Psych Central Professional http://pro.psychcentral.com For mental health, psychiatric and psychological professionals. Fri, 05 Feb 2016 14:17:09 +0000 en-US hourly 1 Electronic Communication between Psychiatrists and Patients: Advantages and Riskshttp://pro.psychcentral.com/electronic-communication-between-psychiatrists-and-patients-advantages-and-risks/0011783.html Fri, 05 Feb 2016 14:17:09 +0000 http://pro.psychcentral.com/?p=11783 email communication doctor and patientDo you use email to communicate with your patients? Chances are good that you don’t. One recent survey of psychiatrists found that just 5% routinely and 25% sometimes used email with patients (Koh S et al, J Psychiatr Pract 2013;19(3):254-263). This means that there is a significant disconnect between what we do and what patients want, as over 70% of patients say they want to communicate with their providers electronically (Schickedanz A et al, J Gen Intern Med 2013;28(7):914-920).

In this article, I’ll start by describing my approach to emailing patients, and then discuss some of the legal and regulatory issues that you’ll need to consider as you develop your own policies.

I have been communicating with patients electronically in some format since beginning work at Purdue University in 2008, in large part in response to requests from the university students whom I treat. In the last several years, this has been via a secure messaging feature that is part of our electronic health record (EHR), which automatically encrypts communications. For many of my student patients, email or texting is their primary means of communicating with friends, family, and professors. It can be unusual for students to even talk on their mobile phones; it is not uncommon for many of them to not even have their voice mail set up.

Advantages of Email

Over the past few years, I’ve found several advantages of using email in clinical practice.

1.    Convenience and workflow efficiency. Email cuts down on “phone tag” and overall time spent on the phone, since I can often address concerns more rapidly by email. Messages can be sent at the provider’s convenience and read at the patient’s convenience, making it a win-win for both parties. For example, I had one patient with depression whose screening lab work showed significant hypothyroidism. I was able to send the results to him directly via secure message, along with a referral list for endocrinologists. He wrote back within the hour stating that he had just made an appointment with an endocrinologist on the list, and was planning to print out his lab results to bring to that appointment.

2.    Enhanced privacy. Yes, you read that right—ironically, given the common worry about privacy breaches with email, such communication often improves a patient’s ability to communicate with us privately. Patients who are at work or in other public settings are uncomfortable having a phone call about their mental health issues, but reading and responding to emails is discrete. I’ve also found that it can be a good way for patients to broach more sensitive topics, such as concerns about gender identity. Initiating a discussion over email provides a sense of safety and distance and can increase comfort about having a more thorough discussion at the patient’s next appointment. However, see the caveat below about protecting patient privacy in accordance with HIPAA regulations.

3.    Enhanced communication of clinical information. When I provide medication instructions via email, I use a concise, clear format that patients can refer to several times if needed, increasing their understanding and adherence. I have found that electronic communication is ideal for sending lab results, medication handouts, referral lists to specialists, handouts detailing relaxation and sleep hygiene techniques, and for receiving and responding to prescription refill requests.

4.    More efficient appointment management. I sometime use email for appointment reminders and to check in with patients after missed appointments. When I do this with university students, it is not uncommon to receive a reply within the hour explaining the circumstances of the missed appointment and stating an intent to reschedule. This is not only a source of relief when working with higher risk patients, but also substantially decreases the amount of time that would otherwise have been spent trying to follow-up with the student. If you are lucky enough to work with an EHR that provides a secure messaging feature for communicating with patients, this information will usually be automatically added to the patient’s medical record, further improving workflow efficiency.

Regulatory and Other Considerations

As you can see, there are many advantages of emailing patients— however, before you begin, you should know about various ethical, legal, and practical issues. (See “Five Tips for Using E-Communication Successfully in Your Practice” on p. 3 for a brief summary of recommendations).

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Treating Substance Abuse and Addiction with Mindfulness and Acceptancehttp://pro.psychcentral.com/treating-substance-abuse-and-addiction-with-mindfulness-and-acceptance/0011729.html Fri, 05 Feb 2016 11:06:56 +0000 http://pro.psychcentral.com/?p=11729 treating substance abuse with mindfulnessThe goal of acceptance and commitment therapy (ACT) is to boost psychological flexibility by targeting six processes that underlie a range of mental health challenges: Acceptance, defusion, present-moment awareness, self processes, values-based living and committed action.

Because of its transdiagnostic orientation, the ACT model allows clinicians to effectively address any co-occurring issues that may be present along with the addictive behaviors that bring them to seek help. This approach is especially relevant when it comes to addiction and substance abuse; 18% of those who meet criteria for substance use disorder also meet the criteria for an anxiety disorder, while 20% struggle with mood disorders (Grant et al., 2006).

Here are some of the ways in which the six mechanisms targeted in ACT can play a role in substance abuse, adapted from the edited volume, Mindfulness and Acceptance for Addictive Behaviors: Applying Contextual CBT to Substance Abuse and Behavioral Addictions.

By understanding what to look for in clients, you will be better equipped to target the root cause of their maladaptive behaviors in your treatment plan.

1. Present Moment

Anyone who struggles with rumination or worry knows that how challenging it can be to stay grounded in the present moment. But an inability or refusal to be in the present moment can make it nearly impossible to respond to present experiences appropriately and can, therefore, inhibit one’s ability to respond with potential long-term consequences in mind.

Some people who abuse substances may be incredibly aware of the present moment including physical sensations and urges from one moment to the next. But conversely, these individuals may be almost entirely unaware of other things like the interpersonal consequences, threats of violence or potential for punishment that accompanies their behaviors.

This area is where ACT’s overall focus on increasing psychological flexibility comes in—targeting the process of present moment awareness allows a clinician to focus treatment specifically on boosting a client’s flexibility of attention.

2. Self as Context

ACT defines three ways of relating to the self: Self-as-content, self-as-process and self-as-context (Hayes et al., 2011). Self-as-content may play a role in substance abuse if a client tends to over-identify with her role as an addict, failing to see options to behave in ways that defy her ideas of what an addict should or would do.

This inflexibility around behaviors could be an area of focus.

When struggling with emotions, urges and unwanted thoughts, the ability to behave flexibly can be compromised. Self-as-process, which is the continued awareness of one’s thoughts, feelings, cravings and so on, may be an appropriate treatment target in this case.

An ACT clinician would work toward helping a client practice mindful awareness of internal experiences without allowing such experiences to define him.

People who struggle with substance abuse can tend to have an excess of inward-focused energy, which can interfere with potentially helpful perspective taking skills.

Self-as-context, also known as perspective taking, is the third way of relating to the self and involves dropping into the role of observer or noticer of one’s internal experience.

It also involves the ability to shift perspectives from the past, present, or future, and the ability to see things through the perspectives of others. If a client has too much inward focus, it can interfere with his ability to see things from others’ points-of-view, which may be an issue if he’s a member of a tight-knit family unit, for example.

Further, difficulty recalling what life was like prior to his addiction, and inability to envision what post-addiction life might be like, might limit motivation to seek recovery.

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The Nightmare of Trying to Separate or Divorce a Narcissisthttp://pro.psychcentral.com/exhausted-woman/2016/02/the-nightmare-of-trying-to-separate-or-divorce-a-narcissist/ Fri, 05 Feb 2016 00:48:58 +0000 http://5.538 NarcissistNarcissists are partially defined by their lack of intimacy with others. This is most clearly seen in a marital relationship. In a dating relationship however, narcissists appear to be very intimate, almost too much so, which is why a person easily and quickly moves from dating to marriage. Trying to separate or divorce a narcissist brings about a chaotic sequence of events.

