Trauma & Attachment Therapy

Boston Globe article about supportive family of transgender child

http://www.bostonglobe.com/metro/2011/12/11/led-child-who-simply-knew/SsH1U9Pn9JKArTiumZdxaL/story.html?s_campaign=sm_fb  A lovely article about the supportive family of male twin who knew from the beginning that she was female, and the courageous family that supported her through her life.

Robert Trivers On Deception

Robert Trivers On Deception. Great one hour talk on self and other deception research. Entertaining and informative. His book is The Folly of Fools.

• The smarter the kid the more he or she lies
• Being "out" is good for the immune system. 
• Talking about trauma is also good for the immune system 
•  The more homophobic a "straight" man is, the more likely he will be aroused by gay porn.
• Everyone deceives themselves all the time, about intelligence, attractiveness and power.  

Using Brainspotting to Resource Positive States

David Grand's Brainspotting is a powerful technique for clearing trauma and strengthening internal resources. It started as an offshoot of EMDR and has become, through the innovations of Grand and Lisa Schwartz, its own effective therapy. Here are two ways I've been using it for resourcing.

1. With fragile, dissociated, stressed, and deeply anxious or depressed clients. I use the Brainspotting "Inside Window" technique to find the "Resource Spot" (this is straight out of the training): I have clients scan their bodies for a place that's grounded, strong, relaxed, connected. We check to see if the place and the feeling are stronger while looking through the right or the left eye; while looking up, down, or straight out; and to the right, left, or straight ahead. When they find their "Spot", I turn on the tappers (Grand and Schwartz use bilateral music) until the feeling is strong. My twist on this technique is to have clients imagine finding the spot when they're stressed or anxious during the week. (Except when driving!). It creates a nice state shift, though not the clearing that is possible with application of the full Brainspotting Protocol.

2. Throughout the years, I've had several clients who report a time in their childhood (often after a move or a divorce or the introduction of a nasty step-parent) when they lost the happy, connected kid, they used to be. I've used several techniques to access the old, happy, state. Yesterday, I used Brainspotting and Ego State work to quickly access and integrate that old state. I asked, "What was that kid like, before the move?"  Client: "Playful, loving, adventurous, caring, sweet. Normal." ""When you think of her, what do you feel in your body? Where? Cover your right eye, is that feeling stronger? It's gone. Cover the other eye. There it is! Stronger looking up, down, or straight on? Up. Right, left, or middle? Middle. (Applied continual bilateral theratappers while we strengthened the sense of that kid, connected with some of her favorite things back then, connected with things the kid part would like about the current, modern life (martial arts, kids, and more), and I asked the client if it was time to bring the sense of that child up to now. "So reach back into the past, and when that kid grabs your hand, pull her up to here and now. . . Is she sitting on you or next to you?  Put your arm around her. How is she doing? Happy and calm. Great, is it time to hug her inside of you? Yes! When the child was inside, we thought of ways the client could access the playfulness, strong sense of self, and adventurouness during a typical week, and imagined that during continual bilateral stimulation.  

If you are interested in Brainspotting, David Grand and Lisa Schwarz have some great trainings coming up. I'll be doing a one-day intro class on January 22, in Seattle. If you want the real deal, with the latest innovations, learn from the masters at http://www.brainspotting.pro/trainings.

Penn State: Was the abuse too horrible to acknowledge?

Here are two similar views of the Penn State child abuse debacle. One from the anonymous humble2humble blog (obviously by a man of faith who understands child abuse): http://humble2humble.blogspot.com/2011_11_01_archive.html. The second is by David Brooks, from yesterday's NYT's: http://www.nytimes.com/2011/11/15/opinion/brooks-lets-all-feel-superior.html

Both speak to the commonality of denial and avoidance. Both are great writing. What do you think?

EMDR with Body-Image Issues

An overseas reader asked what I do with body-image issues. I wrote her this:

If it's full-blown dysmorphia, there's a chapter by DaLene Forester, "Image is Everything" in my book, EMDR Solutions 2, but if it's regular "I don't look like Twiggy, so I'm not okay" distress, I start with the 2-Hand Interweave: "In one hand, hold the way that society tells you that you should look. (body fat, shape, skin color, etc.) In the other, hold the body you have." 10 - 20 BLS. "What do you notice?"   

I then target with the EMDR standard protocol the shame, grief, anger, etc. that arises, taking special care with the cognitions. I often go back to the transmission of the messages: family, teasing, media images. "How did that message get into you?"  And go through the stages of grief in accepting the body they have.   Make sure you target shopping for clothes, being around people who have that ideal shape, and anyone who currently shames them for their shape. You may target them being naked (with a lover, at the gym, at the spa) and dealing with any distress that arises.

As a tall woman with no butt and a big belly (like every person on my dad's side), who got teased a lot as a teen,  I've gone through my own acceptance process. And it comes down to clearing the grief, accepting reality, and realizing that I'm lovable, that the person who matters thinks I'm sexy, and that this body is going to continue to deteriorate in the aging process, so I'd better take care of it. 

Psychotherapy for Gay, Bi, Questioning Clients, and People with Gender Issues

Last week, I was contacted by a sincere, heartful, intelligent man who wanted to hire me for EMDR consultation. After a 45 minute conversation, I turned him away because he doing “reparative therapy”, seeking to "help" gay people become straight. He uses EMDR and other methods to target the attachment issues of gay men, so that they heal their same-sex attraction and are able to function in heterosexual relationships. (Here's a link to wikipedia)  This man uses EMDR, and uses one of my EMDR techniques, the Two-Hand Interweave in some of his work, which I find appalling.

Why am I appalled? This man is using an outdated, disproven Freudian lens through which to see his clients. According to him, gay men got that way by having overbearing mothers and distant fathers. He thinks if he clears up the relational issues with EMDR and nurturing, and he'll get a straight man. I think his skill and empathy and the therapeutic relationship push people into the boxes that his religious beliefs say they should fit in. That Freudian paradigm has been soundly disproven. Every year brings more evidence for uterine influences of androgens and other hormones, in the etiology of gender identification and sexual orientation.(Wikepedia post w/ references) (Psych Today: Finger Length) Like Lady Gaga says, we’re all Born That Way: Gay, Straight, Bi, feminine, studly, androgynous (having both high female and male characteristics) and feeling male or female.

I have worked with sexual minority clients for my entire career. I have read extensively about, taken classes on, taught classes on, and written about these clients. In 1981-83, I ran one of the world's first day treatment programs for seriously mentally ill sexual minority clients. Several of our sickest clients (bipolar, borderline, schizoid, etc.) graduated from the program into jobs, school, and weekly individual therapy. Many had thought they couldn't be sane if they were gay, bi, or had gender issues. When they were able to accept themselves, and to know that their sexual or gender feelings weren't crazy, they were able to do the trauma work, attachment work, or medication regimens that allowed them to heal and function in the world.

When I work with someone who is uncomfortable with his or her orientation or gender, we explore it, and look at the contexts in which the discomfort has arisen: family, religious belief, social expectations at work, with friends, etc. We discuss orientation. I never tell someone what they are. I do explain the oft-replicated Kinsey Scale: 0=absolutely no homosexual thoughts, dreams, activity. 6=only homosexual fantasies, dreams, activities. 3=bisexual, can go either way or both ways.  People might move a bit up and down the scale during their lives. But 0's don't become gay. 6's don't become straight. I tell them about the newest research.  I ask clients where they think they fit today on the scale. And I ask them how they feel about it. 

 That feeling may become the focus of therapy. I often see people go through all the stages of grief: NO! ; Oh shit!; Sadness; Growing Acceptance; Joy.  Some people skip quickly through the stages, coming quickly to joy that they don’t have to try anymore to be other than they are. I never tell clients what or who they should be or love. They realize it and tell me.

