Psych Central Professional For mental health, psychiatric and psychological professionals. Tue, 04 Aug 2015 12:16:34 +0000 en-US hourly 1 Understanding Mental Abuse: Gaslighting Tue, 04 Aug 2015 12:16:34 +0000 http://5.239 Gas Light MovieMental abuse is difficult to assess. Unlike physical abuse where there are visible marks, mental abuse leaves no marks but its effect is just as damaging. One of the tactics of mental abuse is a term coined gaslighting. Understanding this scheme better can help prevent more victims and heal those who have already been victimized.

History: The term gaslighting originates from a 1944 movie called Gas Light. In the movie, the husband convinces his wife that she is insane through intentional manipulation. When the wife notices a dimming in the gas lights of their home, she addresses it with her husband. He, wanting his attic search to remain a secret from her, insists instead that she is imagining the difference and subsequently persuades her that she is instead going insane. Psychologists have used the term ever since.

Basic Tactic: Gaslighters lie about the past making a person doubt their memory, perception, and sanity. They are talented in taking a miniscule about of truth and surrounding it with lies. They claim and give evidence of past wrong behavior further causing doubt and insecurity. This paves the way for portraying themselves as the reasonable and logical party. Sometimes they go to the extreme of staging false events or proof to validate their deception.

Broad Implication: The movie Schindler’s List (1993) portrayed gaslighting on a national scale through the propaganda films the Nazi’s created about the Jewish camps. These short films showed healthy Jewish families enjoying food at a picnic table in a work camp while children were running around playing. This is a stark contrast to the reality of the concentration camps where families were separated, people were starved, no one was happy, and millions perished. The fabricated films were played to show the camps in a positive light and justify further alienation of the Jewish people. Many nations and people believed the propaganda which seemed far more plausible then the reality.

Personal Implication: Gaslighting can be done on a small or large scale to an individual. It can be as simple as the Gaslighter claiming they have a relationship with an influential person when in actuality they have only met them once. Then they use that “claim” to further a career or agenda. Or, in a marital situation, the Gaslighter could allege they have one career when it is actually a cover for another. In either case, any attempts to assert the truth would be met with “you are the crazy one.”

What to do:

  • Relive the past. Look at past gaslighting events and pick them apart. Try to spot the moment the lying started around the sliver of truth. Recall any emotional reaction, insecurity, or feelings of guilt. Gasllighters tend to use the same tactic over and over. Studying the past is good preparation for the future.
  • Just the facts. Remember Joe Friday from the 1950’s TV show Dragnet? He was famous for saying, “just the facts.” Stick to factual information that can be confirmed and verified. Do not rely on data or corroboration that is dependent on the Gaslighter. When there is no valid way to confirm the evidence outside of the Gaslighter, don’t believe them. Since Gaslighters are natural liars, it is better to assume they are being dishonest.
  • Don’t react emotionally. Gaslighters feed off emotions to sway a person. While it can be frustrating in the moment to deal with the tactic, an emotional response will add fuel to the fire. Instead, be as impassive as Dr. Spock from the 1960’s TV show Star Trek. This will aggravate the Gaslighter and steal their control.
  • Go slow. Generally speaking, Gaslighters try to elicit a snap decision immediately following the tactic. Slow things down by saying, “I’ll have to think about that,” or “I need more time.” Distracting the Gaslighter or walking away can also have the same effect. This extra time allows a person to reflect on the logic being presented before making a decision.

While these methods are no guarantee that the gaslighting will stop, trying something is better than ignoring the issue and hoping it will disappear.


Christine Hammond is the award winning author of The Exhausted Woman’s Handbook available on Amazon, Barnes & Noble and iBooks.

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The Hoffman Report & the American Psychological Association: Meeting the Challenge of Change Mon, 03 Aug 2015 13:26:20 +0000 The Hoffman Report & the American Psychological Association: Meeting the Challenge of ChangeIf I value transparency, it is a good idea for me to practice it. So, in the interest of transparency and self-disclosure of my perspective (or potential bias), it is important that readers know upfront that I resigned from APA in 2008 over changes APA had been making in its approach to ethics.

The Hoffman Report discusses these changes. I wrote that “I respectfully disagree with these changes; I am skeptical that they will work as intended; and I believe that they may lead to far-reaching unintended consequences.”

Both my letter of resignation online and my articles and chapters (Pope, 2011a, 2011b, 2014; Pope & Gutheil, 2009) present my beliefs along with the evidence and reasoning that in my opinion support them.

In 2014, the American Psychological Association (APA) made a monumental move toward more transparency. The organization took a courageous step unthinkable at any time in its 121 year history: It opened up to a former federal prosecutor, giving him access to all documents and personnel.

APA hired David Hoffman and his colleagues at Sidley Austin LLP to conduct “thorough” and “definitive” investigation to document “what happened and why” (Hoffman et al., 2015, p. 1).

The Hoffman Report set off an ethical earthquake.

The investigation uncovered emails and other documents containing linguistic tricks that mislead and manipulate, logical fallacies in ethical reasoning, biased ethical judgment, hypocrisy and creative cheating that this book’s five chapters focusing on critical thinking in ethics prepare us to recognize and avoid.

These uncovered documents confront us with the challenge of change. The challenge brings questions. What changes, if any, need to occur in ourselves as individuals, in APA as an organization and in the larger professional community?

What internal and external forces, if any, will block, weaken, delay, or divert needed change?

How, if at all, can we respond effectively to forces that resist needed change? How do we assess whether apparent change is real and meaningful?

None of these questions comes with a simple answer we will all agree with. All come wrapped in complex puzzles of practicality, politics and fundamental values. None of the questions allows us easy escape.

How we answer them—or fail to answer them—will determine whether we bring about needed change. This article takes a look at the questions and challenges that the Hoffman Report has brought to our doorstep.

What Does the Hoffman Report Have To Do With Each of Us As An Individual APA Leader, Member, or Outsider?

What does the Report have to do with us? Our shared human tendency when scandal explodes is to blame bad apples: “It’s their fault! Maybe we made some well-intentioned mistakes, which we regret, but if you’re looking for the real cause of this mess, it’s them, not us.”).

Bad apples come in three varieties: personnel, policie, and procedures. We toss the bad apples, find shiny new replacements and think we’ve fixed the problem.

Countless organizations make personnel moves (transfers, terminations, retirements that are forced or induced by hefty payments and so on), vote to amend or replace policies and create committees to cancel some procedures and issue new guidelines, finding only later that they’ve achieved little beyond good public relations and the illusion of needed change.

Or we can head into discrediting mode:

“We chose the person we believed best suited to give us the definitive account of what happened, but he delivered a flawed report that is nowhere near definitive. He uncovered some damaging facts but we must bear in mind that he’s not a psychologist. He did the best he could without understanding our profession, our organization, our history, our culture, or the way we do things. He made questionable assumptions and got some key things wrong. After all, it’s just one outsider’s opinion.”

Answering the question “What does this have to do with us?” requires us to move beyond our human tendency to deny, discredit or dismiss what we do not want to know or be known.

We may find that harder than usual in this case. The Hoffman Report documents years of improper behavior. But it also documents that, for years, APA as an organization and some APA defenders denied, discredited, or dismissed revelations of this improper behavior as they appeared in newspapers, professional journals, books, reports from human rights organizations and other media.

Changing habitual behavior that has settled into a familiar routine is rarely easy for any of us.
Moving beyond our shared tendency to shield ourselves from unwanted information and personal responsibility allows each of us to learn what the report has to do with us as an individual.

If we can summons the courage and resolve to look without squinting or flinching away, the Hoffman Report can serve as an ethical mirror. When we take the time to read it in its entirety and deep detail, the report teaches us something about ourselves and helps us take a personal ethics inventory.

When we take time to read the detailed report, we begin to see the complex relationship between what we did or failed to do and the events that the report documents. When we take time to read the report, it points the way to effective change, in ourselves and in our profession.

If we set it aside unread or settle for second-hand summaries, we turn the ethics mirror to the wall and imagine a more personally flattering picture.

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Depression and Learning From Other Cultures–Part 2 Mon, 03 Aug 2015 11:46:07 +0000 There are several areas to examine that tell us why African Americans will not partake of the medical model or ask for an invitation to the drug company’s medication orgy.

First and foremost is the discrimination barrier. One must take a chronological view of the African American experience in this country with its  history of slavery, racism and dehumanizing of this population.

This long and devastating oppression is the foundation for mistrust, for underlying expectations that the system, in general, is not going to meet the needs of African Americans.

We are aware that racism still exists, that the degrading experiences of the older generations are transferred to the succeeding generations through narratives and then confirmed by current racial conflicts.

Racism exists and is a foundation for this community’s low participation in mental health and related systems of care.

