Trauma & Attachment Therapy

New blog and a new book

I've got a fancy new website at emdrsolutions.com. All of my old blog posts and all the new ones will be there. The full address is https://www.emdrsolutions.com/ It's easy to read and easy to use. I look forward to seeing you there! And Doing Psychotherapy came out last week. It's the newest book and it's full of everything I wished they would have taught me in graduate school: 1. How to stop and and how to end a session, or a therapy. 2. How to make goals, and meet them. 3. How to work with anxiety, trauma, depression, and many other problems. 4. How to take care of yourself. 5. How to deal with marginalized populations, abuse survivors, and more. 6.How to pick which, of many therapies to use with a client. 7. Even a bit of how to argue with insurance companies. https://professionalbooks.cmail20.com/t/ViewEmail/y/B3BB66A7B9693018/9DB5899D0880DA9CEBAD456BEB5F1DD6

Breathing Ooouuuttt to Create Calm

38 years ago, when I did my first meditation retreat with Stephen Levine, we would do long OMs at the start of many other kinds of practice.  Last night, 35 years after my last class, I started another meditation class, this time with Jamal Rahman, a Sufi teacher. With each of the nearly 40 OMs we did, I recognized that we were directly impacting our vagus nerves by our long outbreaths, creating grounded calm and realized how brilliant the original Buddhist teachers were, so many centuries ago, to create this practice.

When we breathe out longer than than we inhale, it trips the vagus nerve to quiet the unmyelinated ventral part (tied to flight and fight) and switch to the myelinated ventral part, tied to relaxed, socially connectible, "normal" states. People with trauma or anxiety are taught to relax their panic, OCD patterns, flashbacks with this exercise: "Breathe out all the way. Hold. Breathe in halfway. Hold. Breathe out all the way. Hold. Repeat several times."   And they do relax.  I love that the old learning meshes so well with the new! 

My other favorite calm down method for anxious folks is "Silencing the Alarm": "Brush the fingers from the inside point of the eyebrow to your ears, behind your ears, to the point of the shoulder, the point of the elbow, and off the back of your hand. At least 3 times on each side." I learned this in the context of quieting the triple heater meridian. When I taught it to 1,200 people at a NYC conference, Stephen Porges, the Vagus Nerve researcher, told me and the whole conference that it worked because it directly impacted the vagus nerve. Who Knew!

 

Interesting 45-minute documentary of DID woman who got her father put in jail.

https://www.youtube.com/watch?v=lsXFcbPbvI4

Interesting, somewhat sensationalized, video from the Australian 60 Minutes show, about a woman who went to the cops and won in court.

The story is brutal, as is often the case for people with massive dissociation. The outcome is lovely.

Check it out!

Online 2-Day Class of Easy Ego State Interventions

Hello,

I'm going to be in Massachusetts on June 14 -15 teaching my ego state class. If you want to live-stream it (or show up for it) go to this website to sign up:

http://www.markinickerson.com/registration/?action=evregister&event_id=127

Here's the program description:

Participants in Easy Ego State Interventions learn how to see clients through the lens of ego state therapy and EMDR and to distinguish healthy, flexible states from dissociative ones. Through lecture, guided experience, case examples, demonstrations, role-plays, and practice they will be able to utilize their awareness of vagal states, body types, and trauma and attachment histories to make accurate diagnoses, plan treatment, clear trauma, heal attachment issues, and enhance relationships with ego state therapy. The workshop includes content differentiating normal ego states from dissociative states; Stephen Porges’s Polyvagal theory as the basis for many states; how ego state interventions work; the Theory of Structural Dissociation; accessing functional and dysfunctional states; the 2-Hand Interweave technique; a simple trauma protocol with ego states; material on attachment to abusers and working with survivors of sexual abuse to create a healthy sex life; April Steele’s Imaginal Nurturing protocol and healing place interventions if there is a phobia of younger parts; working with relationship issues, including using adult states to pick a good partner; Calming over-active immune systems and chronic pain with EMDR and ego state work; working with personality disorders, including Borderline, and both Exhibitionist and Codependent Narcissists; and several hours on working with Dissociative Disorders including Dissociative Identity Disorder (DID). The DD work includes diagnosis, working within the Theory of Structural Dissociation, many case examples, a review of useful tools, including use of the Dissociative Table, Healing Places, and “Switching” Places. It also speaks to the self-care of therapists who work with this population. 