When people come in with gender issues (Am I a man or a woman? Can I be man and be effeminate, a woman and "butch"?) we discuss the 3 different scales:

1. Orientation: Who attracts you? 
2. Gender: What gender feels right? I've found very few people, including transgender people, to be confused about this question.
3. Society's Gender Expectations: Are you more traditionally "male" or "female". Are you androgynous, with both traditional male and female attributes? Are you "man's man", a "girly girl", a man with traditionally female pursuits and temperament, or a woman who is doesn't fit her traditional gender role? 

Examples across the 3 spectrums:

• My husband is a Kinsey 0. He says that he doesn't understand why anyone would sleep with men, though he's glad that women do. He's happy with his male body. As a slight, sensitive, emotional, artistic, introvert, he has had mostly female friends, was happy playing with dolls and girls as kid, has no interest in team sports (playing or watching), and is uncomfortable with displays of machismo. He’s very male in his single-mindedness, tenacity, and sense of stewardship and responsibility.    
•  
• When I read the new research on prenatal influences of androgen I realized that my male twin that died in utero may have provided me with the androgens that made me how I am: Kinsey 2 ½, in a tall mannish body, with highly androgynous interests:.  In grade school, I had crushes on girls and boys. When the hormones hit, I thought everyone was cute, and still do. I've been in relationships with women and men. I've had this female body a long time, but I'm not that attached to it, or to being male. I think I could be happy either way. Only on camping trips, did I wish I had different plumbing. I'm tall, broad-shouldered, thin-hipped. Because I don't dye my hair, nor wear make-up very often, and can dress androgynously, I get "sirred" often. (Can I help you, sir?) I never had girly interests. I brought home snakes and frogs. I'm bossy, can be aggressive, can be soft and nurturing, can act like a guy around guys,. I've learned to "pass" as more female than I feel, using the gay male idea of "drag": any thing you wear, any way you look is a chosen persona. So I can do girly drag, professional drag, or wear what’s most physically comfortable. I was lucky to have parents who let me be as nerdy and idiosyncratic as I turned out to be, so that I never needed psychotherapy to reconcile my gender, sexuality, and cultural issues.
•  
• A male friend is a Kinsey 6. He says that he has always known he was gay. He thinks women are beautiful, and could not imagine having sex with one. He falls in love with men. He loves his male body. He loves to play through the gender roles, going from black leather macho "drag" to pretty-boy soft fabrics. He goes from nurturing sweet artist to macho man in five seconds. Thirty years ago, he and I did "high drag" together, wearing hyper-feminine drag queen apparel and make-up. We looked like twins of indeterminate gender. 
• A female friend was a sexually abused by nearly every male in her extended family. She thought she was gay by default: women weren’t frightening to her, men were. When she cleared her sexual abuse in years of EMDR therapy, she found out that she was really was a lesbian. Her friends, including me, thought her predilection for highly feminine partners (lipstick lesbians), tomboy sports, and a construction jobs made her an absolutely stereotypical dyke. It turns out she is.
• Her lover is highly feminine, in the arts, loves her femaleness, and as a Kinsey 6, defies all stereotypes.
• A coworker from years ago, was a very feminine boy, who as soon as he left home, took on a female persona when not at work. He hated everything male about his body. It was “not me”. After going to a support group for transgender people and years of therapy, he decided to transition to a female body. Now, she feels at home in her body and is searching for Mr. Right.
• In the early 1980’s, another acquaintance, after decades living as a very butch lesbian, transitioned to a male body, finally coming home to himself. His lover of 25 years, a tiny feminine woman, stayed with her partner throughout the transition. After partner #1 became legally male, they were legally married and shortly thereafter, left the gay community to “pass” out in the suburbs.

 

Therapy Issues

• Don’t project that these clients are coming with issues about their orientation. They may be fine with being gay, bi, or gender variant. They may be coming in with PTSD, anxiety, depression, addiction, or grief.
• Don’t miss the milestones. When I do an intake on gay, bi, or transgender people, I often ask when they first knew, when they first told someone, and when/if they are out in their lives, and what kind of discrimination they experienced. Often there is trauma, grief, or ongoing anxiety. Imagine not knowing how each new person will respond to who you are. Or fearing firing, violence, or death, for being who you are.
• Do notice and acknowledge ongoing stress and fear about being a targeted minority.
• Coming out is differentiation:  “I’m here. I’m queer. Deal with it.”  Differentiation means accepting oneself, even when others don’t.  First coming out to self. Then others. And for many, coming out to everyone. “I’m out” means to anyone who wants to know. 
• Coming out can be dangerous. Never push clients to come out. Always acknowledge clients’ fears of coming out: rejection, judgment, loss of relationships, even violence. I’ve had friends and clients lose their families, experience shunning by their church communities, and lose jobs. I’ve known military people who lost their positions and their health care and their pensions. And this week is the 13^th anniversary of the murder of Matthew Shepard, killed by homophobes in Wyoming.
• Coming out can be exhilarating and empowering. Here’s the subtext: “I’m here. This is me. I care about you enough that I want you to know me. I’m willing to risk our relationship in order to be known.”  And it, in the best of circumstances, coming out becomes mundane: “My husband/wife/partner and I saw a great movie last night.” Or, “Yeah, I look familiar because I used to be Mary and now I’m Marvin.”
• Things are changing, but not fast enough. Don’t Ask, Don’t Tell is gone. Gay marriage is now acceptable to about 50% of Americans. Sitcoms with gay characters are normal and popular. Rosie and Ellen are icons. Chaz Bono is dancing with the Stars. And kids are still being bullied to death, thrown out of families, and fearful of growing up alone and “weird”. Gay people are vilified from many pulpits. “That’s so gay!” isn’t a nice thing to say about anything. One of my favorite referrals is to Dan Savage’s “It Gets Better” campaign. Gay, bi, and straight people giving messages of encouragement to gay kids: “Hang in there. It gets better when you grow up. You’ll find love. I made it. You can too.” There are thousands of videos, some of them musical, all testimonies to the future.
• Community can be powerful. There is no one sexual minority, gay, bi, lesbian, or trans community (except in the minds of certain right wing opposition). There are many groups. And it's a thrill for an isolated person to find "people like me". Back in my day, it was support groups. Now, online communities can be a first step for people looking for support, information, acceptance, and relationships. I warn newly exploring people to watch out for jerks and crazy people. I say, "Just because they share an attribute with you, doesn't mean they aren't out to exploit you. Pay attention! Look for smart, kind, honest people, whether online or in person."
• Steer your clients towards themselves. Be curious. Support. Use your tools towards healing in everyway. I tell my clients of whatever orientation, "When you lay me off, I want you to be as weirdly idiosyncratic as you were always meant to be, and absolutely accepting of all of it." 

Empirically-based Treatment?

Paul Matiuzzi's blog post nails the controversary about "empirically-based treatment"  for therapists: Read it here:  http://everydaypsychology.com/2011/09/yale-psychologist-calls-for-end-of.html 

Empirically-based research is a helpful guide to what works for some people some of the time. I absolutely follow the research in my field. But if something doesn't work for the client in front of you, you must try something else.

In about an hour, I'll be explaining to my editor why I can't, in good conscience, write the protocol-driven trauma treatment plan book she's asking for. Trauma clients are individuals with ideosynchratic biologies, temperaments, histories, and cultures. One treatment plan can't fit all. My last book was all about knowing as many therapies as possible, so that you can find what works for a client in front of you. 

For a scholarly (hilarious) article about the issue, check out this study on "Parachute use to prevent injury", that fails the empirical test for lack of a "no parachute use" control:  http://www.bmj.com/content/327/7429/1459.full

In Ego State Therapy, Let the Client Run the Internal Show.