  1. Once the knot has been tied, the intimacy quickly evaporates leaving the spouse continually wanting. This is the beginning of a vicious cycle. The spouse becomes almost addicted to the excessive passion the narcissist exhibited during dating. They mistakenly believe that this will last for the rest of their marriage.
  2. When confronted, the narcissist informs the spouse that it is their fault that the intimacy is lacking. If only they looked better, cooked more pleasing foods, said nicer things, acted more appropriate, understood them all the time, and were more sexual than the affection would return. So the spouse tries to do all of these things, only to discover they have still fallen short and even more has been added to the list.
  3. Eventually the spouse grows weary and begins to pull away from the narcissist. They become distant, cold, withdrawn, and indifferent to the excessive demands. Subsequently they stop feeding the narcissist their daily diet of attention, affection, admiration, and appreciation. This is precisely what wakes up the narcissist to trouble brewing in a marriage.
  4. At the root of narcissism is a deep insecurity and often an intense fear of abandonment and rejection. “How could anyone toss aside such a fine speciesism of humanity,” the narcissist thinks. Still unsure, they seek out attention from other sources to verify their superior opinion of self. Once affirmed, they begin the attack on their spouse.
  5. Verbal berating, name calling, threats of divorce, gaslighting, guilt-tripping, and bullying are common first line attacks. This tactic almost always works in the beginning as the spouse dejectedly returns back to the narcissist to try the relationships again. But as the cycle repeats, each time the spouse loses more and more ability to subject themselves to a subordinate position. Eventually they have had enough and pull back for good.
  6. Narcissists tend to be very aware when their source of feeding is drying up. While they lack sensitivity with others, they are hyper-sensitive with themselves. Fearing the rejection even more intensely, the narcissist goes into overdrive. This is when the spouse realizes the game has changed and it has become even more extreme.
  7. First, the narcissist will try to isolate the spouse from friends and family. It becomes a game to “get to” a person first to tell their side of the story (which is never accurate) and paint the spouse as the bad guy. The narcissist happily takes on a victim role in order to garnish even more sympathy and attention. The spouse quickly discovers they have very few supportive friends and family and might even begin to question their perspective.
  8. This is exactly what the narcissist wants because the next step is to create an environment of confusion. This is gaslighting on a much larger scale where the narcissist paints such a picture as to make everyone think the spouse is the crazy person, not them. The spouse often feels as though they are in a fog, unable to see even a few feet ahead much less the bigger picture. The narcissist will claim they never did this or never would say that about virtually anything to reinforce the concept that the spouse is losing it.
  9. Knowing the spouse is vulnerable, the narcissist passionately reaches out to the spouse saying and doing all of the things that worked when they were dating. They say, “I can’t live without you,” “You are the most important thing in my life,” or “Life is not worth living without you being there.” They begin to sound like a mushy Hallmark card complete with elaborate gifts to reinforce their undying commitment. If a spouse returns during this phase, they unknowingly have given up every remaining ounce of self-respect. A narcissist knows this and as soon as they return, the abuse returns even worse than before.
  10. If the spouse refuses to believe the latest transformation, the narcissist will abandon the niceties and begin the vengeful treatment. Literally, “all hell breaks loose” as the spouse is confronted with one drama after another. Usually the hottest fire is not the worst problem. Many narcissists will create a mini fire as a distraction from the real issue. This behavior only reinforces the spouse’s decision.
  11. The “I love you and can’t live with you,” statements are followed almost immediately with “You are the worse person to ever live.” This roller coaster ride of emotions is meant to hurt the spouse for hurting the narcissist. They want the spouse to feel their pain more intensely then they feel it and are rarely satisfied until the spouse breaks down.
  12. This final pattern can last well after the separation, into the divorce and even spill over into new relationships. If the spouse enters a relationship with another person before the narcissist finds someone, then the entire cycle begins all over again. However the narcissist tends to be slightly tamer when they find another person first.

So is it ever over? There will be significant periods of time when it is and then it will start up again over something minor. Eventually the periods of time grow further and further apart. For such a quick decision to marry, the separation/divorce process is far longer, much more grueling, and becomes a complete nightmare.

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

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Coping with Obsessive Thoughtshttp://pro.psychcentral.com/recovery-expert/2016/02/coping-with-obsessive-thoughts/ Thu, 04 Feb 2016 13:56:24 +0000 http://7.183 mindsunderconstructionObsessive, recurring thoughts usually indicate an anxiety condition.

Realize that just having recurring or obsessive thoughts – or any thoughts for that matter – does not mean that you must act on them.  Nonetheless, they are annoying at best.

Obsessive thoughts are embedded in an intricate system of feelings, thoughts, and sensations. Part of the obsession is attempting to stop the obsession by trying to figure out the thoughts and believing that they have power.  Obsessive thinking is akin to riding a merry-go-round: While other people jump on and off the playground equipment, you remain in a fixed position of inertia, going round and round.

Maybe you cannot totally eliminate obsessive thinking, but you can definitely reduce its intensity. Remember, the key to all serenity is acceptance.

Here are some helpful strategies you can use whenever you find yourself obsessing over anything:

  • Realize your thoughts do not possess power in and of themselves, rather they contain useless content. Tell yourself you do not need to “heed their call.”
  • When an intrusive thought comes to mind, take slow, deep breaths from your diaphragm.
  • Accept rather than resist the thoughts, allowing them to simply float through your mind.
  • “Act as if…” Pretend the thoughts aren’t there and continue on with your day. This takes away their power over you.
  • Think about your anxiety level. Give yourself a rating between 1 and 10 in order to evaluate your level of anxiety; watch it rise and fall with curiosity.
  • Tell yourself statements that encourage rather than disparage:  “Everything is fine.”  “This too shall pass.”
  • Sometimes it is helpful to just “give” yourself the concept that your negative thought may actually come to pass, and then you can talk to yourself about how you will cope from that point. For instance, imagine how you would actually handle your biggest fears if they were to happen. If you are afraid of spiders, imagine how you could calmly respond to the occurrence of a spider bite. You could go to the hospital, call poison control, etc.
  • Using the analogy of being on a merry-go-round with your thoughts, imagine yourself jumping off and getting on another piece of playground equipment, like a slide…
  • Give yourself a new obsessive thought, such as working through the alphabet, thinking of something you are grateful for, starting with each letter in order.

Things to Avoid:

  • Do not try to push the thoughts away, nor should you engage the thoughts in anyway.
  • Do not analyze your thoughts or try to figure them out.
  • Do not “horrible-ize” your thoughts. That is, don’t tell yourself, “This is awful.” Awful means nothing and is a tool people with anxiety use to keep themselves on the merry-go-round of negativity.
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How to Improve Your Communication to Improve Your Outcomeshttp://pro.psychcentral.com/how-to-improve-your-communication-to-improve-your-outcomes/0011727.html Thu, 04 Feb 2016 11:40:48 +0000 http://pro.psychcentral.com/?p=11727 how to improve communicationEvery General and Admiral who leads our military understands the importance of tactical communications. Precise decisions based on key information is critical to successful operations particularly when much of the information is communicated using technology.

And, astute business leaders understand that competent organizational communications are required in order to be successful. Whether it be in person or through telecommunications, effective transmission of information lays the keystone to every successful operation.

The same holds true for addiction treatment providers. Effective communication gives providers the ability to maximize their potential for treatment success while continuing to welcome a steady stream of new patients.

Increasingly, addiction treatment providers are being required by health insurance payers to demonstrate their outcomes and rates of treatment success. This movement in the field of behavioral health will continue because this practice has long been an established factor in other forms of healthcare delivery and chronic disease management.

Rates of relapse and recidivism are costly to the provider, the payer and the patient. Relapse from chronic illnesses costs the nation untold billions of dollars each year.

Advancements in Telehealth

In addition to the need to contain healthcare costs, advancements in telehealth are giving the addiction treatment space opportunities to expand their modalities.

With a global acceptance of telecommunications, providers today have an increased ability to maintain contact with patient alumni and offer extended support as they transition from residential treatment to long-term recovery.

Many patients view these communication tools as efficient, convenient forms of treatment support and providers are able to maintain a better connection following discharge.

The addiction treatment field has begun to recognize that extended recovery support for discharged patients helps to increase the likelihood of maintaining long-term recovery.

Early indicators in empirical data report for discharged patients who experience a one-time use event or relapse, can maintain contact during a return to addictive lifestyle. A use event is not ideal, however, communication can be maintained between provider and patient during this time.

Post Recovery Support

Return to recovery without readmission is far more likely when communication had been previously established. Additionally, when patients are discharged with a comprehensive post-treatment recovery support plan, family members, loved ones and friends can be included in the communication network.

Because addiction is a family disease, it is understood that loved ones benefit from support during this transition. Loved ones also offer an additional perspective of the overall recovery process. Addiction affects the family unit and recovery support can provide a powerful resource for everyone affected.

The extended support following treatment suggests the need for fewer readmissions which lowers the healthcare tab. As a result, payers have begun to explore reimbursement models for this provision, providing further incentive to reduce readmissions and pave the way for more patients to receive treatment.

For the provider, successful addiction treatment will result in a healthy revenue stream.

From the payer perspective, it is understood that the quality of the operational process is an important driver of overall performance in healthcare.

The reliable delivery of both evidence-based practices and patient-centered care have long been established as key components to increasing treatment outcomes and maintaining costs.

When treatment success rates are high, readmission rates are low and costs can be better anticipated – payers prefer predictability.

However, when recidivism is high, costs continue to rise. Repetitive treatment is costly and payers consider the expenses of treating a discharged patient who receives post-treatment recovery support for addiction (a chronic-care model) to the expense of one treatment episode (an acute-care model) that is statistically likely to need to be repeated.

With the knowledge that payers have begun to compare the costs of successful patient treatment to the costs of readmission, it is important for providers to demonstrate the value of their services. Payers recognize the disparity among the services that are delivered and the onus for effective communication is on the provider.

Improved communication with payers begins with a thorough understanding of reimbursement systems and processes and improved communication in this landscape will ultimately result in reimbursement. Despite coming from what may appear to be opposing sides, providers and payers want the same thing: long-term treatment success.

Developing a Communication Management Strategy is one way for providers to proactively approach the challenge of communicating their message. Both internal and external communication is important in order to maintain consistent messaging whether it be to staff, patients, payers and/or in advertising or educational efforts.

The development of strategic steps that work to define and guide the mission and vision for comprehensive addiction treatment, including extended care and the measurement of success rates, will help providers stay on track and manage the expectations of both payer and patient.

Five Steps to a Communication Management Strategy:

  1. Patient education and engagement
  2. Payer expectations
  3. Brand messaging
  4. Telecommunications
  5. Reporting success rates

Addiction is widespread and rampant in this country and the disease does not discriminate. It kills the young and elderly, the rich and poor, the educated and illiterate, and everyone in-between.

The drug epidemic is being compared to the devastation of AIDS in the 80’s and the ability to foster communication is a vital element for every provider. Through collecting and reporting outcomes data on discharged patients, providers can demonstrate to payers and consumers the value of their services.

With the provision of post-treatment support, we have entered the stage of addiction treatment where a patient’s discharge date is just the beginning.