My History with Ego State Therapy

I wrote this as a prologue to the Greek version of Easy Ego State Interventions and realized that it will make a good post:

I have been looking through the lenses of ego state therapies since 1981. During that year, my first out of graduate school, I took a course in Eric Berne’s Transactional Analysis and learned to identify the “Parent”, “Child”, and “Adult” parts of myself and my clients. It was useful to notice when I, and other people, were coming from our kid states, our introjected parent states, or our chosen, skilled, present-oriented part of self.

In the same year, I read and took classes in various hypnotic techniques, and learned my most used ego state intervention: “Go inside, and find that part of you that (1) having that feeling/ (2) having that belief and/or (3) can tell you when in your life that belief/feeling started.”

My consultant, Thom Negri, gave our group the experience of finding our own inner children, and promising to care for and protect them.  I’ve used this intervention with nearly every client, and learned new twists from April Steele and others, which I continue to use.

Before I learned EMDR, in 1993, ego state therapy was my best tool for healing trauma. I would direct clients to compare their present-day safe selves with their past stuck-in-danger selves, and to rescue the endangered younger selves. After I learned EMDR, I continued to interweave ego state interventions with the new therapy. I, and many others, found that the more dissociation a client had, the more necessary ego state interventions were for both preparation and interventions. With some unstable clients, straight-forward ego state interventions are still the treatment of choice.

In 1988, I started working with my first client with dissociative identity disorder (DID). She had been ritually abused and had at least thirty parts, many of which had no awareness of each other, or the present day. I read every book, took every local training, and started spending more on clinical consultation than I ever collected from that client. Learning how to work with her dissociation informed my ego state work with everyone else. I began to see the “parts” in borderline personality disorder and other attachment-challenged clients. I became more adept at getting all clients to talk to their parts. And, of course, I learned just how brilliantly complicated work with a DID client could be.

In 2006, when van der Hart, Nijenhuis, and Steele’s The Haunted Self, was published, I got a lovely roadmap for perceiving and healing trauma and dissociation. A more accessible book, Treating Trauma-Related Dissociation, by Steele, Boon, and van der Hart, came out in 2017, and is now the bible for working with DID clients.

I’m grateful to be providing this work to therapists in Greece. Ego state therapy can be of use to nearly every client. Seeing and treating people through the “parts” lens is often transformational. Intractable problems can melt away when therapists see the stuck child parts in the dysfunctional adult. I hope you find this work as useful as I have.

Problems with Dear Evan Hansen

Last night, I saw Dear Evan Hansen, the musical about an anxious, shame-filled high school senior. The play deals with broken families, suicide, OCD, social anxiety, and attachment. The music and the singing in this touring production was fantastic. I cried several times, and laughed a few. Still I was distressed with some serious problems:

1. The "therapy", for the boy, which we never saw, was Evan writing a letter to himself, each morning, about how good his day would be. Ineffective CBT, with no dealing with his evident attachment issues (abandoned by dad at 7, and with a completely unavailable (time-wise and attention-wise) mom, nor his obvious social anxiety, PTSD, and OCD.
2. The suicide of a main character, the son of another family, was never fully characterized. We know he used drugs and avoided school, was shame-filled and narcissistically violent, in an attempt to protect from that shame. But we didn't know much else about him.
3. A main character, Jared, was an obviously Jewish stereotype that made me cringe: loud, manipulative, whiny, and somewhat sociopathic. Even though the man who wrote the "book" of the play, is probably Jewish (Levenson), it felt very anti-semetic to me.
4. Evan's own suicide attempt is hinted at, throughout, but never really explained. And he never gets real help. This could have been a great way to show a kid talking to a crisis-line, or in a group, or otherwise getting good care. A lot of teenagers see this musical, and it could have been a great way to show what's available. There were texts, emails, Facebook, and instagram posts in the background of the set, throughout. I wish they would have had Evan or others interacting with https://www.crisistextline.org/ as a way to show where help is available. 
5. There's a homophobic setup at one time. I wish it wasn't there.