Twenty-seven years ago, when I worked with my first DID client, I became the "go to" person for soothing the young, distressed ego states. As a result, I was on-call 24/7, never took longer than a week's vacation, and was constantly fielding emergencies. Finally, a savvy consultant told me to put the "oldest, wisest part" of the client in charge of all distressed, younger, or destructive alters. What a relief! Within three sessions, the client could self-soothe, make adult decisions, and deal with new alters as they popped up. (This was a complex ritual abuse case with lots and lots of parts.) Therapy sessions became case consultions. I worked with the most adult parts of my client to create safety, internal communication between parts, internal and external boundaries, and good, safe rituals of orienting "new" parts to the present and giving them the rules.  The therapy wasn't over then, it lasted 10 years, through trauma processing (which got more efficient when I learned EMDR), lots of sorting out "then" from now, the grief process about her awful losses, and coming to terms with her current life.   The client still contacts me every 9 months or so for a tune-up session.

So, all of you who work with parts: If you help the oldest, wisest, most nurturing parts run the show, the client gets to do more of the work, feel effective and in charge of his or her life, self-soothe, and heal faster. If you want to communicate with younger parts, ask an adult, the adult, or the "team" to ask about or talk to the part. "Can you go inside and tell me how that 2-year-old part is doing now? . . .Can you remind her that you are always there for her so she's never alone again? . . . That she's safe now. . . And that she lives with you in your nice house. . . ."

I do ego state work with 85% of my clients and I rarely speak directly to any but the presenting adult. The only time I do, once a decade, is when I'm working with a new client, who pops into a part I don't know that's amnestic for the rest of life. (The ultimate "Oh S--t!" moment of therapy.) Then I introduce myself, if the part doesn't know, explain that we're in my office, and gather information: age, name, and what it needs, or what it does and "Did you know that you're part of John?". Then ask for "Adult client", to come back. Sometimes, with a count of three. It's always worked. If the presenting client doesn't remember the situation, I offer to set up an introduction. When I do, I refer to the presenting adult, team, etc. as the boss.

Most ego state work is much less dramatic. I often ask people to tell me how old something feels and if they can talk to that 3-year-old, 5 y.o., etc. part. Most people can do this. It doesn't take formal dissociation. For the dissociative disorders of complex PTSD, Axis 2 diagnoses, DDNOS, and DID, formal ego state work, combined with EMDR or Brainspotting or Somatic work for trauma, in conjunction with attachment-based therapies are always called for.

The Names of Love

The Names of Love is a hilarious, serious, heart-breaking, heart-warming French movie that I recommend to everyone. It deals with generational PTSD, Holocaust survivors, war survivors, culture, temperament, politics, art, political correctness, and sex as a positive political tool. (Did I say that it was French?) Here's a website: http://www.namesoflovemovie.com/

One plot line shows a survivor of childhood sexual abuse, treating her body as a tool for her political ends, until she meets a man who truly sees and accepts her while adoring her. (I've heard many survivors who were prostitutes or used sex as a means to other ends who said, "But that is what I'm for."  

Another character, who saw her parents dragged away to a concentration camp, brought her fearful silence into her marriage, infecting her non-Jewish husband and her child. That child, the male lead, is able to open up and speak the truth when he is finally seen, reflected, loved, and well laid. 

And it's a romantic comedy, so you know how it ends. This is my favorite movie since UP! It's lovely. And you must stay through most of the credits.

Cultivating identification with the "other", thus love and peace.

A great article about why we have aggression towards "the other" and how to cultivate identification and peace inside and outside of us. The Wolf of Hate by Rick Hanson on mentalhelp.net   

Vets discharged with PTSD finally allowed benefits.

It took a law suit and it's about time!

http://www.washingtonpost.com/local/dc-politics/2011/08/02/gIQAEm8cqI_story.html?fb_ref=NetworkNews&fb_source=home_multiline

Gottman & Navarra: Couple Recovery Development Approach Workshop

John Gottman and Bob Navarra gave a useful workshop about working with couples in recovery from addiction, in Seattle yesterday. Here are some of the take-aways:

• "Mastery, Not Perfection" A wonderful thing to say to anyone learning a new skill ,is the "perfect" thing to say to recovering addicts, who are likely to be perfectionists. (I often remind them that "the ideal is the enemy of the real.")
• Recovery destabilizes the family system, and can replace alcohol as the "organizer" in the relationship. Couples and families need to discuss what happened when the partner was using, how things are different now, what everyone feels about it, and what both partners need now. New recovery is a perfect time to break up the alcoholic "Don't Ask, Don't Tell, Don't Feel" rules and and replace them with open, differentiated expression and mutual support. (This was frowned upon in the bad old days of recovery work, leading to this joke I heard 25 years ago: "What's a 'slip' in Al-Anon? . . .A moment of compassion.") 
• Gottman and Navarra's approach looks at 3 recoveries: the addict, the spouse, and the relationship. It emphasizes the centrality of the relationship, not just the addict staying clean. It looks at current and historical Family of Origin influences on the individuals and their relationship. It helps each partner learn to care for self and the other in "co-existing recoveries." 
• Couples learn to "create shared meaning; help each other to make life dreams come true; manage conflict; take a positive perspective; turn towards each other; share fondness and admiration; and build Love Maps." (Love Maps is a Gottman tool for couples that have them know each other, from favorite colors to worst traumas.)
• Gottman ran through his "4 Horsemen of the Apocalypse", the actions that predict divorce: Criticism (he teaches whining rather than blaming--"I'm unhappy" vs. "You're a jerk".) Defensiveness, Contempt, and Stonewalling. I had forgotten that he sees Stonewalling as a response to a Dorsal Vagal shut down reaction: flooding. He teaches people to self-soothe so that their physiology can handle the conflict.
• If trust is the number one predictor of marital happiness, how do you build it? Teach attunement. Let the answer to "Are you there for me?" be "Absolutely" and be able to show it by listening, comforting, and showing up, even during conflict. 
• Great acronym: ATTUNE: Awareness, Turning toward, Tolerance, Understanding, Non-Defensive Responding, Empathy. Gottman says that "Bonding created by turning toward any negative affect and fully processing conflict and failures to connect . . .has the power to create trust."
• Never avoid conflict: process it and it's gone. Avoid it and it sticks around forever.
• Gottman showed us part of his "Recovery Kit" for post-fight or post "regrettable incident". It's swell. For $2, you could have a great tool for helping your clients out of fights, and to send home with them, when they understand the simple but effective steps. (it's Gottman's, so it's impeccably researched). Here's the order form from Gottman: http://www.gottman.com/57329/579672/Books-DVDs-and-Workshops/Recovery-Kit.html.
• Navarra spoke about breathing exercises for self-soothing, and how couples can talk about recovery with each other. They both spoke about the importance of positive affect: Gottman, about using humor; Navarra, about bringing up what's working, what's good, and what each person likes. He spoke about the couples' needs to note their shifting identities as couples, and as a result of recovery; shifting boundaries and being choiceful about what they are, and importance of discussing new rituals of connection, old family scripts, and what they want now.
• A nice workshop (despite some A/V and organizational issues).
• John Gottman is the godfather of couple research and couple therapy. You can find out about his great books, DVD's, handouts, and workshops at his Relationship Research Institute: www.rrinstitute.org  My husband and I read a Gottman book to each other on our honeymoon.
• Bob Navarra's research about couples, addiction, and recovery is lovely, and a great antidote to the idea that the addict has a separate recovery from his or her family system. His website is www.robertnavarra.net  He's got a Gottman blog and a recovering couples' blog on his site.

Beware of Prepayment Hoax

1. You get an email or call from an overseas potential client who is coming to your town and wants psychotherapy for a compelling trauma.
2. They want to pay you in advance, because it's hard to move money from there to here.
3. When the check comes it's much larger than you asked for. They want you to deposit the check and send back the rest to pay for their transportation to your town.
4. You find out that it's happened to thousands of therapists all over the country.
5. Keep your eyes open!

I first encountered this hoax several years ago, when I gravely helped a consultee plan treatment for a fraudulent client. When the large check came, we called the FBI and they informed us what to do. Last year, when I replied to an email that I was interested, unless it was a hoax, I didn't hear back from them. Last month, it happened to someone in my office. If someone contacts you, you can say, "Bring cash, since I am ethically unable to take payment in advance." Then see what happens.  Two different consultees, that I know of, have successfully worked with foreign nationals who contacted them from overseas. Not everyone looking for therapy is fraudulent. Be alert! Be curious! Don't be scared.