General photo available from Shutterstock

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How Forgiveness Changes a Personhttp://pro.psychcentral.com/exhausted-woman/2016/02/how-forgiveness-changes-a-person/ Wed, 03 Feb 2016 17:17:42 +0000 http://5.529 Martin Luther King, Jr.Forgiveness is often prescribed as a remedy for healing from a traumatic experience. It is a very effective tool in bringing closure. Instead of remaining a victim, the offended person can regain control over a trauma by choosing a forgiving response. In many ways this destroys the offender’s influence over the life of another and reinforces the empowerment of the offended.

However, too often forgiveness becomes a task on the counseling to-do list instead of a change of heart. This minimizes the full impact and reduces it to a behavioral, instead of an attitudinal experience. Martin Luther King Jr. said it well when he stated, “Forgiveness is not an occasional act, it is a constant attitude.” So how can a person receive the maximum benefit? Here are some suggestions.

  1. Understand the reason for forgiveness. Forgiveness is not for the offender, it is for the victim. When individuals decide to forgive an act, they are releasing themselves from the controlling power of the offensive event or action. It is not something to be entered into lightly, forced upon through manipulation, or guilt-tripped. Those only add to the trauma rather than healing it. Instead, forgiveness must come from a desire to “Let it go.” This does not mean the offensive act is forgotten, just that it has lost the power to control.
  2. Identify large areas needing forgiveness. Accidents, traumas, abuse, disasters, and death are some of the areas where forgiveness might be needed. Each person and situation is different, so it is unfair to project or judge what or who should be forgiven. This is an individual choice. Sometimes a person needs to be forgiven for an offensive act, sometimes people need to forgive themselves for their contribution, or sometimes there is no one person to accept responsibility, so a blanket forgiveness of a culture, religion, or sect needs to be granted.
  3. Begin a forgiveness list. Writing down who – or what offense – needs to be, or has been forgiven will help to bring clarity to the issues at hand. The 12-step process calls this making an inventory. Think of it as a list divided into two main categories: those actions of others a person needs to forgive and those actions of self in need of forgiveness. This is not a list to be distributed or shared with anyone unless in a therapeutic setting. It is only for the benefit of the person creating the list not the benefit of others.
  4. Counteract unforgiving (obsessive) thoughts. Having a hard time knowing what needs to go on the list? Look to obsessive thoughts to identify areas you revisit over and over. Anything that is replaying again and again, with no new insight or understanding, is obsessive. Other examples include envisioning anger rants, imagining horrible scenarios, having a judgmental attitude about others, pondering negative comments, and deliberating past decisions. These thoughts are indications of possible areas that still need to be forgiven.
  5. Recognize anger, frustration, anxiety, depression, or annoyance as possible indicators of emotions that arise in the absence of forgiveness. In addition to thoughts, intense feelings can identify an area needing forgiveness. A strong emotional response to a person, event, or memory, might require more investigation as to its cause. It is normal to relive some emotion when retelling a traumatic story, however, too much or none at all are signals that some issue needs addressing or possibly require forgiveness.
  6. Make forgiveness a daily activity. Adopting an attitude of forgiveness changes the way a person views life. Think of it as a positive verses negative outlook on life. The lens through which a person views life (positive or negative) influences nearly every decision that is made. The same is true for an attitude of forgiveness. Once embraced, this determines a person’s approach, opinion, temper, outlook, mindset, and reaction. It can transform a person at a deep level.
  7. Create a forgiving mantra. “I choose forgiveness,” can be a simple chant to remember when driving on a highway, listening to someone yell, or recalling a past event. Forgiving even the smallest events can bring about a sense of peace and restoration.

Having an attitude of forgiveness changes an individual’s perspective on even difficult events. However, this is not appropriate for everyone and not possible in every circumstance. Just like it is not possible to be positive in every situation, it is also not reasonable to expect a forgiving attitude for every condition.

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

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Coming Out Mad on a Medical Model Unithttp://pro.psychcentral.com/coming-out-mad-on-a-medical-model-unit/0011521.html Wed, 03 Feb 2016 11:21:32 +0000 http://pro.psychcentral.com/?p=11521 coming out mad`Coming out Mad,’ as a professional with a marriage and family therapy license has been a rocky journey over uncharted and lawless terrain.

I share my experience to help embolden others who have experienced trauma, stigma and institutionalization to do the same.

I believe the field and many who become stuck and ineffectual in it need us badly. I pray that others experience less pain and isolation than I have.

Historically, we may prove to be the key to improving care. But with the current state of the mental health field, some may not welcome or support us.

Mad Rumors Leading to Secrets

Mid-career, I was incarcerated in a border state hospital while trying to escape to Canada to seek asylum.

In later years, I was barely aware that there was a survivor’s community. I was busy scratching to survive in the economy to avoid more institutionalization.

During the licensing process, talking about what I experienced made no sense.

Following years of underemployment, I failed at a three month trial period re-entering the clinical world.

People who either liked me or could sense my desperation kept in touch by inviting me out even though I didn’t drink.

Many let me know that the mad rumor was circulating. One professional told me she was glad when I landed on my feet. She would later admit she had been afraid I was going to end up living in a tent.

Instead of returning to homelessness, I got a solid part-time job on a medical model unit that could lead to more. I also participated in a therapy internship for foster care kids and went back to work at the deli in which I had been underemployed.

Every other week, I got a half a day off. At all three sites, I started off fresh, knowing new people. I  faked it in all locations. Honesty and mental transparency had little to do with it.

Class Deficiency Leading to Silence

Although I was successful at that first foster care internship (perhaps because I lived in a ghetto for six years and had street competency), I got cut at year’s end by a doctor who I offended.

They didn’t tell me that they needed the 10 loyal clients I built up for next year’s doctoral students. Instead, the director let me know that I clearly came from a different class and was incompetent to associate with the rest of the staff because I was so ignorant as to call them by their first names.

I should have known that the fact they called each other by their first names didn’t give me that same entitlement.

In selecting a new internship in order to get child and family hours, I did not think that transparency would pay. I was solidly surviving now. My sense that treatment involved a phony class divide was reinforced. So, I misrepresented myself in order to get hired.

When asked a leading question by an interviewer who looked at my resume (and perhaps the color of my skin,) I contained the salty spite I felt. I agreed that I was ready to come home to insulated suburban reality and start the real work.

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Using Transcranial Magnetic Stimulation (TMS) in Your Practicehttp://pro.psychcentral.com/using-transcranial-magnetic-stimulation-tms-in-your-practice/0011720.html Wed, 03 Feb 2016 11:20:38 +0000 http://pro.psychcentral.com/?p=11720 TMS - transcranial magnetic stimulationTCPR: Dr. Lanocha, please tell us briefly what TMS is and how it works.

Dr. Lanocha: TMS is transcranial magnetic stimulation, and it is basically a clinical application of Faraday’s Law, which states that a moving magnetic field can cause an electrical current to flow. TMS may work by modulating activity in the brain default mode network, which is a set of brain regions that oscillate in a synchronous manner and are thought to be involved in affective processing and mood regulation.

TCPR: And how is this related to depression?

Dr. Lanocha: Functional imaging studies have shown decreased activity in the left prefrontal region in patients with depression, and TMS may stimulate those underactive neurons, restoring them to a normal level of function, which can then persist long after the direct stimulation.

TIPR: Is there any pre-TMS imaging workup required to determine where to place the magnet?

Dr. Lanocha: No, brain imaging is not necessary in order to determine the correct placement of the magnet—there are other methods for determining that. The most common approach is to determine the patient’s motor threshold, which is the magnetic field strength required to produce a visible muscle movement. That is usually done by positioning the magnet over the motor cortex and stimulating the area that controls movement of the thumb. Then the magnet can be moved anteriorly by a certain amount and placed over the left dorsolateral prefrontal cortex.

TCPR: Who is the ideal TMS candidate and who is maybe not such a good candidate?

Dr. Lanocha: Any patient who has failed to respond to initial antidepressant treatment is potentially a candidate for TMS. The FDA product labeling for both the NeuroStar and Brainsway devices states that these treatments are appropriate for patients who have failed any number of antidepressants in the current episode. However, it is likely effective in patients who have not responded to treatments in more than just one episode. The most recent systematic review of rTMS for treatment-resistant depression (defined as depression that has been resistant to at least two prior antidepressant attempts) found that those receiving TMS were three times more likely to respond as those receiving sham TMS (Gaynes BN et al, J Clin Psychiatry 20l4;75(5);477-489). As a general rule, TMS works best when it is given relatively early in the course of the illness before more severe treatment resistance develops. But in my experience it works remarkably well, even for patients with a high level of treatment resistance.

TIPR: So while the research shows that TMS works best in those who have failed antidepressants for a single episode of depression, it sounds like you will often treat people who have failed three or four trials for multiple episodes.

Dr. Lanocha: I have never treated a patient with TMS who has failed only one antidepressant. That just doesn’t happen. All of my patients have failed to respond to multiple medication trials, often over the course of many years. What is interesting is that the duration of illness, number of failed medications, and other factors, such as age, appear to be very weak predictors of response. So it is hard to say that there is an ideal candidate versus a patient who should not be considered for TMS. I don’t think that I or anyone would really advocate TMS as a first-line treatment, however. I think that medication and psychotherapy are still the preferred first line of treatment, and when a patient responds, it’s great.

TIPR: A lot of us understand TMS as sort of a noninvasive form of EIT, perhaps even targeting the same brain areas. Is there a relationship between responsiveness to E|T and responsiveness to TMS?