We add to this the stigma that continues to be attached to “mental illness” within our society. African Americans are not isolated from the fear of carrying and being labeled “mentally ill.”

The stigma doubles when added to racism and reinforces the perception that being Black and labeled mentally ill are designations to avoid.

“The first thing they say is “Oh, she’s crazy.” Always acting crazy, you know what I mean? You don’t wanna be referred to as crazy. You might want to be referred to as mentally ill, you know. ‘Cause mentally ill sounds more better than “Oh, I’m crazy!” You know what I mean? Oh, there’s definitely a stigma”.

Another Barrier

The third barrier is embedded in the mental health systems of care. Being Black and labeled mentally ill puts the individual at a disadvantage when trying to access care. African Americans point to the white-dominant attitudes that prevail among doctors and other treating specialists and lack of cultural sensitivity.

African Americans report that they receive fewer sessions, are more quickly hospitalized and directed to medication treatments instead of therapy because of racial disparity. They point out that Caucasian doctors do not take into account that African American women are heads of households and, as such, have obligations to multiple people and cannot spend time or funds in treatment.

They report that most treating individuals are Caucasian and this makes them feel uncomfortable.

When asked by an interviewer about trying to contact a helping person in a mental health clinic, the individual stated that in the initial phone call, he was identified as Black and he believes that his needs were not addressed because of his race:

These are things that we, I think, as blacks—we’re not told about… If you make a phone call and they discover that you are black, then they transfer you to someone else, and by the end of the day, you don’t wanna talk to anyone. You say, Forget it, I’ll just sit here and keep it to myself… So we have to get information…by word of mouth from somebody else. We really don’t get it from the professionals or the agencies or the people who (handle) it. We just get it from a friend. You know. And hopefully, you had a white friend to tell you.”

]]> 0 Depression and Learning From Other Cultures–Part 1 Sun, 02 Aug 2015 13:00:02 +0000 There is an “epidemic” of mental illness across this country and people (including young children) are being diagnosed with depression, bipolar disorders, anxiety disorders and ADHD by the thousands. Individuals are rushing to find remedies; from doctors, gurus, and from diet programs, exercise routines and over the counter pills and tonics.

When you stand in line at the check out counter with that vial of energy supplement grasped in your hand, think about the fact that people in other cultures cope with depression, anxiety and mood swings in very different ways. We can learn from their traditions and their strategies.

The field of cultural anthropology was my focus for many years and I learned that the lived experiences and traditions of other cultures can provide insights and wider perspectives for professionals and lay persons.

We, the majority, view mental health issues through the narrow lens of our own cultural traditions and we have adopted the assumptions that our society promulgates. The assumptions about mental health are as follows:

  • There is a category called “normal” and that it can be described and defined in emotional and behavioral terms.
  • Emotional distress– “mental illness”– is primarily a biologically and brain- based set of illnesses and that diagnostic categories and algorithms lead to effective medications that have been scientifically proven to treat these diseases.
  • Mental illnesses exist as chronic diseases and should be treated as internal disorder and the context (environment and lived experiences) are of secondary importance.
  • Those who are diagnosed with a “mental illness” are not strong or functional individuals who can solve their own problems and cope with stress or understand their own disorders. They require a doctor’s help to recommend treatment.

It is important that we step outside of the boundaries of our own historical assumptions and view mental health through a wide lens. The assumptions mentioned above are oppressive and dictatorial and lead us to consider ourselves “abnormal” if we have feelings and thoughts that do not fit into a “normal” template that has no real definition.

We need to be able to expand our views, to capture our lived experiences in positive terms and take back our freedom of expression.

Within our society, there are minority populations that have not and do not buy into these and other assumptions about mental health.

This article speaks about the African American community specifically because of the author’s own experience base with this community and the reality that their voices should be heard in relation to mental health issues.

Other cultures (Asian/American for example) also have their own perspectives on mental health but have unique qualitative aspects and should be considered separately.

Depression, its “causes” and treatments is a subject of constant debate and depression is, because of its prevalence, a key target for drug companies and their research department.

Recently, a new drug advertised as an “add on” for depression has been developed by Otsuka Pharmaceuticals ( a Japanese company) and the drug is Rexulti, as reported by U S News July 13. It is FDA approved after two, six-week trials with 1,300 people.

A substantial number of individuals who, although they suffer from depression, will not be influenced by the craftsmanship of the advertising for this drug nor will they seek medication at all.

Many individuals in the African American community and especially Black women, who tend to be the spokespersons in this community, view the biologically-based model of mental illness and the medication-based approach as oppressive and abusive.

The issue of depression within the African American community in general has been examined because of concerns about the low participation rate in the mental health system of this population.

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How Did My Child Get an Eating Disorder? Sat, 01 Aug 2015 13:00:23 +0000 Anger. Shame. Disbelief. Receiving the news that your child has an eating disorder can be a very confusing and overwhelming experience. One of the most common questions that parents ask is “How did this happen? Was it my fault?”

It’s important to conceptualize an eating disorder as a “perfect storm,” meaning the perfect combination of biological, psychological and social factors must fuse together in order to manifest an eating disorder. As a parent, it is important to understand that you did not cause your child’s eating disorder. There are several factors that may have contributed to the diagnosis.


People who are born with certain genotypes are at heightened risk for the development of an eating disorder. Eating disorders are heritable. Individuals who have had a family member with an eating disorder are 7-12 times more likely to develop one themselves.

While a genetic component can increase a child’s likelihood of developing an eating disorder, other factors are still at play.


While every child is different, there are some similarities of adolescents who are more prone to developing an eating disorder. Some of these traits include:

  •  perfectionism
  •  competitiveness
  •  sensitivity to reward and punishment
  •  impulsive behavior (predominantly in bulimia nervosa)
  •  rigidity (predominantly in anorexia nervosa)

If your child experiences some or all of these traits, he/she may be more susceptible to developing an eating disorder.


Parents were often blamed as the sole cause of their child’s eating disorder. As a therapist, you sometimes hear a client’s mother describe her husband as “aloof and uninvolved,” whereas the father will describe his wife as “overbearing and too controlling.”

Family dynamics are not to blame for a child developing an eating disorder, but by utilizing family therapy during treatment, the family can become a source of support and empowerment and expedite the recovery process.

Sociocultural Ideals

Technology and social media have increased the pressure of adhering to a certain “acceptable” body type or appearance. Now more than ever, young women are encouraged to take videos and pictures of themselves to post online and often receive feedback from people they know, and often, people they don’t.

Ultimately, it does not matter why a child develops an eating disorder. The most important step is identifying that there is a problem and seeking professional help as soon as you begin to notice physical, mental, and/or behavioral changes. Understanding the etiology will not stop your child’s destructive behaviors, but working with a knowledgeable doctor, nutritionist, and a family counselor can give you your vibrant and healthy child back.

Mom and daughter photo available from Shutterstock

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Wisdom from “On Being a Therapist” Sat, 01 Aug 2015 12:15:00 +0000

“Yet it is hard to tread water with someone on our back without drowning.”
Jeffrey Kottler

Jeffrey Kottler throughout his book “On Being a Therapist” sprinkles seeds of wisdom that will not only benefit the inexperienced therapist but the experienced therapist as well.

Kottler states that many in today’s therapeutic community regard therapy as little more than simple accountability and measured outcomes that are all held together in some limited time frame described as brief therapy.

Kottler believes that therapy is more than brief interchanges between a client and a therapist but an opportunity no matter how slight for the therapist to role model a positive influence on the client’s life.

Along with the relationship between client and therapist, Kottler shares in his book other challenges that confront today’s therapists such as:

  • increased diversification of client base
  • advances and changes in theory and technique
  • increased bureaucracy in health care
  • living in a stressed filled world.

These variables, along with the personal inner struggles professionally and personally that therapists are dealing with, makes the task of being productive in therapy in today’s world a daunting task.

Kottler believes that theories, prescribed rules, regulations and other therapeutic practices have their time and place and are in many ways helpful for the therapist, but he emphasizes that importance must  still be placed on the client/therapist relationship.

Learned Along the Way

Another key point Kottler emphasizes is how the client and therapist change each other during therapy.

Kottler warns counselors to be wary of the destructive energy emanating from a patient that it can pollute the spirit of the healer (Kottler, 2003).

Kottler wonders whether Freud’s habit in counseling sessions to remain detached had more to do with preserving his own emotional safety than transference issues.

It is important not to fall into the same emotional trap that the client is experiencing but rather encourage the client to risk take and act more than reflect on their issues.

Key for the therapist is timing when the client is ready for the next step in the process of dealing with painful issues. Kottler felt that an error in judgment by the counselor could result in tragic consequences or at the least regressive backlash.