A web search for this issue turned up this: http://www.counselingseattle.com/counseling/scams-targeting-counselors.htm#Pre-Payment

Temperament and Genetics

At my third day of a family celebration, I've been watching the genetic trends in my extended family. There is much discussion of who looks like whom. Two Asian mothers in this primarily Eastern-European Jewish family have added some gorgeous, great kids. I've been watching temperament. First I noticed that most introverts are married to extroverts. A nephew has my brothers body, his mother's face and introversion. His sister has her mother's body, a face from both parents, her father's coloration and is extroverted like my brother. The granddaughter of a bipolar man, has horrible OCD. The highly-functional daughter of a highly functional OCD man and "skinny, nervous" mom, says she has OCD, as does her nephew. People say I've got my mother's face, my father's family body (long-limbs, height, big belly, no hips, and the extroversion of most of the Shapiro clan).  Many found out that I have my mom's resonant singing voice, when I chanted at the Torah. (Thanks, Mom.)

When I do an intake, I nearly always do a genogram, a clinically-based family tree that tracks temperament, as well as trauma history, attachment, and current connectedness. (See the assessment chapter of Trauma Treatment Handbook: Protocols Across the Spectrum). It's helpful to know if your client was the only introvert in an extroverted family, or if bipolar, depression, or anxiety-disorders run through the line. Clients often feel less shame about their symptoms when they realize that there's a genetic component, not personal failure, behind a symptom. If bipolar disorder or schizophrenia lurk in the line, I keep a closer watch for related symptoms. When working with someone temperamentally different than the rest of their family, we often target that sense of difference, and clear any shame that accrued.  Keep watch on temperament. It will help you meet clients where they are, and spot issues that you might otherwise miss.

Dissociation Often Caused By Disrupted Attachment

Andrew Leeds' Sonoma Psychotherapy Training Institute posted a great article on its blog: Developmental Pathways to Dissociation. They quote Dutra, Bianchi, Siegel, and Lyons-Ruth saying that ". . . lack of positive maternal affective involvement, maternal flatness of affect, and overall disrupted maternal communication were the strongest predictors of dissociation in young adulthood." Read the whole article here:  http://www.sonomapti.com/sonomaptiblog_files/developmental_pathways_to_dissociation.html

Linehan, creator of Dialectical Behavior Therapy, reveals her own struggles.

Marsha Linehan created DBT, a comprehensive mindfulness and cognitive therapy to work with suicidal, especially Borderline Personality disordered clients. She recently revealed, in a NYTimes article, that she was an out-of-control self-destructive Borderline client as a teenager here:  http://www.nytimes.com/2011/06/23/health/23lives.html?_r=2&src=tptw

I like DBT. With the addition of ego state therapy and a trauma remover like EMDR, it works very well. I especially like its emphasis on mindfulness to help with affect regulation and good therapeutic containment. 

Three Articles for Introverts

These articles refute the myths that introverts are anti-social, shy, and wimpy. My resident introvert husband endorses both of them.

Carl King's review of The Introvert Advantage (How To Thrive in an Extrovert World), by Marti Laney, Psy.D. called 10 Myths about Introverts.

A funnier, snide 2003 Atlantic Article by Johnathon Rauch called Caring For Your Introvert.

There's a long 2010 Psychology Today article by Laurie Helgoe, Revenge of the Introverts, that has been endorsed by many clients, who linger in the waiting room after sessions to finish it. 

Read at least one of these. It's useful to understand the temperaments of your clients, so that they can understand and accept who they are. There's a lot of overlap between introverted people and Elaine Aron's Highly Sensitive People, and those whom I call "skinny, nervous, people". I see every client through the lenses of temperament, attachment, trauma history, gender, class, and culture. We need to take all aspects of our clients into account, in order to fully see them, and treat them skillfully.

Beautifully written survivor blog

I stumbled on an interesting blog. What makes it unusual is that it's by a man, beautifully written, spiritually and religiously and literarilly informed. The writer deals with themes of shame, humility, power-over, abuse, right speech and right action. He's not sanctimonious at all. He seems to know whereby he speaks. The blog is anonymous. Here's the URL: www.humble2humble.blogspot.com

Psychiatric Diagnoses: The Epidemic of Mental Illness

The New York Review of Books carried and a scathing and mostly right-on article about the medicalization and over-medication of mental illness by Marcia Angell. It's a review of three books about the history of psych meds, the power of the drug companies, and the minimization of psychotherapy. Read it here.

Trauma and Trauma Therapy: Interview on "Public Exposure"

I was interviewed by Stan Emert on his cable TV show, "Public Exposure" a few weeks ago. Here is the YouTube link to the show:  http://youtu.be/KsFoHFQxx4o  Topics include trauma definitions, PTSD, EMDR, Ego State Therapy, and a minute of traumatic grief.

Due to a neck injury, I've been unable to spend more than a few minutes at a keyboard in the last few months. I hope to resume posting on this blog after I learn to write with Dragon, a voice-recognition program.

Another Nice Review for Trauma Treatments Handbook

Tim Brunson at the International Hypnosis Research Institute wrote a nice review of TTH. He liked the book though he thought it didn't have enough hypnosis in it and wanted it to discuss research and wished the "Self-care for Trauma Therapists" chapter was longer. Otherwise he said extremely positive things about the book and me personally.  Here is the link: http://www.hypnosisresearchinstitute.org/index.cfm/2011/1/21/The-Trauma-Treatment-Handbook-Protocols-Across-the-Spectrum

Next To Normal: the bipolar musical

I went to the opening night of Seattle's production of Next to Normal, the amazing Tony-winning dramatic musical about a bipolar mother, her family, her delusions, her therapy, and her slow, painful growth. Components: amazing 3 story set, great singing, great score (though a little loud), believable story, believable characters (even the imaginary one), and the best song about psychotropic medications that I've ever heard.

The writer, Brian Yorkey, has done his homework about the disorder and its effects on spouses, kids, family dynamics, and frustrated practitioners. His take on the etiology, genetics, exacerbated by trauma, is plausable. He's got an over-functioning husband, who tries to keep his wife from expressing her real pain. The daughter, also over-functioning, is isolated, ashamed of her family, fearful of trusting or leaning on others. 

The pills only treatment in the beginning turns into four-day-a-week analysis turns into the new two-week long, daily mini-electroshocks.  (See http://www.healthyplace.com/bipolar-disorder/treatment/ect-electroconvulsive-therapy-for-bipolar-disorder/menu-id-67/  )

The play is devastating and often funny. It gets into every character's head and makes you care for them in their struggles. I cried through a lot of it, reminded of clients, friends, and family members who have struggled with this awful disease. My friend Janis, who doesn't have the same job or history, cried just as much, when we weren't laughing. I haven't seen a piece of theater that has moved me so much since Tony Kushner's Angels In America, 16 years ago. 

And the therapist didn't sleep with the client! That alone made it better than nearly every movie or play about psychotherapy. I so wanted to drag each character out and do EMDR on their issues. But EMDR would be extremely boring on the stage.

Go see this play!

A Rave Review for Trauma Treatment Handbook

"Lothlorien" a psychotherapy student and trauma survivor just sent me a link to her rave review of Trauma Treatment Handbook. Check it out here. 

Therapists: File 1099's &1096 forms with the IRS by 1/28/2011!

Due to last year's audit, I now know that self-employed people and businesses must file 1099 forms to anyone whom they pay more than $600. Every consultant, your landlord, and the person who cleans the office. Since I own my office and don't pay rent, I sent three 1099's, one to the office cleaning person, one to my consultant, and the other, in my business as landlord, to the contractor who rebuilt a floor for me. 

Why 1099's? The IRS wants to be able to know if your payees, the consultant and your landlord, are declaring all their income. 