Dr. Lanocha: No. ECT is a convulsive therapy that produces its therapeutic effect by inducing a generalized seizure that involves the entire brain from cortex to brain stem. TMS is a nonconvulsive treatment that does depolarize neurons, but acts in very discrete areas of the brain. It is also very focal compared to ECT, which is very diffuse. Although the data show that ECT is in general more effective than TMS, I have successfully used TMS in patients who had failed to respond to ECT.

TCPR: Can you walk us through what a practice might need to offer TMS to patients?

Dr. Lanocha: You don’t need a lot of space, but you do need a dedicated treatment room that’s probably at least 10 x 12 feet. Of the two devices that are currently available, the Neuronetics NeuroStar System requires a little bit more space because it is an integrated system that includes a reclining chair. In addition to the equipment and the treatment room, most people are also going to want to have a TMS technician to assist them with administering the treatment. It is necessary to track personnel costs in addition to the capital investment of the device itself.

TCPR: What is that capital investment and then what are the recurrent costs?

Dr. Lanocha: The capital investment for the system itself is about $65,000, and the devices can be either purchased or leased. The Neuronetics System, which I use, requires a single-use disposable component for each treatment, but operating costs for both systems are determined by use and are roughly equivalent over the course of the year assuming similar use.

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Utilizing the Present Moment in Sessionshttp://pro.psychcentral.com/utilizing-the-present-moment-in-sessions/0011501.html Tue, 02 Feb 2016 12:52:54 +0000 http://pro.psychcentral.com/?p=11501 utilizing the present moment in therapy sessionsMindfulness has come a long way from the fringes of psychotherapy to a widely used, empirically-supported tool with a host of proven benefits. But when it comes to communicating about present moment experiences and intervening with those experiences, clinicians often fall short.

As humans, it’s not surprising that clinicians struggle to stay present enough to be effective when painful or difficult emotions arise. Our brains have evolved to respond to threat by either fighting or fleeing. It isn’t our fault.

A Road Map

But because there was an evident need for better tools to utilize the present moment in therapy, psychologists Kirk Strosahl, Ph.D., and Patricia Robinson, Ph.D., developed a road map to help.

“As clinicians we have a really hard job. It’s hard to stay present with our clients. Working on this is an ongoing challenge for most of us,” says Robinson, who has pioneered the use of the mindfulness-based Acceptance and Commitment Therapy in primary care and other brief intervention settings.

“When you’re sharing a moment of intense personal pain with somebody, something that maybe they haven’t made contact with in years, it takes a willingness to stand in the moment and to not run away yourself, because that’s what your client is going to try to do.

Our model helps clinicians strengthen their ability to stay centered in the moment, aware of the client’s pain and the pain that it may elicit in themselves, and to use that pain, rather than run from it,” says Strosahl, a clinical psychologist and co-founder of Acceptance and Commitment Therapy.

Getting a client into the present moment is just one phase of Strosahl and Robinson’s intervention model which aims to help clients make contact, experience, and ultimately use their emotions to move forward in the direction of their values.

The five phases are:

1. Notice
2. Name
3. Let Go
4. Soften
5. Expand

Each phase is described in-depth in their book, “Inside the Moment: A Clinician’s Guide to Promoting Radical Change Using Acceptance and Commitment Therapy” along with chapters covering how to apply the model to a range of populations including those struggling with post-traumatic stress, addiction, and lifestyle changes.

Part of the confusion around doing mindfulness exercises may boil down to a lack of clarity about the function they serve as part of the therapeutic process. The goal is to drop into the raw experience of an emotion, in order to access the natural healing power of emotions in their pure form.

“The point of coming into the moment and working in the moment, is to accept what is going on and to use it to transform how the person is living his or her life. A lot of times this involves re-framing what’s going on in the moment, calling out the importance of the experience and helping the person come back, stay there and find a new way of holding that very difficult experience that they’ve avoided sometimes for years, multiple times everyday.

In the process, clients come to realize that the experience of their emotions is not actually that toxic. But it’s usually connected to something very important to them,” says Robinson.

“People sometimes think that emotions are dangerous but the mind is the thing that makes emotions dangerous, not the emotions themselves,” says Strosahl.

But when a client is caught in the throes of harshly judging and evaluating their pain, as we humans tend to do, it may be difficult to tell him or her that the pain is, in fact, benign.

“This model actually works better when the emotion is terribly painful, like when a client has been traumatized as a child or carries some unresolved loss or grief. We try to teach people that emotions are not the enemy. It’s your mind’s evaluations of what emotions mean that is toxic, because that fuels the fires of emotional avoidance,” says Strosahl.

An Active Approach

Strosahl believes that while mindfulness is an important tool, being in the present moment may not be inherently useful. This belief can be a source of stagnation or confusion for clinicians who are new to or wish to begin incorporating mindfulness-based practices in sessions.

“There’s this assumption that something magical will happen on its own and all you have to do is get there, but I don’t think that’s how it works. I think there has to be an active approach to processing what is unfolding in front of the clients as they go through their pain,” says Strosahl.

Strosahl is a primary care psychologist in a community mental health center. Sometimes the typical mindfulness vernacular doesn’t resonate with clients, and just as often, they’re not interested in or able to practice building their skills outside the session. His extensive experience working with these challenges is evident in his and Robinson’s approach; they specialize in making a little go a long way with a model suited for brief interventions in a range of settings.

“I don’t care how weak a client’s mindfulness skills are. With guidance, they can learn how to be present and learn how to directly experience what is there and heal from it. If people are interested in practicing those skills as a result of the interaction, more power to them. We’ll help them do that,” says Strosahl.

Therapy session photo available from Shutterstock

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How Wives Contest the Australian Open Men’s Tennis Finalhttp://pro.psychcentral.com/how-wives-contest-the-australian-open-mens-tennis-final/0011660.html Mon, 01 Feb 2016 10:52:13 +0000 http://pro.psychcentral.com/?p=11660 how wives contest the Australian Open

The Australian Open Tennis final is contested by Novak Djokovic and Andy Murray, who both relatively recently got married.

There is a new theory in psychology that contends marriage impacts the male competitive spirit and even suggests that it’s these background issues in the personal lives of elite players that could ultimately dictate the outcome of sporting contests like the Australian Open Tennis Final.

A study entitled, “Marriage affects competitive performance in male tennis players,” by psychologists Daniel Farrelly and Daniel Nettle, found that professional male tennis players perform significantly worse in the year after their marriage, compared to the year before, whereas there is no such effect for unmarried players of the same age.

 The authors of the study, published in the Journal of Evolutionary Psychology, suggest that following marriage, men experience a psychological mechanism that has evolved over many generations from our ancient past, and which inevitably leads to less motivation to engage in competition.

Farrelly and Nettle investigated male tennis players who appeared in the top 100 players in the ATP singles rankings at the end of each year from 1995 to 2005.

The Impact of Marriage

Their investigation found married players suffered a significant decrease in ranking points between the year before getting married, and the year after, whereas there was no such difference in performance for unmarried players, during the corresponding time period.

Married players also suffered a significant decrease in winning percentages between the corresponding years, whereas there was no such difference in performance for unmarried players.

But married players may not be suffering decreased competitive drive, but merely less ability to commit to tournaments around the world. The authors of this study, based at the University of Worcester and the University of Newcastle, argue that their results indicate this scenario does not seem to be the case.

Success in actually winning matches significantly decreased following marriage.

This result is possibly produced by reductions in the levels of hormone Testosterone, which men experience as a result of marriage. Testosterone is found in much higher levels in men compared to women, and is associated with aggression, competitiveness, dominance and risk-taking.
Testosterone is thought to be important in winning in sports and other adversarial encounters between men.

Psychologists argue that men compete in sports, and other activities (practically anything in fact), to become ‘top dog’ as this image then makes them more attractive to the opposite sex.

The need to beat others is therefore an evolved motivation in male psychology. It could be said to be genetically wired into the male brain.

In ancient times, moving up the hierarchy of the tribe was a sexual strategy for men. Being seen as superior in physical and mental prowess gains greater opportunities to mate with more desirable women, through increased status, according to this theory.

Competing successfully in adversarial encounters with other men, in our ancestral environments, led to maximizing male reproductive success – passing on more genes to future generations.

]]> The Neurobiology of Panic Attackshttp://pro.psychcentral.com/the-neurobiology-of-panic-attacks/0011602.html Sun, 31 Jan 2016 11:54:10 +0000 http://pro.psychcentral.com/?p=11602 The Neurobiology of Panic AttacksPanic attacks are extreme manifestations of anxiety, which are intermittent and discreet episodes where you experience increased heartbeat, chest pounding, chest pain, heart palpitations, shortness of breath, numbness and tingling in your arms and legs, excessive sweating, tunnel vision, muscle tension and trembling.

Panic attacks can occur in different situations. If you have social anxiety, then exposure to social situations can induce a panic attack. If you have a fear of an object (i.e. spiders) or situation (i.e. flying), then exposure to your feared object/situation can also lead to a panic attack.

Finally, if you experience uncued, random and spontaneous panic attacks, then this reaction may be a manifestation of panic disorder.

So what’s the neurobiology behind panic attacks? Well, a panic attack is a manifestation of your fight or flight response being triggered intensely, for a brief period of time. The fight or flight response is illustrated by the following flowchart:

neurobiology-panic-attacks-flow-chart

So when you sense fear, this triggers the amygdala, which is located in the temporal lobes of the brain. The activated amygdala then activates both the sympathetic nervous system (neuron-based) and the HPA axis (hypothalamic pituitary adrenal axis) (hormone-based).