To Kottler, clients become our greatest teachers, who let us know what is working and what is not, that is, if we are paying close attention (Kottler, 2003).

Another interesting aspect of counseling shared by Kottler is learning to love someone unconditionally, non-possessively, non-sexually, with warmth, empathy and genuineness. He states that this experience can be exhausting.

Patients can test the patience of any therapist and that can affect how the therapist relates to the client.. In doing so, we tend to feel more comfortable working with people who are most like us.

But, Kottler states feeling too comfortable with a client can be dangerous. We tend at this point to limit our therapy to:

  • what worked well in previous cases
  • deal with issues that are not personally threatening
  • limit the challenges that the particular case can teach us.

Real learning and growth comes from learning to be flexible, when we are forced to use new therapy styles and realize, that in some cases, it is not the client’s antisocial or annoying behavior that is the problem but our own listless, lack of caring attitude being expressed to the client that is the center of the problem.

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4 Questions To Ask Yourself When Hiring a New Therapist Fri, 31 Jul 2015 17:14:38 +0000 http://2.7355 Hire Me!One of the wonderful challenges that comes from having an abundance of business is the need to add new additional clinicians to your practice. But how exactly do you know who will be a good fit? How can you be sure to make the best choice that will benefit both the clients and your practice?

Not too long after opening Wasatch Family Therapy, I had created relationships in my community and built my online presence to the point that the demand for my services exceeded the supply I could provide. In other words, I needed to hire new therapists! Since I do not have a background in business, the process was entirely new to me, but thankfully I found that it happened quite naturally. I identified a few key criteria (beyond simply having required credentials and experience) that a candidate must possess in order for me to feel like he/she was a good enough match to hire. Here are 4 questions to ask yourself when meeting with an applicant who you may potentially bring in to your practice:

  • Do I like him/her?  

It may seem obvious, but it’s critical that you feel comfortable with an individual who may be working for you. If you do not like to be in his/her presence, why would a client? It goes without saying that people skills are invaluable in this profession; it’s what we do! Look for someone who puts you at ease, is warm and inviting, and who you find yourself attaching with. Be mindful of the emotional climate of your practice; you want to bring someone in who will work well with others, avoid drama, and of course help clients through their emotional struggles. Whether or not I genuinely like someone is the most important factor determining if I hire him/her (interestingly, this same criteria is also usually first on the list of what a client looks for in a therapist).

  • Were they born to be a therapist?   

When looking to add to my practice, I look for individuals who I can sense were born to do therapy. It’s common for practitioners to work with a lot of graduate level interns, and there are a select few who truly stand out; people who are naturally thoughtful, reflective, and sensitive to others’ needs and feelings. I want someone who’s always had the intuition and instinct of a therapist who just had to go through the official training to actually become one.

  • Are they emotionally stable?  

This question is admittedly a bit delicate. While no one has it all together all the time, it naturally follows that someone who has a handle on his/her emotional issues can better assist clients in managing their own. Good therapists often use difficult past life experiences to relate to and help clients, so being “emotionally stable” doesn’t necessarily mean you’ve never struggled mental health or relationship problems; quite the opposite can be true! To use an analogy, you cannot be a tour guide for other people to places you’ve never traveled. Still, I need my therapists to be healthy in order to best serve our clients.

  • Do they reflect the values of my practice?

As the owner of my practice, I need therapists who work for me to be similar to me in many ways. This is not to say, of course, that I am wanting someone with the exact personality, training, and expertise that I have. Still, there needs to be a continuity of approach and therapy style common to our clinicians. Throughout the years, we’ve had inquiring individuals wanting to see me specifically after hearing me speak or learning about me through social media. When I don’t have an available opening to see someone new, I like to be able to state my confidence in another therapist and tell the prospective client that I’ve hand-selected a particular counselor that I wholeheartedly trust to do good work. I suggest that practitioners looking to hire new therapists identify a few specific values that are key to the philosophy and setting of their private practice to look for in applicants.

What do YOU look for when hiring new clinicians?

Let me know!

This post was adapted from an interview I did with Joe Sanok, LPC on” Practice of the Practice.” Click here for access to the full podcast.

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Cannabis and the Endocannabinoid System Fri, 31 Jul 2015 13:00:28 +0000 marijuana-treatmentCannabis, commonly known as marijuana, is the most commonly used illicit drug in the United States. In 2012, nearly 40% of American 12th graders had used it at some point and one in four had used within the past month.

Simultaneously, as the use of marijuana has increased in recent years, the perceived risk from smoking marijuana has decreased (Johnston LD et al. Monitoring the Future national survey results on drug use, 1975–2012: Volume I, Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan;2013).

Considering the increased efforts to legalize marijuana in many states, greater public awareness of marijuana and its potential medicinal uses and new research on cannabis and its constituents, it is essential that psychiatrists understand some of its proposed benefits—and fundamental risks.

Effects of Marijuana

Marijuana is derived from the flowers and surrounding leaves of the Cannabis sativa plant. The psychoactive effects are experienced almost immediately after consuming it (usually by smoking or oral ingestion), peak in about 30 minutes and diminish in about four hours.

Subjective pleasurable effects include a feeling of relaxation, euphoria and laughter. Negative effects include dizziness, perception of slowing of time, drowsiness, paranoia, increased appetite and short-term memory loss.

Cannabis use has also been associated with impairments in ability to focus, loss of coordination and heightened body awareness (Campbell FA et al, BMJ 2001;323(7303):13–16). These effects may persist for weeks to months after discontinuing the use of cannabis, especially in heavy and frequent users (Gonzalez R, Neuropsychol Rev 2007;17(3):347–361).

Young brains appear to be especially sensitive to the effects of cannabis. Cannabis use increases the risk of developing poor overall mental health, depression, anxiety, attention difficulties, poor school performance and other substance use. (Yes, there appears to be real evidence for the ‘gateway drug’ phenomenon [Oltheus JV et al, Drug Alcohol Rev 2013;32(1):67–71]).

The risk is higher in females, heavy users  and those with early age of first use (van Gastel WA et al, Community Ment Health J 2014;online ahead of print). A recent longitudinal study demonstrated that persistent cannabis use was associated with significant decline in IQ and global neuropsychological functioning, particularly in adolescent-onset (vs adult-onset) and chronic users, even after controlling for other substance use and years of education (Meier MH et al, Proc Natl Acad Sci USA 2012;109(40):E2657–E2664).

Several large-scale studies have also reported that adolescent cannabis users have an increased incidence of schizophrenia later in life, with heavier use associated with increased risk (ManriqueGarcia E, Psychol Med 2012;42(6):1321– 1328). While the mechanism of this effect has yet to be determined, it appears that cannabis may precipitate the onset of psychosis in individuals who have a genetic or developmental vulnerability (Degenhardt L et al, Drug Alcohol Depend 2003;71(1):37–48).

Neurochemistry of Marijuana
The Cannabis sativa plant has been found to have over 500 chemical constituents, of which 85 are cannabinoids, ie, compounds that act on cannabinoid receptors.

The most psychoactive constituent of cannabis is delta-9 tetrahydrocannabinol (THC). Concentrations of THC in marijuana have been steadily rising over the years. According to the University of Mississippi’s Potency Monitoring Project, THC concentrations in samples of marijuana have risen from 1%–2% in the 1960s to an average of 9% today (see for example Mehmedic Z et al, J Forensic Sci 2010;55(5):1209–1217). A typical marijuana cigarette (“joint”) contains about 20 mg of THC derived from one gram of leaves and buds of the C. sativa plant.

THC may cause euphoria by inhibiting the release of neurotransmitters like GABA and glutamate. The effects may be biphasic, as higher doses of THC appear to increase anxiety and paranoia, presumably by increasing dopamine release (Mechoulam R & Parker LA, Annu Rev Psychol 2013;64:21–47). Most regular cannabis users can titrate the level of psychotropic effect to provide the outcome they desire, even though this “self-adjustment” of dose is in contrast to most of modern medicine, in which doses are determined by a prescriber.

Another cannabinoid that has received much attention in recent literature is cannabidiol (CBD), which is known to have anti-emetic, antiinflammatory, and antipsychotic effects (Bergamaschi MM et al, Curr Drug Saf 2011;6(4):237–249), as well as possible neuroprotective and anxiolytic properties. It may act as a protective factor against the detrimental psychological effects of THC. Cannabis plants modified to have a high CBD:THC ratio may be useful for therapeutic purposes.

Cannabinoids bind to cannabinoid receptors in the body. First identified in 1990, two types of cannabinoid receptors (CB1 and CB2) have been characterized, both of which are G-protein coupled receptors. CB1 receptors are responsible for the psychoactive effects of THC and are widely distributed throughout the central nervous system and the gut.