How 1099s? You want the 1099-Miscellaneous Income (or 1099-MISC) form. They come 2 to a page. I always ruin one by putting my consultant's name where mine should go. Read carefully. And you need to get the tax i.d. or social security number of every payee. Which, unless they're working under the table, they'll be glad to give you. Put the $ amount in the appropriate square (Probably not "crop insurance proceeds"). When you've filled them out, send the top layer to the IRS, one of the middle ones to the "recipient" and file the rest in your file. When you send the top layers, they need to go with form 1096, which just has the total. After you've done this once, the IRS sends you a pre-printed form.

To get forms call the IRS at 1800-829-3676 or go to www.irs.gov  

If you don't do this, and you get audited, it will cost you for every audit year and every form. I know this the hard way. It will take you about an hour total, to figure it out. So order the forms, get the Social Security #'s, and start figuring out who you paid what in 2010.

Two Takes on Marriage

David Schnarch and the dynamic duo of Ellen Bader and Pete Pearson tell us that the secret to happy marriage is the level of differentiation of each spouse. (Differentiated people show completely who they are and what they want, even when the other partner doesn't like it or agree. They also are able to accept their partners' differences and disagreements, to a reasonable point.) Researcher John Gottman says that for a marriage to last and be satisfying, spouses must know to whom they are married and avoid the "Four Horsemen of the Apocalypse": Criticism (attacking spouse's character), Stonewalling (Refusing to Talk), Contempt (Attacking the sense of self, sarcasm, sneering) and Defensiveness (Warding off spouse's attempt to talk as an attack, when it isn't). Tara Parker-Pope in today's New York Time writes about another variable of a happy married life: "self-expansion", the self-growth and new learning spouses gain from their partners. Read the article here. There is even a simple quiz that you can take about you and your partner here.

Page McBee writes a different kind of story in the Time's Modern Love column. She talks about her sense of unworthiness and her unrealistic black-and-white expectations of marriage that changed after she and her girlfriend survived a near-fatal armed robbery. After the robbery, her childhood trauma and related attachment issues arose, were acted out, and then slowly resolved. When it came time for the wedding, she approaches it through her reasoning and finally fully-present adult self, not her shamed, magical child. It's lovely. Right here.

The King's Speech

Some of the best therapy I've seen on screen is in a great new movie, The King's Speech. Geoffrey Rush plays Lionel Logue, an Australian speech therapist who tackles the debilitating anxiety-driven stammer of Colin Firth's, "Bertie", who become the king of England on the eve of World War II. 

The film shows the stifling lives and roles of the Royals, and the intense pressure on them from their subjects, the Anglican Church, their governments, and each other. It shows how a therapist to the King has to tear down the class barriers in order to make a strong, attached therapeutic relationship. Logue creates the frame be insisting that "Bertie" come to his office ("My castle, my rules."), be on time, and be addressed by his family name, rather than "Your Royal Highness". He sits close, and mixes standard speech therapy with elements of somatic and expressive therapies (some of which are riotously funny) and holds the therapeutic relationship above all. He watches his client carefully, and crafts his client-centered therapy and the environment in which the King must give his speeches to his client's needs. Logue leads his client to uncover the childhood traumas that precipitated the stammer, and the family dynamics that kept it going. And he uses brilliant and funny strategic therapy to hook his recalcitrant client into therapy, and keep him there.

Helena Bonham Carter plays Bertie's supportive wife, Elizabeth, and is excellent, as usual. Derek Jacobi is the Archbishop of Canterbury, with whom Bertie finally shows his adult and kingly differentiation. Michael Gambon plays King George, Bertie's father, as a well-meaning, impatient, worst father a stammerer could have. (It's strange to see Dumbledore be jerk.) Guy Pearce plays Edward, Bertie's brother who abdicated the throne for a woman Mrs. Simpson (Eve Best).

I knew a lot of the history, and I painlessly learned more of the particulars in this wonderful movie. The King's Speech is suspenseful, beautifully acted, funny, sad, and hopeful. I hope you see it, too.

 

 

NYT's Article: A Typical Suicide of an American Soldier

James Risen writes about a soldier, Staff Sgt. David Senft, with PTSD who kills himself in Afghanistan. The article lists many things that predict successful suicide:

• Senft came from a distressed "broken" family.
• He had many attachment disruptions in childhood.
• He had been on multiple tours of duty.
• He had PTSD from a trauma early in his deployments
• He had attempted suicide before.
• He'd been hospitalized by the Army, because of former suicide attempts.
• The Army deployed him, anyway.

The military's mandate for suicide prevention completely failed this man. Read this sad story to know him and know the details.

Attachment Theory and Adult Relationships

"What Attachment Theory Can Teach about Love and Relationships" by Amir Levine and Rachel Heller, in the January 2011 Scientific American is a good introduction to attachment styles, how they affect our ways of relating, and how to get conscious control over some of our dating styles, despite our early experience.

Ailing Parents, Aging Selves

Many of my clients are near my age, the mid-fifties. Many of us are dealing with ailing and dying parents, just as our own bodies are showing signs of mortality. Here are several issues that arise:

• The balance of self-care and care of the increasingly needy parent
• The lack of control over the parent's decline
• The lack of control over one's time when emergencies occur
• The loss, quickly, or by slow degrees, of one's nurturing, supportive, and or independent parent and the subsequent grief
• The grief, mingled with relief, at the death of a parent
• The awareness of our generation as "the next in line" for decrepitude and death

Here are some rules that I've made for myself and have suggested for my clients:

• Make sure you have support to get through this time, people you can talk to about dealing with your parent
• Figure out your limits and do your best to stick to them. That may include limited other areas of your life, like hours of work or volunteer time during critical periods. If I've just spent the night in the emergency room with my parent, I will cancel my clients the next day. If my parent wants something that's not critical, and I need time for self-care, work, or my "logical family" (as opposed to biological family), I say "no" or "not now". 
• Know that you will never meet all the needs of your parent. Practice self-forgiveness. You can't save your parent from aging and from ultimate death. Make sure that all ages of you know that. Get help if you forget it.
• Some people get involved with the care-giving tasks and forget the relationship. Try to spend some time "being" rather than "doing". Hang out, chat, play a game, eat a meal, gossip, whine about your life, "only connect".
• My family talks easily about death, estate issues, and what comes after. It's important for you that your parent have a will and that you know what his or her wishes are for the stuff, the body, the funeral, and the after-life, if any. Otherwise, during the time of most grief, you will have too many decisions to make with no direction from the most important person.
• My anxious clients sometimes become phobic about their own health, when their parents are ailing or dying or dead. I often ask them to imagine their deaths and do EMDR processing about their fears. Often, the terror goes away, and they begin to notice that they're still alive and present.
• I've done the same about the decline of my clients' bodies. "Think about the process of getting older and what it will be like. What is the scariest thing about it? Where do you feel that fear? Let's process it." It works.

These are developmental issues, not pathological ones. I'm constantly normalizing peoples' fear, grief, and overwhelm, when dealing with these issues. 

Tricare Refuses to Pay for CRT & EMDR for Veterans

National Public Radio wrote and spoke about the "Battle Over the Science" of Tricare not paying for cognitive rehabilitation therapy (CRT) for Traumatic Brain Injury (TBI) "despite pressure from Congress and the recommendations of military and civilian experts, the Pentagon’s health plan for troops and many veterans does not to cover” cognitive rehabilitation therapy — a “limitation that could affect…tens of thousands of service members who have suffered brain damage while fighting in Iraq and Afghanistan.” See article in Veterans Today:  http://www.veteranstoday.com/2010/12/21/battle-over-science-money-blocks-widely-recommended-tbi-therapy/ and the NPR story: http://www.npr.org/2010/12/21/132203864/philanthropist-provides-care-that-the-pentagon-wont

It turns out that Tricare hired a research company that it knew (or maybe told to) would find this well-researched therapy to be "not scientific", despite unanimous by 50 clinicians and researchers on a special governmental commission. The reason: It didn't want to pay. CRT is expensive. And necessary. Thousands of military people are returning from Iraq and Afghanistan with TBI's from exposure to roadside bombs. The shock waves from these explosions move through brains, temporarily jellifying the tissue and causing lasting cognitive problems and difficulties with affect regulation. CRT helps people learn to cope and manage despite brain damage. It's necessary therapy.