In activating the sympathetic nervous system, the amygdala activates the locus coeruleus, which is located in the brain stem. The activated locus coeruleus in turn sets off the sympathetic nervous system, where the sympathetic neural impulse sets off various organs directly, such as the heart (increased heart rate and contraction), blood vessels (dilates in skeletal muscles, constricts in gastrointestinal organs), sweat glands (increased perspiration), and eyes (dilates pupils).

In addition to the above organs, the sympathetic neurons directly innervates the inner part of the adrenal glands, called the adrenal medulla. The adrenal glands are located on top of each kidney. When the sympathetic neurons activate the adrenal medulla, adrenaline (epinephrine) and noradrenaline (norepinephrine) are released into the bloodstream.

The circulating hormones of adrenaline and noradrenaline then act on various organs such as the heart (increased heart rate and contraction) and the lungs (dilates the bronchioles, or air sacs) to further perpetuate the panic attacks symptoms.

In activating the HPA axis, the amygdala activates the hypothalamus (located just above the brain stem), which in turn secretes corticotropin releasing factor (CRF). CRF travels to the pituitary (located at the base of the brain), and activates it to secrete adrenocorticotropic hormone (ACTH).

ACTH then travels to the adrenal cortex, which is the outer part of the adrenal glands. ACTH activates the adrenal cortex to secrete cortisol, another stress hormone, into the bloodstream. Cortisol is involved with increasing the supply of blood glucose to fuel the panic attack and also suppresses the immune system.

Another manifestation of a panic attack is hyperventilation, where you are breathing fast and can’t seem to catch your breath. As a panic attack starts, you will breathe faster and become short of breath, as the fear-activated amygdala in turn activates the parabrachial nucleus, which is located in the brain stem.

As your rate of breathing accelerates, you will resort to chest breathing, instead of belly breathing, or breathing from your diaphragm muscles. As you increase your rate of breathing, you start to hyperventilate, where you are blowing off too much carbon dioxide (CO2) from your chest breathing.

This situation leads to respiratory alkalosis, which is a rise in blood pH, and can cause numerous symptoms adding to the panic attack, such as dizziness, weakness, fainting, headache, tingling in the hands and feet, and seizures.

The remedy for hyperventilation with a panic attack is to breathe into a paper bag, so that you can recycle the CO2 back into your bloodstream, normalizing your blood pH, and hence reducing your panic attack symptoms and normalizing your breathing.

For more information and help on panic attacks and other anxiety symptoms, please visit AnxietyBoss.com.

 

Flowchart reproduced with permission from AnxietyBoss.com.

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The Uses of Pharmacogenetic Testing in Psychiatry: Medication Intolerability and Resistancehttp://pro.psychcentral.com/the-uses-of-pharmacogenetic-testing-in-psychiatry-medication-intolerability-and-resistance/0011560.html Sun, 31 Jan 2016 10:00:35 +0000 http://pro.psychcentral.com/?p=11560 Genetic Testing in PsychiatryTCPR: Dr. Hamilton, why would a psychiatrist want or need to order genetic testing on a patient?

Dr. Hamilton: I tend to consider genetic testing for two specific types of cases. One is serial intolerability—poor tolerance of multiple medications, for instance, across SSRIS or even between classes of medications. This gets me wondering if a person has some perturbation in their metabolism; a genetic variant that might affect how they process these drugs. The other indication is when a patient shows resistance to antipsychotics or to antidepressants.

TCPR: Can you summarize briefly some of the genes that are tested in pharmacogenetic testing in psychiatry?

Dr. Hamilton: Because of their connection to a broad swath of psychotropic drugs, it really boils down to two cytochrome P450 genes: 2D6 and 2C19. This is because nearly all psychotropics are metabolized to some extent by the enzymes encoded by these genes. More importantly, there is ample genetic variation in these genes, specifically related to people being poor metabolizers, and these are fairly common in the general population. And with CYP2D6, there is an added level of complexity in that you can have individuals who are what we term ultra-metabolizers, meaning their gene products work at a much higher rate of efficiency than the normal level of functioning.

TCPR: You talk about people being normal metabolizers or poor metabolizers on these genes. What is the evidence that metabolizer status correlates with blood levels of medication and/or clinical outcome?

Dr. Hamilton: There has been a lot of effort put into looking at the correlation between drug levels and polymorphism status. The evidence is good in the case of tricyclic antidepressants. The classic study from the ‘90S showed that nortriptyline levels were highly correlated with metabolizer status for 2D6 (Dalen P et al, Clin Pharmacol Ther 1998;63(4):444-452). Those who were ultra-metabolizers had almost unmeasurable amounts of nortriptyline in their system. SO there are a few clinical observations, such as this, but these are typically clinical pharmacokinetic laboratory studies. What’s really missing are large prospective studies looking at actual clinical outcomes based on metabolizer status.

TCPR: Do you think it is possible that there is a sort of intuitive pharmacogenetics going on all the time in psychiatry? That patients who are regular or poor metabolizers end up on the appropriate dose of medication through the normal process of monitoring and titrating medication?

Dr. Hamilton: Some research shows that, yes, clinicians frequently alter the dose of an individual’s medication in the direction that fits, using a sort of intuitive pharmacogenetics. An older study looked at the genotypes of people taking risperidone (Risperdal). Investigators looked at individuals’ doses of risperidone over time, and later looked at their genotypes. YOU would expect that individuals who were poor metabolizers probably couldn’t tolerate higher doses because it was cleared less efficiently. Sure enough, individuals who had poor-metabolizer status were placed on lower doses, even though the clinicians did not know anything about their P-450 enzymes (Mas S et al, 2012 Pharmacogenomics J;12(3):255-259).

TCPR: The massive STAR*D trial found no individual antidepressant strategy to be better than any other. Is it possible that applying pharmacogenetic strategies to patients in order to guide treatment might have led to better outcomes in a study like STAR*D?

Dr. Hamilton: My own work was involved with genetic studies of the STAR*D sample. We carried out a retrospective genome-wide association study (GWAS) of the STAR*D data. The results we found and published did not meet the standard levels of statistical significance, and were not robust enough to have warranted changing the treatment, even if we had that information before the STAR*D study began. There is an exception to that. We found that CYP2D6 or CYP2C19 metabolizer status did not predict response, and published that finding some time ago (Peters EJ et al, 2008 PLoS One, 3(4):el872). However, in work that we did not publish then, we looked at 2D6 and 2C19 metabolizer status and found that the rates of intolerability—defined by STAR*D as whether an individual could continue taking the medication based on side effects—was correlated with 2D6 and 2C19 genotypes. Knowing that ahead of time may have been useful, because one of the primary predictors of antidepressant response in STAR*D was drug intolerability.

TCPR: Are there any guidelines for the use of pharmacogenetic testing to optimize drug therapy?

Dr. Hamilton: There are about 25 psychotropic drugs for which the FDA has guidance for pharmacogenetics (these can be found at http://l.usa.gov/lcCZvmr). It is an interesting list that I would urge clinicians to check out. Another resource is the Clinical Pharmacogenetics Implementation Consortium (CPIC), a partly NIH-funded group of researchers, in this field, who have come together to create guidelines (www.pharmgkb.org/page/cpic). They provide recommendations for a broad array of medications, including several tricyclic antidepressants.

TCPR: Isn’t it true that behavioral factors contribute to drug response in a way that might outweigh the genetic factors?

Dr. Hamilton: Absolutely. Genetics only make up a small part of the likelihood of drug response or tolerability, and other issues are strong contributors. Other exogenous substances, such as tobacco or dietary supplements, may interfere with the metabolism of antidepressants and other metabolic issues related to age, disease (eg, hepatic disorders), and gender can influence these things. Genetics likely plays some discrete, but measurable, role, but it needs to be taken into account with all these other nongenetic factors.

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Healing from Childhood Sexual Abusehttp://pro.psychcentral.com/recovery-expert/2016/01/healing-from-childhood-sexual-abuse/ Sun, 31 Jan 2016 08:15:01 +0000 http://7.177 childabuseSexual abuse can profoundly damage a child’s sense of value, mainly by the perpetrator of the abuse, and secondarily by the non-abusive parent who either doesn’t believe the child, or somehow is oblivious to the abuse happening right in their own household. .  So often child sexual abuse occurs in families, and in social contexts in which the family knows and trusts the perpetrators.  Sometimes children are sexually abused within families in which the non-abusive parent resides mentally in a world of make-believe where no problem exists.