Interestingly, the low concentration of CB1 receptors in the brainstem accounts for the relative safety of marijuana; a lethal overdose of marijuana in humans has never been reported (Bostwick JM, Mayo Clin Proc 2012;87(2):172–186). The table on page 3 shows how THC’s multiple effects can be linked to its actions on various brain areas.

CB2 receptors are primarily found in the immune system, where they are involved in regulating inflammation, pain perception, and host defense.

The Endocannabinoid System
In the last few decades, researchers have discovered naturally occurring substances in the body that bind to the cannabinoid receptors. The two primary “endocannabinoids” are arachidonyl ethanolamide (AEA), more commonly known as anandamide (discovered in 1992 and named after the Sanksrit word ananda, which means bliss or joy), and 2-arachinoyl glycerol (2-AG). The endocannabinoids, the cannabinoid receptors and the enzymes involved in their metabolism form the endocannabinoid system (ECS).

The ECS plays an important role in the process of neurogenesis. One hypothesis suggests that THC may cause overstimulation of the ECS, especially in adolescent brains, thus disrupting the process of neuronal development and causing psychiatric disturbances. The ECS also moderates the activation of hypothalamic-pituitary-adrenal axis. Chronic stress can lead to down-regulation of cannabinoid receptors, thus leading to symptoms of anxiety and depression.

Some research hints that the ECS may play an important role in the inhibition of aversively motivated learning, and could be a useful target for treatment of PTSD. Other endocannabinoids similar to anandamide have been identified, and appear to protect the brain during trauma and stroke via vasodilation, anti-inflammatory, and analgesic actions (Mechoulam R & Parker LA, op.cit).

Because most drugs of abuse elevate brain levels of endocannabinoids, blockade of CB1 receptors may eliminate or reduce the rewarding properties of some addictive substances. This is the rationale of rimonabant, a CB1 antagonist which showed some efficacy in treating nicotine and marijuana addiction, as well as obesity.

Rimonabant was never approved in the US; it was withdrawn from the European market in 2008 because of psychiatric side effects, including depression and anxiety. Research into CB1 neutral antagonists, which permit constitutive CB1R activity but block excess CB1 activation (like rimonabant), is ongoing.

Medical Cannabis and Pharmaceutical Cannabinoids
Cannabis has been used for medicinal purposes throughout the world for at least the past five millennia. It was used extensively in Western medicine during the late nineteenth century, but went into decline after potent synthetic medications were introduced in the early twentieth century and marijuana was vilified in the popular media, eg, in the movie Reefer Madness, an anti-marijuana propaganda film released in the late 1930s.

Cannabis has been studied as a potential treatment for many conditions, including chronic skin disorders, cancer-related weight loss, chronic pain, Huntington’s disease, sleep disorders, glaucoma, multiple sclerosis, neuropathic pain, seizures, irritable bowel syndrome, inflammation, and hyperalgesia.

Some proponents of medical cannabis exclusively advocate the use of the plant (“botanic cannabis”) and the cultivation of strains that are effective for certain ailments. Unfortunately, federal regulations, such as the classification of THC as a schedule I controlled substance, as well as the rapid and largely unscientific promulgation of medical marijuana nationwide—what some have called “medicine by popular vote” (Bostwick, op.cit)—have resulted in a dearth of good scientific evidence on the putative medicinal benefits of smoked marijuana.

Academic and commercial laboratories have developed a handful of pharmaceutical compounds based on THC and other components of the cannabis plant. Three cannabis-derived chemicals have been approved for human use: dronabinol (Marinol), nabilone (Cesamet), and nabiximols (Sativex).

Dronabinol (schedule III) is synthetic THC and lasts for six hours, while nabilone (schedule II) is a THC analog with a 12-hour duration of action. Both have been approved since 1985 for chemotherapy-induced nausea and vomiting and the AIDS-related anorexia/ cachexia syndrome. While effective, some naïve users are susceptible to adverse effects such as euphoria, drowsiness, and cognitive clouding, due to variable absorption and first-pass kinetics. As a result, chemotherapy-related nausea and emesis are more commonly treated with serotonergic agents like ondansetron (Zofran), and THC is best reserved for resistant cases (Turcotte D et al, Expert Opin Pharmacother 2010;11(1):17–31).

Clinical studies have shown efficacy of synthetic THC in the treatment of neuropathic (but not nociceptive) pain, refractory cancer pain, and glaucoma, by reducing intraocular pressure. Interest has also arisen in the anti-inflammatory properties of THC, for disorders such as rheumatoid arthritis, and for epilepsy and post-stroke neuroprotection.

Nabiximols (Sativex) is a plantderived oromucosal spray containing 2.7 mg THC and 2.5 mg CBD per dose. It has been approved in Europe since 2010 for the treatment of moderate to severe spasticity associated with multiple sclerosis. As with THC, trials have shown efficacy of nabiximols for the management of pain, nausea, and AIDS-related anorexia, but not without frequent side effects like dizziness, sedation, and “thinking abnormalities” (Robson PJ, Drug Test Analysis 2014;6(1-2):24–30).

No cannabinoid drug has been approved for any psychiatric indication, and the effects of THC seem too unpredictable to assure any consistent therapeutic response. However, as mentioned earlier, the antipsychotic effects of CBD have been demonstrated in animals and in humans, and supported by functional MRI studies.

In a double-blind trial of 42 patients with schizophrenia, CBD showed comparable results to the antipsychotic amisulpride (Leweke FM et al, Transl Psychiatry 2012;2:e94). It is plausible that CBD-containing agents (which do not act on the dopamine system) may emerge as adjunctive medications to existing antipsychotics.

CBD may also block a process called “reconsolidation,” in which memories of stressful life events are strengthened by brief exposure to conditioned stimuli, suggesting a potential use in PTSD (Stern CAJ et al, Neuropsychopharmacol 2012;37:2132–2142). There are several case reports and small trials of CBD improving seizures in patients with treatment refractory epilepsy, although the mechanism is unknown (Robson, op.cit). CBD has also shown to improve memory loss in animal studies and is being explored as a potential treatment for Alzheimer’s disease, alcohol-induced neurotoxicity, and migraines (Russo E & Guy GW, Medical Hypotheses 2006;66:234–246).

TCPR’s Verdict:
Claims for the therapeutic use of marijuana are numerous, but the adverse effects of marijuana consumption—especially in young adults—are many, and the evidence base is, at present, relatively weak. That said, the human endocannabinoid system is widespread and involved in the regulation of several physiological mechanisms. Targeted pharmacotherapies based on specific compounds found in cannabis may usher in a new paradigm in the treatment of psychiatric and other illnesses.

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The Role of Diet in Treating Stress and Trauma Fri, 31 Jul 2015 12:12:03 +0000 I’ve often asserted my conviction – based on personal experience as a trauma survivor, professional observation as a therapist and reading of the literature as a researcher – that, to be effective, treatment strategies for dealing with stress and trauma must include cognitive, emotional and body-focused aspects.

In work with clients, I help them create a set of self-care activities that they can engage in over an extended period – after, of course, we’ve done essential preliminary work on connecting to inner resources and establishing a sense of safety.

This post begins a series on such self-care activities, which in the language of therapy I call cognitive and behavioral resolutions.

As a general rule, in therapy I start with things I think clients can do immediately that will bring immediate results. This frees up energy for other more slowly unfolding processes that follow.  I often start with nutrition, not because I’m a nutritionist, but because I’ve found attention to this area so fruitful in dealing with stress and trauma symptoms.

Brain Gut Axis

An intriguing phrase appearing more frequently now in the literature is “gut-brain axis.” Chris Kresser, a functional and integrative medicine practitioner, describes it as “the relationship between digestive health and cognitive function, memory, depression, anxiety and other mental and behavioral health issues.”

Painful personal experience drove me to the reading through which I encountered Kresser’s work. I lived in Africa for several years, working with survivors of severe gender-based violence and with professionals mandated to assist them. This work was stressful for me and I had minimal social or supervisory support. I was stressed for so long that I became chronically physically ill and eventually experienced advanced stages of burnout.

Burnout is well-recognized for its emotional toll, but its physical aspects get less attention. In my case, it all happened gradually and I never had a urgent life-threatening health crisis. Yet I got more and more tired and fatigued, vulnerable to constant colds and infections, reacting to many foods I had long eaten, and feeling miserable most of the time with a constant sense of brain fog.

Worried, I underwent tests. None revealed any significant underlying problems. My doctor suggested depression. But I know depression as a therapist and from my own seasons of difficult times. This was not depression. Something was wrong, out of balance, in my body.