This is reminding me of Tricare's refusal, until just this week, to pay for EMDR therapy for vets, despite EMDR's acceptance by the VA, the APA, and other entities as an "evidence-based practice". This was more about politics than money. Cognitive behaviorist and exposure people had colonized Tricare's committees, not allowing support for other effective therapies. I'm sorry that our active duty people and veterans have been victimized by the political and financial b.s. at Tricare. They deserve better.

In my experience, many "researchers" quote studies that support their beliefs and not the ones that support the facts. Or else cling to lab-based double-blind studies. Many effective therapies were not hatched or researched in labs. They work despite the lack of studies. Some, even after the "appropriate" research is complete are debunked because of the belief systems of the meta-researchers.  My belief: Do what works for the client in front of you.

 

Is Schizophrenia Caused by a Retro-Virus?

Fascinating article, The Insanity Virus, in the November online Discover magazine describes studies that show that schizophrenia and MS may be from viruses that trigger the Toxoplasmosis and CMV viruses that most of us already carry. It's a long read that got more interesting (for me) on pages 3 and 4.

This article makes personal sense to me because I've been around many people with AIDS whose impaired immune systems allowed the CMV and Toxoplasmosis to flourish and make them psychotic for the rest of their lives. I'm interested to see more about this research trend.

It's also interesting because last month at the EMDRIA conference I just heard Paul W. Miller MD, a Northern Ireland-based Psychiatrist, talk about how he has cured psychotic delusions in schizophrenic clients using psychotherapy that includes EMDR.

When Encouraging "Self-Care" Feels Like a Brush-Off

Dr. Kathleen Young, writes in her wonderful blog: Treating Trauma in Chicago, about when self-care is interpreted as abandonment. Read the article and the comments, then look at the rest of this great blog: 

http://drkathleenyoung.wordpress.com/2010/11/08/does-self-care-mean-others-dont/

It Gets Better

The outpouring of support after the spate LGBT suicides has been amazing. The latest and most moving part is a song by young Broadway performers "It Gets Better".

My homeboy, Dan Savage started the project with videos of gay and lesbian adults talking about how they survived harassment and worse and how life got better in the It Gets Better Project. (Many cool videos from all kinds of people)

President Obama recorded a video for the project, though the most moving one I've seen, besides the song, is a long video by a member of the Ft. Worth city council, Joel Burns, where he talks about bullying and a suicide attempt before it got better for him.

I started my career in 1981 working at Seattle Counseling Services for Sexual Minorities. If these resources had been around then (the internet, U-Tube, celebrities supporting gay teenagers to stay alive) I would have spent less time consoling grieving parents and friends and dealing with clients' failed suicide attempts. Back then, kids were routinely kicked out of their families for coming out. It still happens, but Oprah, Ellen, Rosie, and the increasing acceptance of gay people as human beings, legally and socially, has made this country a much healthier place to grow up gay, bi, or trans. Thank God.

Living with the Awareness of Evil

    I've had to confront evil again. In my every day life, I see it all the time. 60% of my clients have been sexually, physically, and emotionally abused by the adults, mostly their parents, who were in charge of them. As a consultant I hear therapists' most horrific cases. I read the newspapers.This political election is particularly ugly and full of disingenuous lies and distortions. African paramilitary continue to rape, murder, and hack off limbs. The wikileaks site has sent out another torrent of how people in power misused it to torture and murder. Members of our local Stryker Brigade are on trial for having tortured, then murdered Afghanis, for fun. And greed continues overpower humanity everywhere we look.

But it gets worse. I attended two conferences in three weeks, EMDR International Association (EMDRIA) in Minneapolis and International Society for the Study of Trauma and Dissociation (ISSTD) in Atlanta. The ISSTD conference is smaller and often more scholarly than EMDRIA, 400 people, many of them researchers. Most of the EMDRIA presentations were upbeat: How to use EMDR to cure schizophrenia, depression (mine), shame, dissociation, etc. At ISSTD, some of the research-based presentations were about dysfunction with no talk of cure. Dr. Martin Teicher presented research on how different kinds of child abuse affect brain structures and which developmental windows impact brain structures and function the most. He didn't discuss neuroplasticity and how we fix these things. Then Ellen Lacter presented "Torture-Based Mind Control: Psychological Mechanisms of Installation and Continued Control" with Alison Miller and Ada Sachs throwing in their awareness of torture in ritual abuse. The single most distressing thought that stuck with me is that the worse the torture, the more the victim becomes attached to the perpetrator. 

M. Scott Peck defines "evil" as something possible only when one human doesn't see another human as a human being. I'd like to add that for evil to occur, one human has to have power over another and see that other as an object, a means to an end. Evil isn't a new idea for me. My step-father, Peter, was a survivor of the German Holocaust. I was beat up by neighbor kids for being Jewish. I work with the effects of abuse every day. And I spent 20 years clearing the trauma and dissociation of one ritual abuse client. But learning about the number of organized groups that are "breaking people", intentionally causing dissociation through torture, set me back and left the conference stunned and hunkered down.

How did I get through it this week?

1. I reminded myself to feel it. When I connected inside, I felt my fear, grief, and anger about what we humans are capable of doing to each other. Focusing on the affect, and allowing it to move through.
2. I moved my body, feeling the aliveness in it as I walked.
3. I noticed the beauty in fall leaves and incoming clouds.
4. I connected with other people: my sweet husband, my mom, my friends.
5. I went to my consult group and spoke about my distress.
6. I joined the ISSTD Special Interest Group that deals with Ritual Abuse and Mind Control.
7. I reminded myself of the good works in the world.
8. I gave money to some politicians I see as helpful and good.
9. I'm going to the local Rally for Sanity (based on John Stewart's DC rally), with the sign "Therapists for Sanity". (Irony is very helpful to me.)
10. I played sad music and inspirational music. Aaron Neville was helpful. So was "One Love, One Heart: Let's get together and feel all right."
11. And I reminded myself of my limitations. I can help a limited number of clients, write books slowly, and consult to a limited number of people. I can't stop the abuses of the world. I can continue to respond to them.

It's worked well. I've been back for 6 days and I'm breathing fully, feeling more hope than despair, and about to have a book party for the my newest trauma book: Trauma Treatment Handbook, my contribution to healing trauma and making people whole.

New Theory Links Chronic Brain Inflammation to Depression

The more stress and depression, the more inflammation. University of California, San Diego, medical school report from Newswise: http://www.newswise.com/articles/view/569853/

Imaginal Nurturing, Ego States and Attachment

I've taken two different versions of April Steele's Developing a Secure Self course. Each time I learned more about creating good, strong, attachment experiences in clients with unfortunate childhoods. (Most of my caseload!) April teaches assessment, therapeutic stance, and has scripted protocols for bringing clients' loving adult attention to their infant and toddler selves. Clients can take home Cd's of the soothing protocols to enhance their experience of loving containment. Most of my attachment disordered clients loved them. A few, with phobias of their smaller selves, hated them, until we did enough trauma work that they could accept all parts. No matter what kind of therapy you do, April's training manual and scripted Cd's are very helpful.

April just came out with a distant learning course, complete with DVDs of lecture, power-point, and wonderful client videos. Because she's "practicing for retirement", she's no longer doing in person training. Here's what she says about it:

"Imaginal Nurturing, Ego States, and Attachment: An Integrated Approach to Early Deficits is the most up-to-date material on the Developing a Secure Self approach. It is not simply a video of a workshop you were unable to attend, but rather was created specifically for distance learning. In it, you will have the opportunity to "sit in on" segments of numerous sessions with a client who generously allowed some of her therapy to be videotaped to foster the learning of other therapists in the Developing a Secure Self approach. Many other clinical examples are given throughout the training. There are also two experiential segments so you have some personal experience of what you will be asking clients to do. 