If you have been victimized by emotional incest, physical touch, rape, voyeurism, frotteurism, fondling, inappropriate conversations or non-verbal communication of a sexual nature or in any other way used by a person of more power than you as an object, then these steps will help you overcome the impact of your objectification and emotional hurt.  There is no greater injury than being a small child who is used for the sexual gratification of an adult.  Following is a list of healthy steps to take in order to heal and recover from sexual abuse:

  1. Break your silence. The saying, “you’re as sick as your secrets” definitely applies to childhood sexual abuse.  Children and adults who have been subjected to the dishonorable experience of having an adult use them for their sexual gratification, have no desire, ever, to tell anyone of their secret, because of their deep seated feelings of shame and humiliation.  However, the only way to heal from this horrendous crime is for the victim to “find her voice.”
  2. Journal often about how you have been personally affected by the abuse. List how you were betrayed by those who were supposed to protect you and nurture you. List and describe the different ways you suffered and what you lost because of the abuse. It is important to assess and face the damage in order to heal.
  3. Face the Shame. There is great healing to be found in facing the shame your perpetrator put on you; talk about it, and place it off yourself and back on the shoulders of the person responsible for abusing you.  Facing your shame and giving it back to your abuser (figuratively) helps you embrace your vulnerability and see yourself in a new light.
  4. Grieve your losses. In order to recover from abuse, it is necessary to fully discover and complete the pain caused by your losses.  You may feel many losses from being abused, such as, a loss of safety, comfort, innocence, trust, a childhood; a loss of being seen, known, and valued, etc. Think specifically about how your life has been impacted by abuse and write each loss, fully allowing yourself to grieve.  Write about how you’ve been betrayed. Share your experience with a safe listening partner.
  5. Be Compassionate with yourself. Do not abuse or neglect your value and needs as others have.  Learn to talk to yourself with kindness and acceptance. Do not condemn yourself for the past or in the present.  Recovery is a lifelong process and developing a constant “inner compassionate companion” will help the rest of your life be a satisfying experience.  No longer do you have to be victim to others and to the negative dialogue within your own head. Remind yourself that being abused is not the fault of the victim, for any reason, ever.

Remember that sexual abuse is a form of trauma, and that those who have been affected, suffer with post-traumatic stress.  Healing requires patience, understanding, safety, and validation.  Therapists helping victims of abuse should offer clients a safe space and presence for facing difficult emotions, and should allow clients to work at their own pace.  If a child was abused prior to age six, his memories may be repressed. Never imply that abuse occurred by putting ideas into your client’s mind, just listen to him as he remembers feelings, sensations, hurts, and allow him to talk about events when he’s ready.

When individuals are in therapy, learning to talk about their experiences and feelings, they will most likely have dreams, which are in effect, the mind’s effort at working through the deep feelings. Encourage your client to discuss his dreams, noting that dreams are metaphors. Have him personalize what each object in the dream signifies metaphorically.

Help clients realize that their healing is not dependent on confronting their abusers, but that healing, really is a matter of coming to terms with the abuse internally.  Many times, confronting abusers can be very invalidating and counterproductive for victims of abuse. Remind clients that all abusers (especially sexual predators) are master manipulators, and when confronted will tend to do some strategy to minimize, project, deny, or otherwise invalidate the victim’s position. It is better for the victim to just adopt a policy of “no contact” with their abuser and if a confrontation is needed, then have it done merely on paper and read to a therapist.

The more all of the feelings with the abuse are processed by the victim, the more thoroughly the trauma is worked through and felt to completion. There will come a day when the victim will no longer need to process her feelings and she will realize she has been set free.  Over time, the negative feelings and thoughts of abuse will dissipate, and not due to repression, but rather due to facing them and feeling their impact in the safe presence of a good therapist or other listening partner.

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The Dark Underbelly of Psychiatryhttp://pro.psychcentral.com/the-dark-underbelly-of-psychiatry-2/0011614.html Sat, 30 Jan 2016 15:00:09 +0000 http://pro.psychcentral.com/?p=11614 the dark underbelly of psychiatry

I conceptualize psychotherapy as a contemporary spiritual path designed to address the vicissitudes of human suffering through an elaborate understanding of the human condition.

By holding a sacred space with humanity and insight, illusions can be stripped away and truths unlocked. Suffering can be assimilated, so that healing can occur and actualization can unfold. As Jean Vanier wrote in Becoming Human:

“I have discovered the value of psychology and psychiatry, that their teachings can undo knots in us and permit life to flow again and aid us in becoming more truly human.”

Indeed, in its purest form, the principles of psychology embrace the merits of discerning one’s inner self and the transpersonal meaning of life.

Nonetheless, life and history reveals to us that more often than no,t idealism succumbs to moral depravity and ideologies become corrupted. One of our greatest challenges as a species is to defy power’s temptation.

“None of us stands outside humanity’s black collective shadow” (C.G. Jung)

C.G. Jung’s contention that noble aspirations and virtuous ideals conflict with the unconscious shadow aspects of the psyche supports the notion that on a collective level, the human species embodies a universal primordial proclivity for evil.

Proclivity for Evil

Regrettably, this proclivity for evil is starkly evident in historical trends of stigmatizing mental disorders, and asserting malevolent social control over those who require compassionate treatment. Further confirmation of this egregious propensity is evident In Clockwork Orange-like inquisitions directed at vulnerable disenfranchised populations.

Founder of Bioenergetic Analysis Alexander Lowen said:

“Beneath the seemingly rational exterior of our lives is a fear of insanity.”

According to Jung, what we fear becomes a shadow projection, whereby we vilify those who embody the traits we despise within ourselves.

Those qualities we find intolerable within ourselves can unconsciously be righteously projected onto select others, who become defined as inferior, scapegoated as deviant and even designated as evil. Ergo, those who personify our feared madness are dehumanized and stigmatized.

Sociologist Erving Goffman defined stigma as “a phenomenon whereby an individual which is deeply discredited by his/her society is rejected as a result of the attribute.”

Goffman emphasized the role stigma plays in psychiatric diagnosis and treatment by expounding on its insidious barrier to recovery and the dehumanization and de-personalization that stimulates further damage and marginalizes victims.

The characterizing of women as naturally masochistic, prone to victimization and morally undeveloped (Freud) is a grim example of psychiatry’s role in promulgating shadow projections and stigmatization.

Early in his career, many of Freud’s female patients frequently reported sexual abuse, most often naming their fathers as the abusers.

Initially Freud attributed his female patients symptoms to repressed memories of sexual abuse trauma.

That these symptoms were so prevalent throughout Viennese society meant that child abuse was rampant.

According to Freudian scholar Dr. Jeffrey Masson, Freud dodged the prospect of scandal and political suicide by discrediting his findings of sexual abuse. Rather, he revised that these traumatic memories were in fact unconscious fantasies.

One of the tragic repercussions of Freud’s decision is documented in Louise DeSalvo’s book “Virginia Woolf: The Impact of Childhood Sexual Abuse on her Life and Work” (1989). DeSalvo postulates that Virginia Woolf’s confusion about Freud’s Oepidal theory, which states that children fantasize their sexual abuse, contributed to Virginia’s decision to commit suicide.

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How to Handle Controlling Peoplehttp://pro.psychcentral.com/exhausted-woman/2016/01/how-to-handle-controlling-people/ Fri, 29 Jan 2016 17:52:36 +0000 http://5.523 controlling peopleCan controlling people be successfully managed? It depends on the type of behavior and the willingness to try several tactics. A controller can be a friend, neighbor, boss, co-worker, spouse, or parent. Here are several ways to effectively deal with them.

  1. Identify the type of controlling behavior. There are many ways a person can be unscrupulous. They can tell lies about the victim’s family members or friends in an attempt to create a dependency on their opinion. They can embarrass, humiliate, or shame to make the victim feel small. Or they can deliberately set up scenarios where the victim explodes so the controller can justify their domineering behavior.
  2. Don’t believe the lie. Controlling behavior is not about the victim, it is about them. They are the broken ones who feel the need to manipulate. A domineering person insists that the reason for their cunning behavior is because of the victim’s attitude, actions, tone, or body language. This is a lie. There are many ways to confront a person in a healthy manner without the use of serpentine behavior.
  3. Recognize the triggers and patterns. A controller often uses the same pattern of dysfunctional behavior over and over again in a variety of environments. It is far easier for them to repeat familiar offenses than it is to discover and test out new ones. Once recognized, this becomes an easy way to identify the possible triggers. Knowing the spark, allows time to either plan an appropriate response or an escape route.
  4. Carefully choose a response. Do not directly answer a control tactic. This is precisely what the controller wants and most likely they have planned out responses to whatever is stated. Their goal is to incite the victim to a defensive subordinate position so they can overshadow. Instead, choose from one of these responses.
    1. Ignore and walk away. When the controller seeks out secret information about the victim and uses it later as a tool for embarrassment, this is a good moment to ignore and walk away. Indulging their historical revisionism will only increase the humiliation as the victim responds defensively. Stepping aside politely and quietly will highlight the dysfunctional behavior for anyone else who might be around.
    2. Distract or change the subject. When hour long explanations are given for simple issues in an effort to wear the victim out, distraction is the best method. Usually the controller has an almost rehearsed speech so when interrupted, they can’t easily return to where they left off.
    3. Ask a question. When the controller fails to see shades of grey making an issue either their way or a complete opposite extreme, this is the time to ask a question. Preferably a question which reinforces the concept that there is more than two options available. Do not ask “Why” questions however or the controller is likely to become defensive and react in a verbally aggressive manner.
    4. Apply logic to the statement. When a guilt trip is given such as “I gave birth to you therefore you have to …,” this is a great time to apply logic. Counteract the guilt with reason, never emotion. “You taught me that I don’t ‘have to’ do anything,” is an appropriate response instead. Have a couple of statements prepared ahead of time for use.
    5. Answer the fear. When the controller is jealous of the relationship between the victim and another friend, respond to the fear of abandonment. Actually say the words, “I hear that you are fearful I will leave you for someone else.” Then only speak about that topic, refusing to divert back to the obsessive envious comment.
  5. Try, try again until done. When one method fails to work, try another one and if needed, another after that. But at some point the relationship might have to come to an end. As the Kenny Roger’s song The Gambler goes, “Know when to walk away, know when to run.” A controller who resorts to more extreme forms of manipulative behavior is not worth the trouble of having a relationship.