Australian Prime Minister Apologizes to Sexual and Ritual Abuse Survivors!

Here is a link to speech by Scott Morrison, the Prime Minister of Australia, from 11/25/2018, apologizing for his society's lack of support for and belief of sexual and ritual and institutional abuse survivors. I would like to see every leader of every country make this speech.

For the video: https://m.youtube.com/watch?v=zp5IgxPhee4

For the transcript: https://www.sbs.com.au/news/i-believe-you-your-country-believes-you-pm-s-apology-to-child-sex-abuse-survivors

Easy Ego State Intervention Workshops

Dear Readers,

Ego state work has been around since before Freud, and in latter years, has been the main stay of many practices. Interventions can range from "How old did you feel when you were yelling at your wife?" to "Let's identify those dissociative states that take over your body." I've been working with this stuff since I became a therapist, 38 years ago, and have read, been taught, taught, and written about it, extensively. It's one of the most versatile tools and lenses through which to see clients that I have.

In January, I expanded my 2-day Ego State training to 3 days and presented it in near London, England. there was time for practice, demonstrations, and some case consultations. Participants raved about the workshop, saying things like "I know MY parts now!" "I know exactly what to do with many of my clients!" "This is the most practical workshop I've taken!" There is special info for EMDR practitioners, but you don't have to know EMDR to take the workshop and get credit. EMDR practitioners get 12 hours for EMDRIA and 12 for their profession. Others get it for their profession.

I'm  giving it several times this year. 

• 4 days in Milan,Italy.  May 10 -13 https://www.international-isc.com/wp-content/uploads/2017/12/brochure-shapiro-ing.pdf
• 3 days in Seattle, WA, June 8 - 10 https://www.eventbrite.com/e/easy-ego-state-interventions-seattle-tickets-44375863402  
• 2 days in Des Moines, Iowa October 20 and 21st, link to follow
• 3 days in Boston November 9-11, link to follow

Here is what I cover:

• Distinguishing Healthy/Flexible and Dissociative Ego States (and map your own)
• Overview of Ego State Interventions
• Identify Vagal States
• Use Embodied Ego State Interventions (includes practice)
• Clearing Trauma (includes practice)
• Theory of Structural Dissociation
• For EMDR practitioners, distinguish when EMDR, when EMDR and when both are the treatments of choice
• Tools to work with sexual abuse, and then bring back healthy current sexuality
• Work with Attachment Issues, including April Steele’s Building a Secure Self (practice)
• Couples Therapy
• Calming Over-Active Immune Systems, Multiple-Chemical Sensitivity (possible demo, if someone has one)
• Pain Protocol
• Shame (practice)
• Suicidal clients
• Resourcing (including installing your own “team”)
• Healing Personality Disorders
• Working with Dissociative Identity Disorder

If you can't get to a workshop, you might read Easy Ego State Interventions or sign up for one of the many good trainings on this subject. It's good stuff to know!

Grieving the Loss of a Child

A participant in an overseas workshop sent an email request: 

"A patient of mine, a woman in her 80's, lo"st her son at the beginning of the year. She already took antidepressant drugs, but at the moment she no longer does. However, she still feels deeply sad. What are your suggestions?"

This is what I sent her: 

It is absolutely normal for a mother to grieve her dead child for many more than 9 months. Do EMDR with the trauma around the day he died or the worst parts of the dying process, and the wanting to see him/talk to him and he's still gone. If she feels that should have saved him, do EMDR with the cognitions about that. Otherwise sit with her, hold her hand, look in her eyes and let her know that horrible grief is a sign of the good attachment she had with her son. (My mother took a few years after the death of my brother to start to feel okay in her life. We all still miss him, 21 years later, but no more acute grief.) Let her know it will worse on holidays, his birthday, her birthday, and especially bad on the anniversary of his death. She had at least a 50-year attachment to this child. That's an enormous loss!

