crackers, try apple slices with cashew or almond butter.
3. Add more leafy greens to your daily meals by incorporating them into your smoothies, soups, soups, stir fries, egg scrambles, omelettes, and frittatas. Try a variety of greens in your salad instead of just one type (e.g. kale, spinach, swiss chard, romaine lettuce and mix all together)
4. Avoid “white” carbohydrates – bread, rice, cereal, potatoes, pasta, pastries and fried food with breading and add more whole grains, nuts, seeds, legumes, and vegetables instead.
5. Avoid drinking “sugar” – soda, store bought juice, fancy coffees, alcohol, flavoured water and instead make your own green juices and drink filtered water with lemon or infused with fruits and herbs of your choice. Anna likes adding slices of lemon, orange and some mint leaves for a deliciously refreshing naturally flavoured water.
Here are 5 fitness tips from Giuliana:
1. Get a gym buddy! Make going to the gym social and fun.
2. Take the stairs!
3. Make sure half of your plate is veggies
4. Eat slowly, your body will tell you when it’s full
5. Follow the 90/10 rule. Eat sensibly 90% of the time and enjoy a little treat 10% of the time!
Be sure to sign up for our Physical Wellness workshop to hear more and establish your own personal wellness goals!
Thanks and Be Well,
September 19th, 2015
What is Stress?
Stress is a response to threatening situations or demands. When threatened, we instinctively enter into fight, flight or freeze mode. This is an automatic sympathetic nervous system response that was once life saving when faced with a threatening snake or lion. Stress can be helpful if it is short-term and manageable, as it gives us the motivation and energy to perform under pressure. Adrenaline, cortisol and noradrenaline readies the body for action. When we are faced with too many demands or pressures, however, we tend to worry about things that are out of our control and feel overwhelmed. Burn out can happen if stress builds up over a long time.
Signs of Stress:
Physical signs include accelerated heart beat, increased blood pressure, stomach in knots, cold hands or feet, sweaty hands or feet, sweating, jittery arms or hands, cold chills, tightened muscles, tight jaw, clenched fists, shallow or rapid breathing, headaches, insomnia, fatigue, muscle tension, tight chest, stomach issues, suppressed immune functioning, aches and pains, loss of sex drive, etc.
Emotional/ Cognitive signs include moodiness, irritability, agitation, loneliness, isolation, being on edge, guilt, sadness, worry, blame, shame, fear, boredom, anger, feeling overwhelmed, hyper-sensitive, anxiety, memory issues, inability to concentrate, poor judgement, pessimism, racing thoughts, etc.
Behavioural signs include avoidance, withdrawal, isolation, aggression, relationship problems, procrastination, neglecting responsibilities, hyperactivity, substance abuse (drugs, alcohol, cigarettes), over-medicate, over-eating, under-eating, sleeping too much or too little, nervous habits (nail biting, pacing), too much tv/computer, etc.
How to Manage Stress:
Change the stressful situation if you can, accept the situation if you cannot change it, deep breathing, self-relaxation, pre-sleep technique, self-hypnosis, counting backwards from 10, self-talk, eat healthy, get enough sleep, exercise regularly, reduce caffeine and sugar, hot bath or shower, yoga, finish unfinished business/chores/duties (open cycles), visual imagery of happy place, self-care (make you time daily), adjust expectations, love yourself (know that you are enough and doing the best you can), use your social support network, find a mentor, talk to someone you trust, stay positive, meditation, practice mindfulness, prioritize, use healthy boundaries, seek counselling services, regain your sense of control, etc.
These techniques help you to de-stress, as it is in direct opposition to your sympathetic nervous system response. It is your parasympathetic nervous system taking over to help calm your body and mind.
A study carried out at Pennsylvania State University found that stress was not the problem, but rather how we react to stressors. It appears that how people react to stress was a predictor of their health ten years later, regardless of their present health and stressors. The lead researcher, David Almeida, said, “For example, if you have a lot of work to do today and you are really grumpy because of it, then you are more likely to suffer negative health consequences ten years from now than someone who also has a lot of work to do today, but doesn’t let it bother her.”
See Ted Talk on “How to make stress your friend”, by Kelly McGonigal. She says stress is not the enemy, it’s how we perceive the stress that matters. If you believe that stress is harmful for your health, it will be. It’s all about attitude. When you change your mind about stress, you can change your body’s reaction to it. Signs of stress can be seen as preparing you to meet the challenge before you. If you see stress as helpful, blood vessels do not restrict as they do when you are under stress and see the stress as bad. Your stress response (ex: shallow breathing, etc) becomes healthy when you see it as helpful to you. Oxytocin (cuddle hormone) is also released during stress response, which motivates you to seek social support. Oxytocin protects your body from the effects of stress, especially on your heart. Human connection and caring is built-in stress resilience. Kelly says, “How you think and how you act can transform your experience of stress. When you chose your stress response as helpful, you create the biology of courage.” You can handle the challenges that come up in life, and you don’t have to face them alone. Go after what brings meaning to your life, and be confident in handling the stress that follows.