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

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Belsomra for Insomnia: A New Hypnotic? Don’t Get Too Excitedhttp://pro.psychcentral.com/belsomra-for-insomnia-a-new-hypnotic-dont-get-too-excited/0011575.html Fri, 29 Jan 2016 13:02:13 +0000 http://pro.psychcentral.com/?p=11575 Insomnia medicationIn the wake (pun intended) of last year’s FDA warnings of next- morning impairment and the lower dosing recommendations for “Z drugs,” wouldn’t now be the perfect time for a new hypnotic to enter the marketplace?

Suvorexant, which will be marketed by Merck & CO. under the brand name Belsomra, was approved by the FDA in August 2014. It truly is a new chemical entity with a first-in-kind mechanism of action. Unlike currently marketed hypnotics, suvorexant does not exert its hypnotic effects via activity at receptors for GABA, histamine, or melatonin.

Considered a “DORA” or dual orexin (0X1 and 0X2) receptor antagonist, suvorexant alters the signaling of orexins. Orexins are neurotransmitters that regulate the sleep-wake cycle by promoting wakefulness through excitement of brain regions involved in arousal and attention.

But what does this mean clinically? Does it work? Is it safe? What about long-term use?

What Studies Show

Several pre-clinical trials have examined the efficacy and safety of suvorexant in 1,784 patients with insomnia, with 160 patients taking the drug for one year or longer. Compared to patients taking placebo, those taking suvorexant tended to go to sleep more quickly (depending on the study and the dosage used, an average of about two to 22 minutes faster) and spent less time awake throughout the night (on average, about 20 minutes more total sleep time). In general, the higher doses (30 mg to 40 mg) tended to be more effective than the lower doses (15 mg to 20 mg). These studies all compared suvorexant with placebo, so unfortunately there is no data allowing us to compare it with the hypnotics currently in use.

The most common side effects were somnolence, headache, abnormal dreams, and dry mouth, which were reported in about 2% to 8% of patients in the studies. There were also some rare side effects (reported in less than 1% of patients) that could become quite problematic. These include sleep paralysis (inability to speak or move for up to a few minutes during the sleep-wake transition), cataplexy (leg weakness for seconds up to a few minutes, reported both in the nighttime and daytime), and hypnagogic hallucinations (including vivid and disturbing perceptions).

The Fight for FDA Approval

An interesting part of the history of this drug is that Merck expected to gain FDA approval in the summer of 2013. However, the FDA expressed concerns about safety with the 30 mg to 40 mg dosing range Merck was proposing and denied approval. The approval finally came in August with the newer, lower dosing range of 10 mg to 20 mg nightly. The next-day driving tests requested by the FDA showed that even those who took the 20 mg dose were impaired in the morning. For this reason, the recommended dose is 10 mg nightly, however, the labeling does allow for dosage increases up to 20 mg nightly. Along with the concern for next-day impairment, the usual warnings for hypnotics also apply here: avoid alcohol and other CNS depressants, exercise caution in patients who are depressed or suicidal, monitor for behavioral changes including amnesia and complex sleep behaviors (eating, texting, sex while still sleeping).

Suvorexant will be available as 5, 10, 15, and 20 mg tablets by late 2014 or early 2015. It will be a schedule IV controlled substance (same category as Zolpidem (Ambien) and temazepam (Restoril), among others) although the data thus far have not shown withdrawal and rebound upon discontinuation.

TCPR’s VERDICT: Other than a new mechanism of action, there’s not much to recommend suvorexant. It likely works just fine as a sleeping pill, but there’s no reason to expect it to work better than the many hypnotics already on the market. We’re concerned that next-day impairment is a potential side effect at the highest approved dose of 20 mg, particularly since sleepless patients may decide on their own to take even higher doses. Be very clear to patients about the potential dangers of driving the next morning. Suvorexant also will likely be expensive, and only a couple of thousand people have been exposed thus far, mostly in short-term trials. This is definitely not a first line medication—nor even a second line.

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The Psychoanalysis of Politicians Like Donald Trumphttp://pro.psychcentral.com/the-psychoanalysis-of-politicians-like-donald-trump/0011490.html Fri, 29 Jan 2016 12:58:56 +0000 http://pro.psychcentral.com/?p=11490 the psychoanalysis of politicians like Donald TrumpDonald Trump’s extraordinary success represents a political paradox to many opponents who reject what they perceive as his extremist xenophobic, simplistic politics. Critics continue to be perplexed as to why the richest man to run for President attracts such passionate support from the poorest white constituency.

Or are politicians like Donald Trump simply more astute psychologists than their rivals?

Jay Frankel, from the postdoctoral program in psychotherapy and psychoanalysis at New York University and the Institute for Psychoanalytic Training and Research, has recently published a paper entitled “The traumatic basis for the resurgence of right-wing politics among working Americans.”

He suggests that grasping the appeal of a candidate such as Donald Trump requires psychoanalyzing the electorate’s relationship with him. What, internally, does he represent to them? Simple politics isn’t enough to account for all that Donald Trump symbolizes.

Making It

The more conventional interpretation for why an impoverished electorate poll for the super-rich is they also hope to ‘make it.’ Politicians like Donald Trump represent an aspirational vote. Hence, why voters underclass, destined never to realize the ‘American Dream,’ believes a billionaire, enjoying a lifestyle completely alien to their own, will indeed represent their interests when elected.

Jay Frankel points out, contrary to the national myth, intergenerational income mobility in the U.S. is worse than in most other developed countries. Maybe certain politicians, perhaps like Donald Trump, grasp that popular electoral appeal is often more about fantasy than reality.

It is notable, Frankel writes, that the U.S. is on track to become a “majority-minority” country, with non-Hispanic whites drifting into the minority in just 30 years. Perhaps this injects a sense of paranoia among swathes of the white population, a feeling rendered more acute by the election of a Black president.

This group may also feel abandoned by their own society because of the economic consequences of the recent recession. Both financial and cultural shifts lead this part of the electorate to have lost a sense of a secure place in their own nation. If you no longer feel you belong to your own country, maybe this especially heightens paranoia and anxiety in a way that can be exploited by a canny candidate.

Identification with the Aggressor

In particular, Frankel believes that these various psychological forces combine to allow into the election the famous psychoanalytical concept of ‘Identification with the Aggressor.’ It is this powerful unconscious force which may be driving underclass support for remote elites.

Fearful unease about survival and abandonment drive ‘Identification with the Aggressor.’ Increased fears of a terrorist threat following the attacks of September 11th, 2001 have also been exploited by the political right, compounding a widespread sense of insecurity across the USA.

Frankel contends that what happens in an abusive family may be analogous to what unfolds in an unjust harsh society.

‘Identification with the Aggressor’ might therefore resolve the paradox of why those who have been most economically dispossessed are often more likely to support political movements that appear to oppose their own economic interests.

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Emotional Rehabilitation: Recovery from Losshttp://pro.psychcentral.com/emotional-rehabilitation-recovery-from-loss/0011519.html Thu, 28 Jan 2016 12:57:16 +0000 http://pro.psychcentral.com/?p=11519 emotional rehabilitation: recovery from lossPhysical illness has an emotional reaction such as anger, shock, denial or acceptance.

In most cases, the onset of a medical problem or condition has a range of underlying emotions. Illness imposes an impact on the person, moving from a place of freedom to a loss of control or to a type of confinement.

Rehabilitation is a course of therapy, a journey, to recover and return a person to her prior level of functioning, to the best of her abilities following an illness, surgery or injury. Unlike physical rehabilitation, where you are subjected to the manipulation of physical, occupational, respiratory or speech and language therapists; emotional rehabilitation is the strengthening of one’s emotional ability to cope with a loss or change in their lives.

Working Through Loss

Emotional rehabilitation is a method of steps to work through the pain of loss and to return to a stable and healthy place.

A person must use the emotional muscles inside her heart and mind to help her get there and utilize resources to help move forward. As the individual builds her emotional core, she will also return to a stronger self– filled with determination, confidence and competence.

Emotional muscles are typically invisible. Other people have a spectrum of emotional use from poor to capable, with varying skills reflecting the different degrees of emotions, how they are processed and expressed.

In order to do emotional rehabilitation, one must be prepared and ready to process the pain and associated thoughts, typically ambivalent feelings. Some people have never had an opportunity to use these specific muscles because of their own past history and need to be taught how to identify their feelings and thoughts about themselves.

The 4 “S”s in Muscle:

Stretch: Let yourself loosen up the feelings, give yourself permission to cry and get rid of the tension building up in your body. In essence your facial, neck, head, stomach and lung muscles get a work-out.

Slowly: One must not move too quickly or else will not really own the emotion, acknowledge and process the pain. One can’t skip the process as the pain may return when one least expects.

Strengthen: Using various methods to improve one’s emotional response to the loss is necessary in order to adjust one’s thinking, feeling and insight. This approach takes practice, exercises and support to move forward.

Stronger: At the end of emotional rehabilitation, one’s skills and abilities to cope will be improved. The outcome is improved positive self-regard and confidence. The emotions, attitude and behavior will be healthy and functional.

The process of rehabilitation takes into account the grief and mourning process. Grieving varies per person and stage per Kubler-Ross. The amount of time is dependent upon one’s ability to process the intense uncomfortable feelings, bear them and then let go of the pain.

Mourning Well

Many people may be told to keep as busy as possible, yet that very action actually prolongs the grief process, as you will be repressing your feelings. In order to mourn well, one must consciously take the time to feel the pain and let it out in order to move forward.