I discovered writings of Kresser and others studying nutrition and health. I also located a well-trained practitioner of natural medicine who worked with me to create a path of treatment that I still follow. I have no miracle stories to tell, no surefire solutions to pass along. But I gained useful information about myself in this experience and began noticing interactions between nutrition and mental health that I am convinced get far too little attention among mental health practitioners.

Stress as a Trigger

From recent findings, we know that different types of psychological stress affect the composition of the gut microbiotica (Mayer et al., 2014).

Such findings suggest that an imbalance in the gut could play a key role in many symptoms such as chronic fatigue, brain fog, low and high blood pressure, insomia, PMS, PMDD, and other symptoms and conditions that people experience during anxiety and panic attacks or depression.

Recently, the Gut-Brain Axis has received a lot of media buzz.

Here is a long article about the connection between gut bacteria and mood. Here is an article describing the connection between depression and gut inflammation; a similar article describes the link of suicide and inflammation. Here is a more controversial post about ketogenic diet and its benefits dealing with mental health issues. Dr. Emily Deans, an evolutionary psychiatrist writes a stimulating blog on junk food, gut and the brain.

Several of the links above indicate a complex relationship between stress/trauma and the ratio of good and bad bacteria in our gut. An increase in bad bacteria affects how we feel both physically and emotionally and increased consumption of processed foods and sugars The connection holds in the other direction as well. That is, what we eat effects how we feel, and increased consumption of processed foods and sugars is associated with greater sensitivity to stress.

A Wholistic Approach

Medicines have their place, including psychiatric ones. But when someone needs a root canal we don’t just give them pain pill, we treat the underlying cause. I think the science emerging about the brain-gut axis is pointing us towards a root cause that is largely overlooked by current mental health and medical practices.

For stress management and trauma therapy to really help survivors achieve trauma integration, we need to work with people as a complex, interacting whole. After trauma, such an approach must include working on cognitive, physical, emotional and spiritual aspects of healing.

Diet and nutrition need to be included in treatment plans. I suspect the day is not so far distant when trauma practitioners will routinely be trained in more than one modality of therapy and that psychobiology and nutrition will be recognized as key elements of trauma treatment.

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Narcissistic-Like Traits Within Mental Health Professionals Thu, 30 Jul 2015 12:32:47 +0000 It’s common for mental health professionals to have a notion of narcissism as a conglomeration of characterological features occurring solely in psychologically corrupted individuals. However, there seems to be a vague awareness of the possibility of mental health providers displaying some of these personality traits.

It is rather unusual to contemplate that altruistic career aspirations can unconsciously become distorted into ego-driven ambitions of owning more titles, distinctions, awards, salaries and exclusive jobs, for example. Therefore, if we explore the altruistic nature of the mental health profession we may argue why such ego driven impulses are even present in the work we do.


There is enough literature already on the clinical presentation of a narcissistic personality disorder. They tend to present themselves as overachievers in distinct areas of their lives and will look for constant re-assurance and admiration from others.

Their grandiosity is usually based on fantasy ideals of socially esteemed constructs. When confronted, they tend to react defensively. Also, their empathy for others is secondary to their unique special attributes, which is a reason why they are likely to devalue people around them.

An important aspect about subjects with narcissistic personalities is that they can be socially functional. Therefore, they rarely seek therapy on their own. They usually seek therapy when it’s asked by their partner, suggested by an enforcing social agency (i.e. DCF) or mandated by court.

The root of Narcissistic Personality Disorder is yet unclear. However, there are many theories that recurrently point out to a fragile ego identity that leads to a sense of inferiority. As a defense mechanism, the subject tends to overcompensate by fantasizing about an idealized self-concept of themselves. This internalization helps them endure and disguise their shame about their true self.


Our society seems to over value the self-image of individuals. This experience is seen at a very young age in life, when our caregivers constantly remind us to “study in order to become someone in life.”

People who are not able to accomplish this goal may be left with a feeling of shame and failure. In order to manage their distress, they may eventually turn into unhealthy behaviors (i.e. workaholic, drugs, hyper-sexuality, criminal activity, etc.).

There appears to be a general belief in our culture that if you own more, you are better by default. Individualistic competition is usually rewarded with power and distinction from society.

This superiority charade permeates into the collective unconscious of our society as something desired and something for which to aspire. Therefore, people generally tend to get inspired (and obsessed at times) by those who enjoy of more materialistic possessions and social recognition


Mental health professionals are commonly trained and/or fostered to compete mercilessly against each other in higher educational institutions. It is usual to notice apprentices and professors undermining the work of other clinical programs (i.e. M.D. vs. Ph.D. vs. Psy.D. vs. Ed.D. vs. M.S.W. vs. M.S. vs. M.A., etc.) instead of acknowledging its value.

In the same way, it is common to observe researchers, clinicians and professors in the field getting into endless debates about their grandiose-like work and attacking those who don’t agree with their intellectual superiority.

Such people tend to enjoy these narcissistic-like intellectual battles, and can certainly get addicted over time to their thrill.


Aspirational goals should never be seen as negative, but on the contrary a healthy feature of human life. It is solely when career aspirations turn into obsessions, when the subject begins a journey into a destructive pattern of thoughts, emotions, attitudes and behaviors. Nonetheless, even if the subject gets what he longs for, his insatiable ego will most likely continue to push back by seeking other objects representative of power.

Throughout this greedy path, the subject learns the game of getting what he believes should be awarded to him.

If the subject’s morality is not well founded, he may even go as far as necessary regardless of how unethical it may be. If the mission is accomplished the person is rewarded by a feeling of power and control. However, if the subject fails, he is left with a feeling of shame, guilt and low self-esteem.

When the tragedy of failing the mission occurs the subject may also become resentful toward others he believes are holding the trophy (i.e. object) of his admiration. Constant criticism against others is common, as an unconscious act to reduce the anxiety it creates being unable to satisfy his own narcissistic needs.

In this act of narcissistic rage, the subject is left struggling with resentments and will usually look to disguise his/her identity through the creation of superior fantasy ideals of the self.

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Seven Dimensions of ABA (Applied Behavior Analysis): Changing human behavior the scientific way Thu, 30 Jul 2015 02:05:19 +0000 http://3.463 7 dimensions of ABA graphic

ABA (applied behavior analysis) is based on scientific methods and is founded on 7 core dimensions (Baer, Wolf, Risley, 1968). This means that all interventions that are provided through ABA services should fall within these 7 categories. This is important to ensure that the interventions are supported by research, that the interventions are effective and socially significant, and that interventions are closely monitored to ensure consistent progress or to provide support for modifications to the interventions if a previously implemented intervention hasn’t found to be effective for a particular client.

According to BehaviorBabe, the 7 dimensions of ABA can be remembered with the acronym, “Get A Cab.” See below for a list of the 7 dimensions as described by BehaviorBabe as well as a video which provides an example of using the 7 dimensions in ABA practice.


1. Generalization: skills/behavior occur in environments other than where they were discretely taught

2. Effective interventions are monitored to evaluate the impact on the target behavior

3. Technological procedures are described clearly and concisely so that other may implement accurately

4. Applied socially significant behaviors are selected

5. Conceptually Systematic interventions consistent with principles demonstrated in the literature

6. Analytic decisions are data based

7. Behavior observable and measurable behaviors are targeted

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21 Ways to Beat Exhaustion Wed, 29 Jul 2015 21:19:16 +0000 http://5.235 Exhaused WomanAre your clients exhausted from doing too many things at once? Some research suggests that multi-tasking is impossible — when done, a person is actually giving only partial attention to many things. With all the advances in technology, it seems that life doesn’t stop long enough to give full attention to anything. Many find they are exhausted not just in the physical sense, but deep inside to the bone.

What can be done? A mental health day might just do the trick. This is not a vacation day with the family or a day to catch up on annual doctor visits. Rather, it is a day to detach from the electronics and explore new horizons.  It is a day to regain some rest and release some emotional build-up. Here are 21 ways to spend the day:

  1. Take a day at the spa and get a massage to relax stressed-out muscles.
  2. Try a new task such as a recipe that sounds interesting.
  3. Do something creative that is enjoyable like painting or playing an instrument.
  4. Revisit pictures from 10-20 years ago and take time to remember the influential and encouraging people.
  5. Clean up a pile or closet that has long been ignored.
  6. Reconnect with a friend long ignored by having lunch.
  7. Return to nature by going to the beach or a park.
  8. Take a nap to catch up on some sleep.
  9. Watch a sad movie to release crying, sadness and anger.
  10. Watch a comedian to spark laughter – it is truly the best medicine.
  11. Read a book just for fun, not work or relationship focused.
  12. Practice deep breathing randomly though out the day using yoga breathing exercises.
  13. Explore your city by going to a museum or an unfamiliar part of town.
  14. Get out of regular routines by taking a longer bike ride or walking someplace new.
  15. Go to the library or book store and explore an unfamiliar but interesting topic.
  16. Take a class at a craft store.
  17. Complete a puzzle or crossword.
  18. Meditate intentionally on a peaceful passage or phrase.
  19. Write a story or poem just for fun, not to be critiqued by anyone.
  20. Listen to music with eyes closed paying attention to the rhythm.
  21. Write a note of thanks to inspiring people.