So, what’s the bottom line for you, the reader of this blog? Take time out for yourself to manage the day to day busyness that life throws at you with the “How to Manage Stress” suggestions above. When there is a stressful event that you recognize with “Signs of Stress” listed above, then view it as your body helping you to get over the particular hurdle. Your body reacting is not trying to hurt you, it’s trying to help you. Listen to your body, thank your body and address that particular stressor. It is especially helpful to reach out for help when needed. Asking for help is not a sign of weakness. As Brené Brown put it best, “Most people believe vulnerability is weakness. But really, vulnerability is courage. We must ask ourselves…are we willing to show up and be seen?”
September 12th, 2015
The Importance of Premarital Counselling:
Four Reasons why Premarital Counselling is Critical to your Relationship
Every single engaged couple should participate in premarital counselling. Every single one. “But Melissa”, you may ask, “we are just starting out in our relationship and we don’t have any problems. Why should we be in counselling already?” To that, I say that premarital counselling is essential preventative work for every couple to lay a strong foundation for a lifetime together, and I will explain four reasons why.
Firstly, with the divorce rate close to 50%, we can’t afford not to take every measure necessary to prevent this from happening. Premarital preparation programs, such as PREP-Enrich, have been shown to decrease the divorce rate by as much as 30% (Stanley, Amato, Johnson & Markman, 2006). That is significant, and definitely worth the effort. There are many known benefits of marriage (health, financial, etc) (www.imfcanada.org, Waite & Gallagher, 2000) and known negative outcomes of divorce and marital conflict for adults and children (emotional, psychological, financial, academic, social, etc) (www.http://www.mdrc.org/publication/effects-marriage-and-divorce-families-and-children; http://www.thefamilywatch.org/doc/doc-0073-es.pdf), so if there is a way to honour the value of marriage by making it stronger, why not do it?
Secondly, in premarital counselling you have the opportunity to discuss areas of your relationship that you may not have otherwise talked about. Everything is on the table- finances, children, in-laws, household duties, sex, habits, family of origin, personality, etc. You discover your strengths and areas of growth as a couple. “The average participant in a premarital program tends to experience about a 30% increase in measures of outcome success” (Carroll & Doherty, 2003). I have never met a couple who did not have any areas of growth at all, so every single couple can benefit from this proactive work.
Even if you are already married or living together, you can still benefit from this approach. That is the “Enrich” part of the “PREP-Enrich”. The program helps to further enrich your relationship, no matter how long you have been together or what the status is of your relationship. It would give you the opportunity to talk about those things that have already come up in the relationship, and to further expand upon your existing strengths as a couple.
Thirdly, premarital counselling helps you to be feel happier and be closer in your relationship. You learn critical relationship skills such as communication and conflict resolution that you take with you for a lifetime. Learning these skills early on helps the couple to manage the inevitable stressors and issues that come up along their journey when they do happen. That way they can address the issues confidently and resolve them effectively before they turn into larger issues down the road. Couples who participate in premarital work significantly increase their satisfaction in their relationship. In a study done by Knutson & Olson, they found that couples improved in 10 out of 13 relationship categories (Knutson & Olson, 2003) after participating in the PREP-Enrich program, including marriage expectations, personality issues, communication, financial management, children and parenting, family and friends, role relationship, spiritual beliefs, couple closeness and couple flexibility.
Finally, fourth, participating in premarital counselling allows you the opportunity to get to know the counsellor and the process of counselling. It then feels familiar, so that if in the future you require further intervention, then you are already comfortable with the concept and have an idea of what to expect. The couple then recognizes that reaching out is helpful and healthy. Premarital counselling has been found to increase the likelihood that a couple will seek out and use future marital and family services at the first sign of distress, compared to couples who did not participate in premarital counselling (Knutson & Olson, 2003).
If you are engaged or in a relationship, I hope that my article inspires you to reach out for premarital or enrichment counselling. There are many resources out there. Feel free to check out www.enrichcanada.ca or www.prepare-enrich.com for more information on the PREP-Enrich program. Also feel free to check out my website for more information, at www.thecouplewellnessexpert.com
Feel free to contact me at 647-830-7473 or firstname.lastname@example.org I would be glad to answer any questions you may have, and offer a free 15 minute telephone consultation. My husband of 11 years and I both offer premarital counselling using the PREP-Enrich program, and also offer wedding officiant services.
Treasure your significant other, cherish each other and hold each other tight for life.
Melissa Johari, The Couple Wellness Expert
Carroll, J.S. & Doherty, W.J. (2003). Evaluating the effectiveness of premarital prevention programs: A meta-analytic review of outcome research. Family Relations, 52, 105-118.
Knutson, L. & Olson, D.H. (2003). Effectiveness of PREPARE Program with Premarital Couples in Community Settings. Marriage & Family, 6 (4), 529-546.
Stanley, S.M., Amato, P.R., Johnson C.A., Markman H.J. (2006). Premarital education, marital quality, and marital stability: findings from a large, random household survey. Journal of Family Psychology, 20 (1), 117-26.
Waite, L.J., & Gallagher, M. (2000). The case for marriage: Why married people are happier, healthier, and better off financially. New York: Doubleday.