Factors which impact the length of each Stage:
1. Age
2. Sex
3. The meaning of the relationship for the individual. How one defines the level of importance and significance for the one who is lost.
4. Length of time in the relationship.
5. The causes of the end in the relationship.
6. Past ability to cope with loss and change.
7. Resources and supports available.
8. Self-awareness or cognitive awareness of where one is the continuum of grief.

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Cognitive Behavioral Interventions for Children with Autism Spectrum Disorder (ASD)http://pro.psychcentral.com/child-therapist/2016/01/cognitive-behavioral-interventions-for-children-with-autism-spectrum-disorder-asd/ Wed, 27 Jan 2016 21:52:59 +0000 http://3.591

According to the National Standards Project 2015 report from the National Autism Center, one of the 14 established interventions for children with autism spectrum disorders is the use of cognitive behavioral interventions. I also mentioned this intervention in a previous post about the 14 evidence-based interventions for kids with ASD.

The National Standards Project (2015) report states that cognitive behavioral treatment has been an established (evidence-based) treatment for individuals with anxiety disorders as well as depressive disorders for many years. According to the report, cognitive behavioral interventions are found to be an evidence-based treatment for children ages 6 through 14. However, it’s possible (and likely) that cognitive behavioral interventions are beneficial for individuals younger and older than that age range, as well.

The report cannot claim that cognitive behavioral interventions are evidence-based interventiosn for younger and older individuals because there doesn’t appear to be enough research on those age groups with the use of cognitive behavioral interventions. With that said, there isn’t enough research on adolescents and adults with autism spectrum disorder in almost any treatment approach. This is a population which would benefit from further research to support effective, evidence-based treatments.

Cognitive behavioral intervention packages have been created specifically for individuals with autism although there are packages that are made for specific concerns, as well, such as anger management (National Standards Project, 2015) or anxiety.

Following is an example of how cognitive behavioral treatment can be used with children with autism.

Cognitive behavioral interventions typically address maladaptive belief systems in relation to the individual’s behaviors. For example, a child who struggles academically may say to himself or may say out loud “I can’t do this. I’m not smart.” In cognitive behavioral interventions, this belief system would be addressed and the practitioner would help the child to change his belief system to something more beneficial, such as “This assignment is challenging, but I can try my best. I am smart.”

Additionally, behaviors would be addressed in regards to what the child should do in response to that thought, so instead of laying on a desk and throwing his pencil maybe the child could learn to take deep breathes and complete one problem on the homework assignment. (Then, of course, complete the next one, and so on.)

Some aspects of cognitive behavioral interventions include:

  • Educational Component: This is an aspect of intervention that would focus on teaching the child something related to the presenting concern, such as teaching them to label emotions, to identify statistics on how many kids experience a similar issue, to educate on coping skills, etc.
  • Cognitive Restructuring: This is a component where the practitioner will help the individual change maladaptive beliefs that the individual holds. Following is an image of common problematic cognitive beliefs.

Common forms of faulty thinking. Cognitive Behavioral Therapy (CBT) is a scientifically proven therapy effective for thoughts and behaviors associated with depression, anxiety, and other common mental health concerns.:

  • Visual Supports: This is especially helpful for kids with autism who often have strong visual perception skills. Using visual supports can be done in many ways including using a visual scale to rate severity of symptoms from 1 to 5. Following is an example of a visual support to help kids understand different levels of voice for different situations and another one for helping a child to figure out what to do while completing challenging academic work.

  • Homework Assignments: It is common in cognitive behavioral interventions that the individual completes assignments to practice the concepts discussed in session. It is also beneficial to have the individual complete relevant data collection to go along with the homework.
  • Parent training: As with many interventions for kids with autism, parent training is beneficial for kids with ASD because parents can help support the suggestions provided by the practitioner. Parents can help the child to find opportunities to practice skills and also help to reinforce attempts and appropriate behaviors when helpful.

The National Autism Center suggests that cognitive behavioral interventions be provided by practictioners who have experience in both working with kids with autism spectrum disorders as well as experience and training in cognitive behavioral interventions.

References:

National Standards Project (2015). National Autism Center.

image credit: mikemols via Fotalia

image credit: PsychologyTools.org

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How To Do Grief with Your Clientshttp://pro.psychcentral.com/kickstart/2016/01/how-to-do-grief-with-your-clients/ Wed, 27 Jan 2016 16:00:20 +0000 http://4.759 Thank you to Jill A. Johnson-Young, LCSW for this great guest post.

How to Do

Grief, loss of a loved one, and bereavement are some of the most common key words used by potential clients looking for a therapist. They represent a practice specialty that many therapists approach as a generalist area not requiring advanced training. I’m not going to claim everyone needs training, given the right background, but most therapists are not experienced in the business end of death and grief.

Clients seeking help from someone unprepared for the conversations and process after a death can do tremendous damage. It can shut a client down, and make them wary of therapy for years.  I’ve seen the results in my office.

A licensed therapist was one of the speakers for a recent caregiver’s conference. Her topic was coping with grief and loss, and she opened with the “well known and well understood five stages of grief.” I cringed. She assumed there are five known stages of grief. She even attributed them to Elisabeth Kubler-Ross. Why did I cringe?

Elisabeth Kubler-Ross was a genius at getting us talking about death and dying back in the day, but she wasn’t talking about grief. She focused on anticipatory grief, owned by the dying person, not the survivor. Her work was descriptive and unapologetically unscientific, and eventually her goal became talking about death so the dying could prepare and be supported by loved ones who would understand their process. Did you know it wasn’t supposed to apply to survivors grieving after a death?

There are multiple of theories about grief, and even more “stages” that have been created and shared. My personal favorite is this one:

Grief

Do you notice what’s missing at the end? Acceptance, closure, peace? An end? A timeline? A neat and clean process? Grief is messy. It has its own clock. And it’s completely personal and intimate, specific to the griever and the loss they had, informed by prior loss experiences. In my approach to grief I frame the goal for grief work to be recovery, not closure. Closure implies leaving something behind, and it shuts down someone searching for a means to work through their loss without fear of losing their loved one forever.

When you are working with clients who have lost a loved one it’s more important than at any other time to start where they are, and to allow them to tell you their story as they experienced it. Most of the time there is no prompting needed. They are in your office to be heard. A griever is looking for a therapist who is realistic, and who doesn’t use platitudes or assumptions they’ve heard from a grief curriculum.

When I first meet with a grieving client, after they tell me their story I ask what things they’ve been told that they know were said with good intentions, but caused anger or hurt. The list will roll off their tongue with emotion, no matter how old the client may be. That list always includes “they’re in a better place”; “you should be glad they are no longer in pain”; “God needed another angel”; “You can meet/give birth/find another (insert here)”; “You need to be strong”; “Aren’t you feeling better by now?.” Even children have lists in their heads of things they’ve been told that have caused them stress because of the expectations they implied or the message that the death was a good thing in some way. The cause of death may have been terrible. They may be exhausted from caregiving. The accident might have been gruesome. The griever’s reality is that they didn’t want another angel, they want their loved one back, and if you want another angel so badly you send one of your loved ones to heaven and get theirs back. They need a therapist who is fully aware of the stuff not to say, and able to hold the space for them to initially talk through the death, the impact, the pain. They need someone who knows that after a loss every morning when you wake up your loved one has died all over again, because in sleep they may be there.

Grievers are usually unaware of the true impact of grief. I do a lot of education about the things they are or will experience. Most don’t attribute their loss of energy, change in appetite (which can cause nutritional issues that impact everything), inattention (car accidents, tickets, stove being left on), irritability, avoidance of loud or crowded places (Costco), difficulty with daily tasks (paying bills), illnesses, change in sleep patterns, and many others to their grief process.

Others will be quick to tell them they are depressed and need meds. What they need, in that moment, is to know this is normal. That’s the moment to timeline their prior losses, and to look at how they coped, who was their support, and how long they grieved- as well as acknowledging that even years after a loss it can still hurt at times.

Doing grief is to help your client identify the “woulda, coulda, shoulda’s”- the stuff left unsaid, undone, the dreams not fulfilled, the apologies needed (on both sides), the thank you’s we all know we should say every day, and then suddenly there are no more days. Writing them down, and then allowing the client to express them. My clients write a letter with them, and close it with “goodbye.” They choose what happens to the letter- the symbolism is theirs. I don’t make suggestions- it’s not my loss.

A therapist skilled in grief work can address losses of all kinds. Your clients experiencing loss need permission to do their grief their way, help and support to use the time in grief to move toward their new normal, whatever that may be, normalization of their experience, an ear open for complications and a history of depression, and absolutely no formulas or rules about what should occur. Being linked to other grievers can be very helpful, but some won’t want to attend a group. Being flexible about what resources you offer is a necessity. For those who may never feel safe in a group there are online programs- many are focused on a belief system, a few are not. I offer “Your Path Through Grief,” a totally online program with a closed online support group accessible around the clock (grievers don’t sleep much),  education including videos, a grief workbook, blogs, a memorial page to build a memorial for their loved one, daily emails for a year, and resources. It can be found at www.yourpaththroughgrief.com.

unnamed (2)Jill Johnson-Young, LCSW is co-founder of Central Counseling Services and the creator of Your Path Through Grief. She’s an experienced hospice social worker, grief counselor, and a Certified Grief Specialist through the Grief Recovery Program. Jill is also a double widow, and is now married to a funeral director. She will be addressing the California State Funeral Directors Association in June, and has presented at national, state and local conferences for several organizations.

 

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