Here are some tools for both of you from my writing about grief:

"Normalize the grief experience. explain that people move through the stages over and over. It may be in minutes, on seeing someone who looks likes the loved one on the street, then realizing the loss, again, the anger at self for being mistaken, the hopelessness, again, that the loved one is really gone, and re-integration. or the stages may last for months or years. When clients can identify the stages, they feel less out of control, and see a progression to the process. Move on to the Rules of Grief, normalizing the experience and that our society doesn’t have a realistic idea of the depth and length of the grief process. I often paraphrase Stephen Gilligan: “It is the job of life to make every human being feel every possible emotion at every possible intensity. It is the job of human beings to allow every emotion to move through unimpeded.”

Stages of Grief:  (May occur in succession or over and over.)

1. Shock and disbelief
2. Anger and blaming: Self, the one who is gone, doctors, fate, God, et.al.
3. Sadness, depression, hopelessness, yearning
4. Integration, alternating with all of the above.
5. Over the acute grief and still missing your person.

My Rules of Grief:

1. It always hurts more than you think it should. 
2. It always last longer than you (and others) think it ought. 
3. It makes you tired, cranky, stupid or feeling hopeless. 
4. avoid it and it stays terrible, creates depression and/or useless busyness. 
5. Feel it all and it gets better

Differentiation and Integration in The Big Sick, Fun Home, and Trumpet

    In the last three days I've had the pleasure of watching the fabulous movie, The Big Sick, the incredible musical Fun Home, and reading Trumpet, A Novel. All three are great art. The first two are based on the writers' lives. All are about "coming out", or not, to one's self and one's family and culture. All show how how when people hide who they are, they are separated from the people around them and have internal parts that are dissociated from each other.

    In Big Sick, Kumail Nanjiani (who plays himself) is a Pakistani-American in love with a white, non-Muslim woman, who cannot show his parents who he is and who he loves. In Fun Home, Alison Bechdel does come out to herself and her parents. Her father, a closeted gay man, commits suicide rather than being fully known in his small town. Jackie Kay's Trumpet, is a novel about the fallout surrounding a married transgender man's outing upon death and it's effects on a variety of characters, in and outside the family. 

We all have ego states. We may have a different persona in a work situation, at home, hanging with our best friend, or dealing with an emergency.  Unless we are highly dissociated, we can move smoothly between "parts" and roles, bringing up the most germane set of skills for each situation. When we are not "acceptable" as we are, we may hide that part, even from ourself. We may repress it, or simply develop a separate persona in a separate arena--the secretive gay bars and "tea rooms" of the past, the hidden online communities for any "kink" you can imagine, of the present.  

When we accept who we are and what we are, and can be that person, we can be whole, but the process is not easy. Telling the family that we are not practicing the religion, the gender role, the choice of partner, the expected occupation can bring us disapproval (at the least), ostracism, and in some cultures, death. Even if it's "mere" disapproval, it's difficult. We are wired to please those people, to belong, and to be protected by the family. We define ourselves by how we are seen and treated. Going against that by choosing differentiation (being who and what you are even if people don't agree or approve) is scary and can bring up big shame. Not doing that, kills the possibility of true intimacy: being known. And it may separate us from ourselves.

In Big Sick, we get to see Kumail, after being accepted by another family, be able to "come out" as secular and in love with a blonde. In Fun Home, Alison goes to college, falls in love, and is able to accept herself and tell her family. Later in life, she creates a (wonderful) graphic novel about her coming out, and the tragic end of her father, who never could. In the musical, Alison as a child, a college student, and an adult sing together, bringing all parts together for a perfect integration, that brought down the house.