Most importantly, enjoy the day!

Christine Hammond is the award winning author of The Exhausted Woman’s Handbook available on Amazon, Barnes & Noble and iBooks.

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When Music is the Language Between Us Wed, 29 Jul 2015 12:30:19 +0000 I spend a lot of time thinking about relationships in autism. This is especially true in a toy aisle when I become queasy over all the so-called “interactive” toys that are battery-powered, embedded with flashing lights, 15-seconds of whiny music and spinning parts. An immediate wish, command and gratification are all so easily enticed by a magic button. So, push it, push it, push it again!

What would these objects look and feel like if I had an Autism Spectrum Disorder (ASD) and what effect would they have on me and those in my closest circles – my parents, siblings, therapists?

These are not idle wonderings. In my practice as a Developmental Music Educator who interacts using live music-making with children who have ASD, I am stymied by these addictive crazy whiz boxes more often than I care to remember.

To me, the best musical toy may be a drum — no batteries, no electronic sounds, no automated drumsticks. It would defeat the power of the drum to install a button for it! No, we use our hands; feel the taut drumhead push back our palms and fingertips; the vibrations tingle up our fingertips, up our arms; the vibrations are organic, they touch the energy and life in our bodies. And the interactive component the child gets is me, not a button.

Joy Through Music

Take Michael, a 5-year old boy with autism who I recently met. Michael was brought to me by his anxious, loving parents whose introductory description of him was weary and rote. “He doesn’t talk. He doesn’t like to look at anyone. He likes to be left alone with puzzles. Sometimes, he makes odd sounds and it’s getting harder to connect with him. Oh, he loves music.”

Great! I hope he doesn’t have a bunch of whiz boxes, I think. When I ask them to elaborate on the music, they perk up. They tell me it’s the only way to get him to do anything – go upstairs, brush his teeth, get in the car.

I ask how they can tell he loves music, and they say that he smiles, he moves to the music, he hums along, he even drags them to the cd player.

These are impressive, hopeful signs to me that Michael could find joy through music within relationships with other people.

I learned my trade as a practitioner of autism-related work from the late Stanley I. Greenspan, MD (1941-2010) and his colleague, Serena Wieder, Ph.D, both pioneers who founded the developmentally-based approach known as DIR® (Developmental, Individual, Relational), with its catchy practical core known as “Floortime™.”

Thanks in part to Greenspan’s long tenure at National Institute of Infant Mental Health (NIMH), his early research into neurological data associated with special needs provided his and Wieder’s seminal formulations and applications with a sturdy scientific foundation.

`On the Floor’

By late 1990’s and the new century, parents, clinicians and educators around the world were “on the floor” with children, especially those with social and communicative challenges, engaging, relating and securing developmental milestones based on individual differences while using this unique cross-disciplinary frame.

My own mindful embedding of music into Floortime™ happened around the same time as the hard sciences also reached exciting, positive conclusions about the social benefits of early music, including strong ways it plays out for those with certain neurodevelopmental challenges and strengths.

I consider the body and mind of a young person whose senses over-, under-, or differently react to the environment; who hears words but may not understand them; who emits sounds that others may not interpret as communicative.

No wonder children with ASD often seek the safety of ordered repetition.

Yet repetition without variation means no adaptability – a necessary life skill. But, music! Music, by its very nature, is ordered — its patterns are mathematical, in fact. And yet it is also one of the most malleable of mediums, so that stability and change can go hand in hand. Predictability, anticipation, and surprise are orchestrated even while staying grounded.

When Michael pounds on the wide drum between us, I join his tempo and we go at it together. Getting in sync this way feels wonderful – scientists name the phenomenon entrainment. When he stops, I stop too, with an exaggerated freeze to make the point; when he starts up, I do too. After a few times of game-like cause and effect he realizes he has the power. He smiles and looks at me. He’s got that “gleam in the eye,” as Dr. Greenspan named this special relational moment.

I add another layer, singing a simple children’s song on top of our drum beats — and we are now a genuine duo making music. And we haven’t even gotten to louder and softer or faster or slower or a myriad other things we can try as we each lead and follow. Mom and Dad take turns with Michael, too, and it becomes a family activity of musical companionship.

Music is the perfect first language between us. And so much better than those flashy, whiny, whiz boxes with buttons that soon leave a child alone and with nowhere to grow.

Boy with drum photo available from Shutterstock

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What Would Yalom Do? Wisdom for Counselors Wed, 29 Jul 2015 11:28:26 +0000 During the winter of 2014, I bedded down for a long deserved rest.

As a counselor educator, I basked in the idea that after posting final grades, the university would be closed for the holiday season. I made myself a cup of Jasmine tea, started a fire in the fireplace and pulled my new Christmas throw over my tired shoulders.

Inhaling the scent of Jasmine mixed with the musty pages of the selected paperback, I immersed myself in the titillating experience of Dr. Yalom’s literary masterpiece entitled “When Nietzsche Wept” and I swore my allegiance to his wisdom.

For within this teaching novel, Yalom brilliantly intertwined the lives of the successful Dr. Josef Breuer, the neophyte Sigmund Freud, the despairing Frederick Nietzsche and the seductive Lou Salome’. The encounter that ensued captured the essence of the sacred-yet-murky therapeutic relationship and the courtship that occurs between healer and healing.

I reflected on my role as a counselor educator, a midwife to second year clinicians-in –training who (as they experience the final stage of their birthing) make one final attempt to remain safe in the womb of graduate school.

“There must be more to this therapy-thing? Surely I do not know what I am doing! Teach me your tricks. Offer me your magic wand!” they implored as they faced their launching into the professional community.

I assured them that they will remain in the shelter of supervision and community as they continue their journey as helpers. I commented on the vast amount of continued work they will do both professionally and personally. I reminded them that the most important element of the therapeutic relationship is…the relationship.

Yet, I wanted to be supportive. I wanted to offer an elixir to relieve their discomfort. I pondered the unrest of the neophyte counselors and inquired “What would Yalom do?” It is to this question that I defer to the work of Dr. Yalom and I provide my learners with final lessons as interpreted by me and borrowed from “When Nietzsche Wept”:

1. Symptoms are Messengers
Yalom’s Nietzsche suggests:

“Perhaps symptoms are messengers of a meaning and will vanish only when their message is comprehended.”

The DSM-5 has provided all of us with a new manual for categorizing and labeling sets of symptoms. For many counselors, in particular new counselors, the responsibility of diagnoses can be daunting. Many of my students chide me as I refer to the “patterns of behavior” a client manifests versus a specific diagnosis.

Yalom further challenges that all behavior is purposive and serves the host. Therefore, discovering how these patterns or symptoms serve the client may provide insight into deeper meaning.

2. Cultivate Meaning
Viktor Frankl, psychiatrist and author of the groundbreaking book, “Man’s Search for Meaning,” describes meaning construction as paramount to the human condition. He notes,

“You can take everything from a man, accept his attitude about his circumstance.”

Yalom concurs that the cultivation of understanding is key for a client’s wellness. Therefore, I am inclined to assess what meaning is ascribed by the client to a particular symptom or patterns of symptoms?

For example, I had a client who presented with concerns over discovering that her husband had a fetish for wearing women’s lingerie. Initially, I thought her discomfort was related to possible concerns about his sexuality. However, upon further exploration, this client’s real discomfort was related to her own body image. She found her husband to be more comfortable wearing his pink nightie than she, and this resulted in her envy and resentment.

3. Model Honesty
To truly be honest one necessarily experiences risk–risk of rejection, risk of betrayal. Yet, vulnerability can offer great rewards in relationship. As clinicians, we ask our clients to be truthful and often negatively refer to those who withhold information as “resistant.”

However, do we ask the same of ourselves? Do we allow ourselves, as Yalom suggests, to model this behavior so that our clients can “learn there is no horror in openness and honesty between people?”

Brene’ Brown, the author of the 2012 #1 New York Times Bestseller entitled “Daring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead,” writes,

“Vulnerability sounds like truth and feels like courage. Truth and courage aren’t always comfortable, but they’re never weakness.”

4. Healer and Healed are In Courtship
Yalom poignantly reminds us that the secret to the therapeutic alliance is the unconscious dance that occurs between the healer and the healed. This intricate pattern between transference and counter transference may resemble a perfectly executed waltz or a more random quick step.