The 12-hour program consists of 6 DVDs, 2 CDs, and a comprehensive 53-page manual. It requires only a DVD player and CD player. More information is available at http://april-steele.ca/training-information.php or you can contact April directly at april@april-steele.ca."

It's $200 and for a bit more you can get 12 CE's for taking the post-test.  I think everyone should have this training. If you need consultation after the training, April is available by Skype or phone from her home on Gabriola Island in British Colombia.

The Frugal Practitioner: How to start or support your private practice in hard times

The Washington State Coalition of Mental Health Professionals and Consumers put on a workshop for practitioners in Seattle this morning. First, Brian O'Neill, the CEO of Office Ally spoke about his free online billing and practice management services. I've been using Office Ally for billing for 3 years. It's easy, completely confidential and safe, and has wonderful 24-hour patient customer support who will walk you through the set up and answer as many ignorant questions as you can ask. I haven't mailed a bill in years. And it is absolutely free. I'm going to look into the Practice Mate services. I'll let you know how it works.

Then, Heidi Wasch, Jay Gelzer, Robert Odell and and I spoke about frugal practice. I went first and spoke about starting and marketing a private practice. I said, 

• Get your professional and state and city business licenses in order.
•  Sublet an office, if you're starting out, where there are other therapists for support and potential referrals.
• Make or download forms to make charting easier, or use good practice management software (see Practice Mate, above).
• Get on every insurance panel you can, that pays a decent fee. Robert Odell added that if you can't get on the panels, get on the EAP lists. He and audience members added that you can sleuth out people who have fallen off the panels, by calling them to see if they're still in practice. Then tell the insurance company that they're not actually full since these 10 people are no longer operating in your zip code. You can also get physicians or mentors to write letters for you saying that they want you on the list to send referrals to you.
• Market yourself: Tell everyone you know. Do that by developing an expertise that is something you know about, are good at, and love to do. 

1.  Get a website. If you don't want clients under 35, you may not need it. People find services on the internet. GET A WEBSITE if you want clients and professionals to find you. Make sure there's a picture on it. Look at other people's to see what works.
2. Establish yourself as an expert by writing a blog or doing twitter. Use your blog or twitter account to give useful information to professionals and/or clients. Don't "friend" clients on Facebook. Don't share personal information on your professional blog or twitter account. We don't care what you had for breakfast or that you're in love. We want to know how to do what we do better. Always give credit to others. Never badmouth anyone in your professional blog. The net is forever.
3. Go to networking groups and speak up.
4. Give workshops, write books, be known.
5. Get on referral services, either general (Psychology Today) or specific (EMDRIA).

• Never stop learning. Become a workshop junkie. Never settle on just one kind of therapy. If you do, you won't be able to help many who come to you. Keep the work fresh by bringing new eyes to it.
• Get great consultation. To save money, network, and get more hours of consult that you can afford yourself, join a consult group. Create or join a free peer consultation group. It's best not to be the most senior or knowledgeable person in the group: you're there to learn. Do not stay with a mean or unsupportive consultant. This work is hard; find someone who has expertise and can support you through the tough clients.

Jay Gelzer (who btw wants you to know that she loves to work with "gifted" people of all ages) gave great handouts. She suggests converting your business land line to a cell phone, and sharing office space. And she talked about looking closely at your revenue and expenditures: know what your real expenses are and your real revenue. Know what you're actually taking home as spendable income. She said that in this recession, or as a new practitioner, it might be necessary to support your practice, until it supports you. And market yourself (see above).

Robert Odell and Heidi Wasch took questions. Odell suggested a web-based fax service: faxaway.com and a web-host: Aplus.com. Someone else suggested blogspot.com  Heidi suggested swapping offices one day a week with someone in another location. It works for her and has expanded her client base.

It was a very nice 3 hours with a nice turnout for a sunny Saturday, about 35 people.

Staff Diaries Prevent PTSD in Surgical Patients

I've written about medical trauma, especially surgeries, creating PTSD. This article shows a simple way to prevent traumatization in some instances. 

Video with Amen brain scans and EMDR treatment of PTSD

Here's a 6 minute video of a Gulf War soldier's PTSD diagnosis with brain scans and then treatment with EMDR. He had a scary childhood, fear for his life in combat, and then was retriggered by witnessing a horrible accident. 

Nancy Smyth on Why therapists should know about social media.

Nancy Smyth writes a great blog about social workers and technology. Her latest post is about how some therapists proudly acknowledge ignorance and no interest in Facebook and other social media and explains why they're wrong. See it here. Then check out the rest of her blog.

Launching the new website

The new website is up now at www.emdrsolutions.com. The old one was out of date and I didn't have the expertise to modify it so I paid a site-building company to help me. Here are the questions we tried to answer. Click on the colored links to see the pages.

1. Who is it for? I wanted to be easy to find and easy to contact on line by any potential client, consultee or trainee, old school friend, conference planner or people interested in my books. 
2. What's it for? The above and providing information to people before they talk to me or who might want to link to other information sources. I want people to find out who I am, what I do, that I have this blog, and something about the books. I wanted them to have an easy way to sign up for my infrequent newsletter.  
3. What's it do? The above and save time. New clients can read the Client Information sheet online before their first session. Consultees can find out how my groups and individual consultations work and how much they cost. I plan to spend much less time on the phone and on email when I can refer people to these pages. 
4. How does it work? I have a small home page that has links to everything I do. The main links show at the top of every page so it's easy to navigate. Most links go to pages on the website. Some go to other sites. I'm on the EMDR-Humanitarian Assistance Program board and I link to them. There is a whole page of links to trauma websites and organizational sites. There are links on the book page for people to buy the books.

Why go through all this? The entire culture is moving to the web. If you want to be found, you'll move there too. Many people don't use phone books anymore, they type names and hit "search". People who teach, or work with other professionals, or who offer services like psychotherapy need to get their faces into the marketplace. Authors who have web pages support their books by creating easy online access to them.

My father was a business owner, selling industrial supplies. He sold everything from nuts and bolts to forklifts. From the ages of 8 to 16, I pasted hand-typed mailing labels and stamps on his catalogs to let other businesses know what he was selling. I'm doing something similar. By having a website, I'm letting people know that I'm here, what I'm selling, and how to get in touch. If you want to promote your practice, you may want to do the same.

My website was built by CHS Internet Development. I paid them $2000, met once in person, provided all the content, and had many phone calls, discussion, and some conflict. It is possible to do a simple website by yourself. Mine is a hybrid, developed by CHS, but I can modify it myself, as my professional life changes.

 

Therapeutic Metaphors from Star Trek and other Popular Culture

Utilization is the idea that therapists should use the culture and the language that their clients already use. If your client has watched Star Trek, they already know how to utilize these great tools. 

• Safe place: "Do you know what a containment field is on Star Trek? Great! So imagine your safe place has a containment field around it. No one can see it, no one can get through it, and it will keep you completely safe from harm."
• 
  
• Sharing between Parts with highly dissociated clients: "We've cleared a lot of the trauma that that part holds. Does the Adult part feel ready to know what happened back then? Good. Then let the child do a Vulcan mind-meld with the adult and share the information about what happened and what it was like for her. Let me know when the transfer of information is complete."
• "So lets bring this to the Holodeck and run through the event so you can control how it turns out this time."
• Practicing: "So lets create this situation on the Holodeck, you can direct the Holodeck to create facsimiles of all the players and you can practice how you want to talk to that person/ those people until you feel that you know exactly how to do it in real life."
• "Now imagine transporting that 5-year-old self out of that bed and out of that time, letting her rematerialize right here and right now. Is she here? Then let her know who you are and where she is and that she's finally safe from that guy."
• Other magic:
• "What would Harry Potter do? What spell would you cast?"
• "Imagine you had Superman's/Wonder Woman's strength? What would you do then?"
• "So could you go back in time with Doctor Who and rescue that child?" (For Brits)

My clients are delighted when I speak their language and use what's already in their brains. If they've spent years with Star Trek or Doctor Who or the mutants in Heroes, their mirror neurons have already had them doing the magical activities, and are ready to take them into a different reality. 