After 25 years of marriage and 36 years of doing therapy, I can speak to the importance of self-acceptance and true intimacy to my life and my relationship. As a bisexual person, a Jew in a Christian country, and not-very-gender conforming person, I can speak to the importance of being out and known, even when I'm not accepted. I am known by the people who want to know me. I am self-accepting (knowing that I can always improve). My husband and I strive for openness, even when the other one doesn't adore or agree with an opinion or aspect of us. 

As a therapist, it's my job to help people accept all of themselves, heal what can be healed, and bring all parts to eventual integration or integrity.

 

 

    

Volk Decision: Washington State Therapists Now Liable for Violent Acts of Former Clients!

This is from Laura Groshong, the lobbyist of the Washington State Coalition of Mental Health Professionals and Consumers. I'm appalled by this decision and that we are now liable for every client we have ever seen!

Changes to Practice of Mental Health Clinicians Based on Volk Decision

April, 2017

Laura Groshong, LICSW, Mental Health Advocate

The Washington State Supreme Court recently decided the case of Volk v. DeMeerleer (No. 91387-1) on December 22, 2016. The 2017 Legislature declined to undo the decision through legislation this session.  The defendant in the case was a psychiatrist who had seen a very disturbed patient off and on over several years in Spokane who had not mentioned intent to commit violent acts. The former patient then murdered two people three months after leaving treatment. The Supreme Court held as follows:

“We hold that Ashby (the psychiatrist) and DeMeerleer (the patient) shared a special relationship, and that special relationship required Ashby to act with reasonable care, consistent with the standards of the mental health profession, to protect the foreseeable victim of DeMeerleer….The foreseeability of DeMeerleer’s victim is a question of fact appropriately resolved by the fact finder.”(bold mine)

The Supreme Court overturned the trial judge in the case, holding that the judge was in error by using the standard in the Tarasoff case, which requires a licensed clinician to take reasonable precautions to protect only an identifiable victim that is threatened by a patient.

The Court instead relied on the case Petersen v. State of Washington (100 Wn.2d 421 (1983)), in which the Washington State Supreme Court found that Western State Hospital had a duty to take reasonable precautions to protect anyone who might be a foreseeable victim of a patient at Western State.   It is important to understand that the Petersen case was decided in the context of inpatient treatment, while the therapist in Volk was a psychiatrist who saw patients on an outpatient basis. With the Volk holding, the Washington State Supreme Court appears to have created a new duty for outpatient clinicians: that a mental health clinician has a duty to take reasonable precautions to protect anyone who might foreseeably be endangered by the clinician’s client - even individuals who have not been identified by the client.

The idea that an outpatient clinician can determine whether there is a “forseeable” risk of harm to 1) someone who has not been specifically mentioned to a clinician as a target of harm and/or 2) is no longer in treatment with the clinician is hard to fathom, but that appears to be the holding of the Washington State Supreme Court in Volk.

The case will now be returned to the trial judge to determine whether the individuals who were harmed by the therapist’s client were “foreseeable” victims of the client. 

Impact on Mental Health Clinicians

Due to the fact that the Washington State Supreme Court has decided to hold outpatient therapists to the Petersen standard, as opposed to the Tarasoff standard, we as clinicians need to consider what changes we may need to make to minimize our liability for patients who do not tell us they plan to harm a specific person, even if the treatment has ended.

Consultation is one of the best ways to protect ourselves from liability.  When homicidal thoughts or actions are discussed, consultation should be considered, just as it would be when suicidality is discussed.

Clinicians should gather information on patients who may become homicidal (or suicidal; they are often related). Of course there is no way to determine whether a patient is likely to become homicidal or suicidal when they are no longer in treatment, but making these assessments while a patient is in treatment is a best practice.

One of our pre-eminent mental health agencies, Wellspring, has developed a Risk Assessment Tool for use if there is any concern about possible violent actions, suicidal or homicidal, on the part of a patient. This Tool is adapted here. Many thanks to Wellspring for sharing this Tool.