Rarely understood outside the counseling community, it is within this complex relationship that healing occurs. Furthermore, the healer is often equally touched by the experience of being in relationship with the client.

Hermann Hesse’s novel “Magister Ludi” expresses this best where two great healers discover one another. In desperation, the young student seeks the help of the great teacher and remains in service to him until his dying days. However, it is during the final scene as the sage healer is dying that he confesses that he too had sought out the care of the younger healer and that both were served by the relationship.

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Quick Summary of the Matching Law: A mathematical equation for why people make choices Wed, 29 Jul 2015 02:00:33 +0000 http://3.461

As you can see in these two videos that describe the matching law, this scientific description of choice-making allows practitioners to utilize a formula, observations, data, and a systematic approach to hypothesize what a person will do. Additionally, behavior analysts can use the matching law to create increases in desired behaviors by assessing the behaviors that result in the highest reinforcement and then changing the environment to suit which behaviors the behavior analyst, parent, or teacher would like to see more of from the child, depending on the needs of the individual child and the goals of his or her treatment.

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News of Note: Insomnia and Antidepressant Medications Tue, 28 Jul 2015 15:18:32 +0000 drugs_pillsFDA Issues Safety Warning on Lunesta
In mid-May of 2014, the FDA released a warning that eszopiclone (Lunesta) can cause next-day impairment when taken at the recommended target dose of 3 mg/ day. As a result, the FDA has lowered the recommended starting dose to 1 mg/day.

The FDA cites a double blind, placebo controlled study of 91 adults that found working memory and the psychomotor coordination required to drive a car were impaired for up to 11.5 hours after a 3 mg bedtime dose of Lunesta.

They also determined that subjective perception of sedation and coordination—in other words, patients’ abilities to realize they were sleepy or impaired—were no different than placebo, although these patients were actually quite impaired. Women and men were equally affected.

In fact, according to the data summary from the FDA, a 3-mg dose of Lunesta was almost as impairing as 7.5 mg zopiclone, a medication often used as a positive control in studies of driving impairment (and, interestingly, the parent compound of Lunesta).

Doses can be titrated up to 3 mg from the new starting dose of 1 mg, says the FDA, but patients taking the 3 mg dose are cautioned against driving and related activities the next day. Read the warning.

Move Over Ketamine? New Fast-Acting Antidepressant Shows Promise
A new drug is showing rapid, long-lasting results in early rodent studies, according to a paper presented by Jeffrey Talbot of Roseman University of Health Sciences at the annual meeting of the Federation of American Societies of Experimental Biology (FASEB) in April 2014.

The drug, Ro-25-6981 (nicknamed “MI-4”) has been shown to reduce depressive symptoms almost immediately, similar to ketamine. However, unlike the ketamine data thus far, this new study shows that those effects can be maintained for about three weeks, says Dr. Roseman.

The medication has a unique mechanism of action according to an April article on the website Science Daily. While working as an NMDA antagonist and stimulator of neurogenesis (at least in vitro), MI-4 also works through triple reuptake inhibition to increase levels of dopamine, norepinephrine, and serotonin.

Triple reuptake inhibitors are also known as serotonin–norepinephrine–dopamine reuptake inhibitors (SNDRIs). Amitifadine, a SNDRI developed by Euthymics Bioscience has shown positive results in clinical trials. The SNDRI liafensine was dropped by Bristol-Myers Squibb in phase IIb trials when it failed to perform better than Cymbalta. Dr. Roseman’s research will be published later in 2014.

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Do You Work with a Sociopath? Tue, 28 Jul 2015 13:27:28 +0000 http://5.229 Sociopath at workAt first glance, a sociopath may be difficult to identify at work. They generally don’t draw attention because they have no internal need to socialize or interact with co-workers unless there is something to be gained from the experience. When they choose to intermingle, they present as charming, intelligent, balanced, sexy, and yet seemingly harmless. But this is a front.

Sociopaths are often confused with narcissists and psychopaths but they are very different. A narcissist is an attention whore who needs a constant flow of admiration from a flattering staff. Even when they are not in charge, a narcissist will assume the role and eventually take things over to feed their lust for power and domination. Sociopaths, in contrast, do not need attention to feed their ego.

Unlike the narcissist, a psychopath would never draw so much noticeable attention as they prefer to be extremely selective about who sees what face. They are chameleon-like with the ability to instantly change from one persona to another. Employers see only the best side of a psychopath while co-workers see another irresponsible, manipulative side.  Sociopaths differ in their ability to maintain the chameleon image. Psychopaths can maintain the façade for decades. Sociopaths become too easily bored with the same role.

What is a sociopath? The term is encompassed under the definition of Anti-Social Personality Disorder along with psychopath. However, psychopath and sociopath are not interchangeable terms. Think of them as two separate parts of a whole personality disorder. A sociopath has more erratic behavior, is unreliable, lies for no apparent reason, and takes greater risks than the psychopath.

At work they may present as the following:

  • Charming and superficial only to people that can give them something such as power, money, or empathy.
  • To everyone else, they are cold, distant, and aloof as if those people don’t exist.
  • Completely lacking in emotion or the ability to empathize with others but they do possess the ability to fake it for a short period of time.
  • Unpredictable and unreliable at work completing only the tasks that they enjoy or get instant gratification for finishing.
  • Lies to see what they can get away with without any master plan unlike psychopaths who are more intentional about lying.
  • Blames others for their own mistakes without any remorse or guilt taking pleasure in seeing punishment administered to others for their blunder.
  • Takes unnecessary risks out of boredom just to stir things up.
  • Continues to make the same errors over and over with no self-awareness.
  • Uses their appearance or sex for self-promotion and/or manipulation.
  • Openly makes threatening remarks of harm towards others and themselves (suicidal comments).
  • Doesn’t remain in a job for too long, constantly change career paths and frequently are fired.
  • Commits illegal activity because they can.

Working with a sociopath is only dangerous if a person gets in their way, attempts to expose the manipulative self-seeking behavior, or has something the sociopath wants. Otherwise they can appear harmless. The best advice is to avoid the sociopath and ignore their behavior. Eventually, they self-destruct or become bored an move on to another work environment.


Christine Hammond is the award winning author of The Exhausted Woman’s Handbook available on Amazon, Barnes & Noble and iBooks.

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Take the Fear Out of Marketing Your Practice Tue, 28 Jul 2015 13:18:26 +0000

Five Tips

1. Like therapy (and life), marketing is about relationships. You are good at relationships or at least have the skills to be. You can build relationships in so many different ways- online or in person or even through audio or video content that shows your potential client that you understand where s/he’s coming from and that you can help.

2. Networking is just conversations. You have conversations all the time. You have probably had at least 10 so far today. Sitting down and talking with another human being is what you do for a living. You aren’t there to pitch your practice, so take a deep breath. You’re there to hear about the other person’s practice, his or her needs, what they love about what they do.

You’ll need people to refer to and here’s a great way to find just the right person for a client who may need a type of therapy you don’t offer or a presenting concern with which you don’t work. Yes, talk about what you’re looking for in your practice, but please don’t make it all about you. Does that take some pressure off?

3. Marketing doesn’t have to be sales-y. In fact, sales-y marketing is going to hurt you. The way you present your practice doesn’t have to include tag lines or hooks to get people in with limited time offers. Just love what you do and talk about it. If you don’t love what you do because you’re burned out, increase your self care and get some help to find that love again.

4. You don’t have to speak publicly, but if you do, remember that most people in the audience are rooting for you. If you’re visibly anxious, the audience will notice and relate to it. Make sure your content is solid so you can cognitively fall back on the fact that you know what you’re talking about.

Use that nervous energy as proof that you’re alive and full of vitality. Notice that it’s there without judging it and it’ll probably fade the longer you speak. Eventually, you’ll have enough exposure to public speaking that it won’t be a big deal. But again, public speaking isn’t necessary to building a successful practice.

5. Failure is all in your head. The big secret is that private practice isn’t difficult. Having patience as it builds is difficult. Setting and holding firm to boundaries is difficult. But maintaining a practice with solid systems is a breeze. And, marketing can actually be fun once you let it be about relationship building.

Man offering a business card photo available from Shutterstock

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HIPAA Security Rule Compliance for Private Practitioners Tue, 28 Jul 2015 06:59:55 +0000 http://2.7331 HIPAA Security Rule Compliance for

Guest Post by Rob Reinhardt, LPCS, Technology Consultant for Mental Health Professionals, CEO of Tame Your Practice

Wouldn’t it be nice if someone would provide us with a brief checklist of things we need to do in order to comply with HIPAA (the Health Insurance Portability and Accountability Act)? I strongly recommend that you not wait for that to happen. HIPAA was purposely constructed to be flexible so that both large hospitals and solo practitioners would be able to comply. You wouldn’t want to follow the same checklist as a hospital would you? Further, because HIPAA now covers electronic Protected Health Information (ePHI), it’s important that it be flexible since technology continually evolves.