Years ago, a cult-abused DID client cured her insomnia by imagining a Star Trek containment field around her bed, which she turned on before sleep. Later, after years of trauma-clearing and Vulcan mind-melds between related parts, she did a mind-meld between all remaining parts and integrated (mostly) in my office. 

  

Trauma Treatment Handbook: Protocols Across the Spectrum

My copy of the new book arrived today. Here is what Diana Fosha says about it:

"This is a thorough, accessible, and very practical book, filled with resources and sound ideas, filtered through the intelligence and experience of a savvy, compassionate, down-to-earth, and very experienced clinician. It is like a travel guide to the land of trauma and trauma treatment: if you are new to it, it will orient you to all there is to do and see; if you're a frequent traveler, it is a worthwhile reminder of all that is out there, above and beyond the familiar places you always visit. Once could ask for a better guide. I highly recommend it."

I explain trauma, complex trauma, dissociation and how to assess them and prepare for treatment, and all the kinds of treatment that I know about from the main-stream to the obscure. I talk about working with military, sexually-abused, and relationally traumatized people, and how to take care of yourself while doing the work.

 Some of my heroes comment on it. Dan Siegel wrote the introduction, despite my lack of research. Diana Fosha, Stephen Porges, Kathy Steele, and Onno van der Hart wrote very nice blurbs on the back. I'm humbled by their support.

This is the first book written completely by me. I'm amazed to be responsible for synthesizing so many people's therapies in one book. The design is great, and the photos, by Doug Plummer (my beloved) are gorgeous.

First Person Account of EMDR

Mary Elizabeth Williams talks about receiving EMDR after a mugging. On Salon's site:

http://www.salon.com/life/feature/2010/07/23/emdr_after_a_mugging/index.html

Is life more fun without children?

Is life more fun without children? Read this lovely, heart-breaking story from Jennifer Lawler, a mother writing about her experience with her severely brain-damaged child:  http://jenniferlawler.com/wordpress/?p=747&cpage=9#comment-1554 . I think her answer is, "It doesn't matter."

"Anxiety" on To The Best of Our Knowledge

A great hour of interviews about anxiety on one of best radio shows around. This one includes Patricia Pearson, author of A Brief History of Anxiety, Yours and Mine, and her own experience with anxiety medications and learning to self-soothe; Ethan Waters, talking about the globalization of American psychiatric diagnoses and pharmaceutical cures; Dr. Daniel Carlat, a psychiatrist talking about the problem with psychiatry, especially in regards to medications and drug companies; and a cool discussion about anxiety-provoking sounds in Kafka's writing. Lots of good links on their website. Check out the anxiety podcast at the top of the links page here.

Chillout song from ZeFrank

Here is a sweet short song about being okay, "just fine" and breathing. Good for anyone.

Chillout song from zefrank

EMDR-Humanitarian Assistance Program and Doctors Without Borders

I spent yesterday afternoon at a fundraiser for EMDR-HAP's Haiti project and last night at "Living in Emergency", the new Doctors Without Borders/MSF film, followed by a live discussion with MSF staff/volunteers. I'm left with two feelings: overwhelmed that there is so much untreated physical and emotional trauma in the world and gratitude and hope that volunteers have taken on the task of doing what they can to heal it.

(Full disclosure: I'm on the board of EMDR-HAP.)

The EMDR Humanitarian Assistance Program started 15 years ago as a sub-program of the EMDR Institute, to address the psychological trauma of disasters. HAP's first big project was sending therapists to work with first responders after the Oklahoma City bombing. After volunteers used EMDR to clear the trauma for medics, fire-fighters, police, and others, some stayed to train therapists to work with the rest of the population. HAP started out responding to disasters and now has a new mandate: building capacity to serve underserved traumatized communities. While they still respond to specific disasters like Katrina, the Turkish earthquake, the tsunami in Indonesia, etc., they are building capacity by training therapists to do EMDR in those places, and in underserved communities in the U.S. and around the world. HAP has done trainings for community mental health centers, rape crisis centers, children's agencies and military services in the U.S. Its volunteers have trained therapist who work in Israel, the Palestinean territories, Iraq, Egypt, India, Bosnia, Indonesia, Kenya, Mexico, Columbia, and many other countries. Therapists or agencies may pay the expense of the trainings (dirt cheap, since all trainers and facilitators work for free) or grants may underwrite the entire expense. HAP, under its wonderful director, Dr. Robert Gelbach, has turned to "building capacity". Its goal is for each country or region to eventually grow its own training capacity, so that we can bow out and send our volunteers to other places.

HAP is also promoting Trauma Recovery Networks, regionally-based mostly autonomous groups that train themselves to work with disasters or underserved populations. I'm in the beginning of starting such a group in the Seattle area.

Doctors Without Borders (Medecins Sans Frontieres/MSF) was started in 1971. It sends medical personnel to over 60 countries to deal with victims of war and other disasters. Volunteers sign on for a 6-month or more hitch and deal with the medical issues of extremely underserved people. Most of the medical people come from developed countries and most do their stints in places with inadequate supplies, electricity, and communications. In "Living in Emergency", I saw the doctors deal with the deaths of patients they would have been able to save in more modern settings. I saw them dealing without the basics of sanitary surgery and doing amazing work (as far as I can tell). Many doctors smoked. All drank. Many used sex to affirm life while surrounded by death. The stress was amazing. About half do a second stint. Some sign on indefinitely.

I noticed the difference between HAP and MSF. Most HAP volunteers fly away for 3 or 4 days or a few weeks, at most. HAP, being a mental health-based agency, pays attention to the stress of its volunteers. MSF, according to the movie and to the discussion, believes that volunteers are responsible for themselves and should deal with their own problems. There is debriefing, but no formal mechanism for support. It made me wonder about a HAP-MSF connection. Could we at HAP have our EMDR therapists available to assist traumatized MSF personnel?

Go see "Living in Emergency". If you want to learn more about Doctors Without Borders/ MSF go to http://www.doctorswithoutborders.org/ . If you want to learn more about EMDR-HAP go to www.emdrhap.org . Feel free to leave a donation at the websites. These folks are doing great, life-giving work.

 

 

 

Washington State Parity Law for Psychotherapy Sessions

On July 1, 2010, insurance companies in Washington state will have to provide unlimited sessions for psychotherapy clients in most categories. After fruitlessly spending more than 10 hours trying to get Regence Blue Shield to flip an inpatient benefit into outpatient sessions, I remembered the new law. I then called up another part of the company and a nice man explained to me that the client will have unlimited sessions starting July 1.

Don't assume it with every client. Check with the company if you're not sure.I'm sure this means that we Washingtonians will have to be even more scrupulous in record-keeping and diagnoses to prove "medical necessity". Otherwise, Hallelujah!

This came about by the tireless efforts of the Washington State Coalition of Mental Health Professionals and Consumers http://www.wacoalition.org/ and especially the great work by Laura Groshong our amazing lobbyist. Thank you WS Coalition!  If you are a therapist in Washington State, go to the website and join now. It's a wonderful organization.

 

 

Insurance Company Scam

If you get a phone call from Multiplan asking you to lower your fee with an insurance company in order to get "expedited payment", turn them down. This happened to me and to a colleague of mine. First your insurance company doesn't pay you for sessions that you did. Then Multiplan calls you and says that if you lower your fee it will help your client. They wanted me to lower my fee $30. After intensive questioning, the agent told me that it would lower the client's copay by $5. Guess who gets the other $25? That's right! It's the insurance company. Given that the companies make massive profits and the executives get millions in bonuses, I'm not willing to further subsidize them. And neither should you.

And what's with withholding pay and offering "expedited payment." WTF?