Risk Assessment and Protocol for Duty to Warn under Volk

HIPAA and Washington State privacy laws permit a therapist to disclose a client’s health information if the therapist, in good faith, believes the use or disclosure:

• Is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public; and

• Is to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

The definition of “imminent” under Washington law is: “the state or condition of being likely to occur at any moment or near at hand, rather than distant or remote.”  RCW 71.05.020(20).

Therefore, a threat could be “imminent” if a client informs a therapist that he is leaving the session to shoot family members. In this circumstance, the therapist is permitted to take steps to protect the forseeable victims of the serious and imminent, such as notifying law enforcement, the Designated Mental Health Provider (DMHP), or the client’s family members who could be targets of the client.

A threat might not be “imminent” if the threat is more hypothetical (e.g. sometime in the future the client might be a threat to family members).

In order to determine imminent threats that might be posed by a client, therapists should engage in a risk assessment similar to the following:

1. Consultation - Any case that presents with reckless or dangerous behavior that may involve danger to self or others should be brought for consultation. Even if no specific threat is made to another person, consult as soon as possible with a knowledgeable colleague.

2. Suicide Risk Assessment – use accepted measure of suicide risk assessment and thoroughly document (factors to be assessed below). 

• Mental illness
• Physical illness
• Previous attempts
• Family conflict
• Unemployment
• Social isolation
• Suicidal Ideation
• Substance use
• Purposelessness
• Anxiety
• Feeling Trapped
• Hopelessness
• Withdrawal
• Anger
• Recklessness
• Mood changes

3. Homicide Risk Assessment - Use accepted measure of violence/homicide risk assessment and thoroughly document (factors to be assessed below):               

• History of violence
• Substance abuse
• Mental incapacity
• Organized plan
• Unavailability of support group
• Violent environment
• Mental illness
• Physical illness
• Previous attempts
• Family conflict
• Unemployment
• Social isolation

4. Documentation – Once the assessments are complete, document the decision making process, i.e.: “Based on the presence/absence of these risk factors and warning signs, I believe there is/isn’t a serious and imminent threat to harm, and that there are/aren’t any foreseeable victims.  I will continue to assess the situation, and if it appears that a serious and imminent threat to foreseeable victims is evident, I will contact those potential victims, the DMHP, and/or the police.”

5. Other Professionals Contacted – Document the names, contact information, and times any other mental health professionals, lawyers, DMHP, police, doctors, etc.

6. Forseeable Victims – Document any contact to potential victims of a patient. The clinician may contact individuals or entities who are reasonably able to prevent or lessen the serious or imminent risks to potential victims, such as the potential victim(s), DMHP or the police. In making the disclosure of the client’s health information, the clinician should comply with the HIPAA concept of disclosing only the “minimum necessary” amount of information to accomplish the intended purpose.  In other words, the clinician should release only the minimum amount of information to victims or police that would allow a forseeable victim to gain protection.  The disclosure might include a description of the client, name, workplace, history of violence, and why the forseeable victim may be in danger. 

Below is a summary of the suicide and homicide risks mentioned above that may be used as a way to identify the risks of a given patient:

Suicidality and Homicidality Assessment

Date:

Patient Name:

Date of Birth:

Presenting Problem(s):

History of Suicidality:

History of Homicidality:

Specific Current Factors Contributing to Suicidality:

___Physical illness(es)

___Previous attempts (detail)

___Organized Plan

___Family conflict(s)

___Unemployment

___Social isolation

___Suicidal Ideation

___Substance use (detail)

___Anxiety

___Depression

___Feeling Trapped

___Hopelessness/Withdrawal

___ Anger

 ___Recklessness

 ___Sudden mood changes

Other Factors:

 

Specific Current Factors Contributing to Homicidality:

___History of violence

___Substance abuse (detail)

___Intent to harm

___Unavailability of support group

___Violent environment

___Mental illness(es)

___Physical illness(es)

___Family conflict

___Unemployment

___Social isolation

___Access to weapons

___Target of violence

Other Factors:

Caring for Our Clients and Ourselves in the New Political Landscape

Two weeks ago, I gave a workshop for forty Seattle-area psychotherapists about getting their clients and themselves through the new political situation. People spoke about their fears, their clients' distress, and specific issues that have come up in therapy.( Steal all that you want, but give me credit, if you teach it.)