That said, there are some basic parameters and processes to be aware of. Once these concepts are understood, HIPAA no longer seems to be this overwhelming, unintelligible, monstrosity. It takes on a role similar to progress notes and other paperwork; that stuff that gets in the way of our client time, but we know we need to do it.

Here then, is a brief summary of the most important things to know about HIPAA:

It’s More Than Just the HIPAA Privacy Notices

HIPAA started out in 1996 with the Privacy Rule, which regulates the use and disclosure of Protected Health Information (PHI) by Covered Entities (CEs). Protected Health Information is any data about health care that can be linked to a specific individual. Covered Entities are health plans/insurers, clearinghouses, and providers who engage in “Covered Transactions”. For most mental health clinicians, that means filing electronic insurance claims (even if you don’t, be sure to read on). This is the part of HIPAA that brought us the HIPAA Notice of Privacy Practices, where providers detail for clients how and when they will use and/or disclose their PHI.

In 2003, the Security Rule was added in order to set standards for securing ePHI. It requires that CEs establish Administrative, Technical, and Physical safeguards to ensure the privacy of client data. This was further enhanced by the HITECH Act (Health Information Technology for Economic and Clinical Health Act) in 2009 and the Final (Omnibus) Rule in 2013.

I’ve found that most therapists have the Privacy Rule down pat, so in the following sections, I’ll focus on clarifying information from the Security Rule.

HIPAA Security Compliance Is An Ongoing Process

One of the primary components of complying with the Security Rule is completing a Risk Analysis and Management Plan. This is a process of documenting reasonably anticipated threats to the security of ePHI (i.e. theft, loss, fire) and a plan for dealing with those threats. This is required to be reinforced through a documented set of Policies and Procedures (yes, even if you’re a solo practitioner). Therapists wouldn’t dream of assessing a client at intake and then never re-visiting that assessment. Similarly this Risk Analysis process needs to be re-visited on a regular basis. This ensures that new technologies and threats are addressed appropriately.

Software and Devices Can’t Be HIPAA Compliant

If you listen to the marketing speak, you might get the impression that a CE can be in compliance as long as they choose software and devices that are “HIPAA Compliant”. The problem is that such things do not exist!

Only Covered Entities or Business Associates can be compliant with HIPAA by engaging in the processes described above. A Business Associate (BA) is any third party that a CE shares PHI with. This could be a billing agent, an EHR vendor, or a telehealth application vendor. In creating this relationship, the CE is required to establish a Business Associate Agreement with the BA, outlining the responsibilities of each. The good news is that, due to the Omnibus Rule, this requires that the BA is held to the same standards for compliance as the CE. To be clear, this doesn’t release the CE from all responsibility. They still need to conduct a Risk Assessment. However, it’s often the case (especially with EHR) that using a third party vendor will greatly decrease the scope of (read: amount of work involved in) the CEs process.

(Side Note: It’s important to note that financial transactions are exempt from HIPAA, so typically financial institutions don’t fit the definition of Business Associate. However, there are some circumstances to be aware of, such as some of the features offered by services like Square).

But I Don’t Take Insurance So I Don’t Have To Worry About HIPAA

It’s true that, if you (or your billing representative) are not filing electronic insurance claims, you likely don’t fit the definition of Covered Entity. Technically then, you don’t have to comply with HIPAA. You should be aware of and consider the following, however:

  • Standard of Care – HIPAA is becoming recognized as a “Standard of Care” when it comes to Privacy and Security. If how you handle privacy and security ever comes into question, there’s a solid chance that HIPAA will be the measuring stick for whether you’re doing a good job.
  • Ethics – Our codes of ethics require that we keep client information confidential. In line with the first point, what standards can we use to prove that we are doing so, especially with ePHI?
  • State Law – Be sure to understand your state laws regarding client privacy. If you’re in Texas, for example, your state laws are in some cases even more stringent than HIPAA.
  • Best Practices – Similar to the idea of Standard of Care, the set of requirements in HIPAA are considered “Best Practices” for securing client data. While HIPAA may seem bloated and overdone in parts, the core requirements make sense and are a good path for significantly reducing the risks to privacy.

Rob Reinhardt is a Licensed Professional Counselor Supervisor in North Carolina and CEO of Tame Your Practice. In addition to helping therapists integrate technology into their practice, he is the column editor for Counseling Today magazine and creator of Describe, a therapy tool appropriate for individuals and families of all ages!

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Therapist Blog Challenge #21: Maintaining Space in a Relationship Mon, 27 Jul 2015 22:37:45 +0000 http://2.7201 Blogging

I’m excited to present a blog challenge that has to do with one of my favorite topics: relationships. Specifically, you’ll have the chance to explore the idea of how a person can maintain his/her own space (physically and emotionally) while also being in a relationship.

[Headline] Come up with a headline to give your readers an idea of what is to come. Here are a few examples:

“‘Give Me Some Space!’ Maintaining Healthy Boundaries in Relationships”

“Creating an Appropriate Amount of (Emotional) Space With Your Significant Other”

“Absence Makes The Heart Grow Fonder; How Spending Time Away From Your Spouse Can Strengthen Your Connection”

“Preserve Your Relationship By Taking Time For Yourself!”

[Strong Intro] Write an introductory paragraph to explain the topic more and lay the scene for your main points. You may write your own or use the following:

Movies and pop culture often portray two people in love as inseparable and completely enamored with one another. Some struggle when they realize that the experience of real life can be quite different. The truth is that almost everyone in a relationship needs a little personal space and even time away. But how can you get a breather while still maintaining your relationship? Here are some reasons why space is important and also ways to create boundaries and still keep your connection strong:

[Scanable Content] Break up your content to make it more digestible and easy to read. Under each point, flesh out your idea by elaborating on your thoughts.

1. Tune In To Your Feelings

Acknowledging your emotions that you need a little space in your relationship is the first step. Maybe you’re feeling a bit cut off from other people or are even feeling a bit smothered. Some may be inclined to ignore such feelings or consider them “bad,” but instead express to yourself if you are wanting a bit of a breather from your significant other.

2. Communicate About Your Needs

It may be a bit tricky, but tactfully communicate that you would like to branch out a bit. Be careful to let the other person know that you are not ending the relationship, but just want to find ways to enrich your life and experience. Express how you are feeling, and listen to your love’s response; it’s possible that he/ she is wanting the same thing!

3. Pursue Your Individual Passions

Take time to “get to know yourself” and do something that you enjoy (but perhaps have been neglecting). Go ahead and sign up for that pottery class, or recommit yourself to your exercise regimen that has suffered a bit. Encourage the other person to likewise engage in activities that he/ she likes.

4. Nourish Your Friendships

Although your spouse or significant other is likely your “number one,” remember that no single person can fulfill all of your needs. We as humans are wired to connect, and we have something to learn from different people in our lives. Moreover, there is likely someone in your circle of influence who needs you, so take a break for a day or two and spend an evening with a friend.

5. Come Back Together Stronger Than Before 

If you need some space and give yourself permission to take it, you’re practicing self-care and can become even closer to your significant other. Famed German psychologist Erik Erikson explained that “identity precedes intimacy.” Paradoxically, your relationship can be strengthened by developing your self and then creating and maintaining space!

[Strong ending paragraph] Wrap up your post by summarizing your main points to conclude and then possibly offering a further idea or two for readers or a call to action. Here’s an example:

Relationships need a lot to thrive: time, love, honesty, and connection. But each person taking time for him/ herself is an important (and sometimes overlooked) component in creating and maintaining a strong and healthy relationship. Tune in to your feelings, communicate, spend time with your friends and doing what you like, and come back together stronger than before.

Additional reminders about the 2015 blog challenge

  • Write and post your blog article in the next 2 weeks. If you miss the deadline or you read this article months later, that’s OK too. Post a link for this blog challenge in the comment section of this blog post.
  • Read, comment, and share other therapist’s articles.
  • Tweet your post using hashtag #therapistblog and tag @drjuliehanks so I can retweet it.
  • Pin it on the challenge Pinterest Board. I’ve invited everyone who posted a comment on the initial blog challenge post as collaborators so you can pin onto the group board.
  • Spread the word and invite mental health colleagues to join the challenge. Articles can be added anytime throughout the year.
  • Write no more than 600 words, make it easy to read, use a conversational tone, and gear your articles toward your ideal client (not other professionals).
  • The goal of a professional blog is to provide value to your website visitors, help them get to know your professional perspective, increase traffic to your private practice website, and build your practice.

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