1.Fear of getting beaten, killed, or yelled at on the street by people who are obviously not white or non-Christian.

2.Fears of losing healthcare and social security. Distress about the environment.

3.Trouble dealing with family or others who voted differently. 

4. Hopelessness and Overwhelm with Media Coverage.

Here are some of the slides:

For yourself and clients:

• Feel everything and name each feeling.
• Decide how much media to take in
• Decide how you will do more self-care
• Connect with positive community
• Pick your active response: calls, letters, marching, volunteering for a threatened community, etc. And figure out your level of activity. Don't overdo.

How to talk about it with clients:

Grist for the therapy mill:

• Fears, current feelings, trauma, ego states
• I’m here for you, whatever happens (unless your insurance is canceled)
• Sharing? Clients first. Then, you may say how you’re adaptively coping.
• “I’m in your corner, whatever our differences.” “Do you notice I’m still caring about you?”

Look at their trauma history for Tx targets:

• Generational: Immigrant, ethnic or religious minority, violence
• Personal: bullied, discriminated, assaulted/abused?
• Witness: clients, media, friends, community

And deal with their here and now mobilization and possible tx:

• Immediately connect with here and now.
• Are you safe?
• Are you supported?
• Will you, personally, be threatened?
• Is it time for trauma therapy?
• Bad dreams, intrusive imagery or thoughts when doing something else, mobilized body?
• EMDR, Somatic Work, etc.

For yourself or your clients: Coping with Hopelessness (Dorsal Vagal States)

• Sag (acknowledge what you can’t do.)
• Move: feel strength. (“NO!”, “I want.” Warrior stance. Deep breath. Legs pushed into floor.)
• Acknowledge what you can do: Time, $,
• https://99waystofighttrump.com/
• https://www.indivisibleguide.com/web
• https://www.bustle.com/p/100-ways-to-fight-back-in-the-first-100-days-of-the-trump-presidency-31817

Address the past first:

• dress the past first. “What old stuff is arising in response to Trump?
• “He’s just like my abuser.”
• “That pussy-grabbing thing reminds me of ______.”
• “The bullying I got for being ________.”
• “When my family had to ________.”

Sometimes it’s historical:

• “When my grandfather got shot by the side of the road, for getting his mail, while black.”
• Pogroms, Holocaust, Hidden Identities, Family stories, Genocide, Families split apart.

Recognizable Minorities: Race, Religion, Accent, etc:

• Instantly Identifiable: No where to hide
• Historical Trauma
• Currently even more targeted
• VALIDATE the reality of the fears
• Go after the past
• Go after the present
• Look at the future: Safety, allies, working for the community, including self

LGBTQ:

• May have lost family, church, and/or community for coming out
• Bullying for identity or gender-nonconforming appearance
• Targeted by Religious Right and Trump administration, 
• 30% of transgender youth report a hx of at least one suicide attempt. More in female-to-male people. (https://www.sciencedaily.com/releases/2016/08/160831110833.htm) Rate goes down when recognized as chosen gender.
• Scared of what happens now: marriage, adoptions, legal protections for jobs and services
• “When We Rise”, amazing new 8-hour show: http://abc.go.com/shows/when-we-rise: watch it if you want deep background on the community

Sexually or otherwise abused as kids or adults:

• Many triggered by Trump’s demeanor.
• “Grab them by their pussies.”
• Some now being harassed or grabbed in the name of Trump.
• Flashbacks, deskilled, regressed, or “switched”.
• Calof: “Every time you work with sexual abuse, you’re committing a political act.”

No trauma history, but

• Watching our country fracture, daily shocks
• Fear for the environment, healthcare, status of our country.
• Loss of healthcare
• Distressed by shootings, immigrant and border hassles, oligarchy, erosion of rights.
• More bad news, almost daily.

Discussing the Situation with Clients:

• Stay Client-Centered
• Share, for the client.
• Let clients bring it up
• Ask questions about their experience and their affect.
• “Does this connect with anything from your past?”
• “What age goes with this feeling? What was happening then?”

Trauma Therapy: Go after historical and clients' past traumas first.

1.Use the best trauma therapy you know with past occurrences—may be a lot

(EMDR, Ego State, Life Span Integration, Somatic Tx, etc.)

2.Go after the current traumas: threats, shootings, Trump’s demeanor, the news

3.Look at future occurrences. It’s not over. How will they cope if _________?

4.Plan for current life,

1.media (how much to watch)

2.community (hang with people who care for you and support you) Singing? Dancing? Snuggling?

3. self-care: what works to make you feel good? Exercise? Meditation? Good food? 

4.action: political, volunteering, phone calls, letters, talking to people, marching.   How much is enough? Have limits, pick what works, do it.

YOU CAN'T FIX THE WORLD. YOU CAN HELP YOUR CLIENT COPE WITH THE WORLD.

And here is an article from the Seattle Times about the same thing: http://www.seattletimes.com/life/wellness/mental-health-therapists-see-uptick-in-patients-struggling-with-postelection-anxiety/

 

Healing MCS and Graft vs. Host Disease

MULTIPLE CHEMICAL SENSITIVITY CASE

On Friday and Saturday I gave a workshop about combining EMDR and Ego State Therapy. At the workshop, I did a demonstration with an attendee who was 8 months out from a horrible allergic reaction to crab meat. Since then she's had daily hives, breathing issues, and has had a very limited vegan diet.  She reacted to meat and fish,wine, air-borne odors and chemicals, and substances she can't identify.  We used EMDR to clear the first huge horrible reaction from 8 months ago. Then I asked her to imagine the control room of her immune system in her brain, and asked her who was in there running it. "A big burly guy named Bruce." I told her to put on her CEO business suit and persona, march into that control room and tell him to Stand Down, aim the immune system only at bacteria and viruses and stop being so over-protective. She immediately started to feel better. We imagined that if "Bruce" began to over-perform that she could tell him to "Stand Down" again.

The next day, she told the group that she'd felt much better, had had to tell Bruce to calm it down about 4 times and that she was no longer reactive. She'd had a glass of wine for the first time in 8 months. Last night I saw her eat her first fish in months, with no reaction. And she was having none of her life-long allergy to cats, at least not to my cat.

GRAFT VS. HOST DISEASE

About 15 years ago, I invented the above protocol when my friend Elizabeth and I were practicing on each other at a training. Over a year ago Elizabeth contracted a horrible leukemia and spent months in the hospital awaiting a good match for a stem-cell transplant. Finally, the cells arrived from Europe and the transplant was done. Elizabeth then developed Graft vs. Host disease: the new cells attacked her body and started to kill her. (GVHD has a 50% mortality rate.) The doctors gave her steroids and other drugs to knock back the immune response, but they didn't stop it and Elizabeth got sicker and sicker. She called me to the hospital. In two sessions we used the same kind of ego-state work, with nearly continuous bilateral stimulation, that we had done years ago for her MCS.

I asked her to personify her new immune system--it was a scared little boy. "Too bad you don't know what to do with anxious kids," I said to the wonderful mom and amazing child therapist."I'm holding him and telling him he's safe, he's with me, and he doesn't have to attack anything."    After a while she reported he had calmed down.

Me: "Tell him you're going on a tour of the body and you'll show him what's safe and what he needs to protect you from."

And we went through the list of bodily organs and places, while he was safely held." Elizabeth was exhausted after about 30 minutes of processing. When I checked in with her a few days later she had more energy and she said the little boy was chasing butterflies in a field and much happier, and she was much better.

The next week, she called me again. The "attack" was more localized: just to her digestive tract. And there were many boys.When I got to the hospital, I had Elizabeth round up the boys and announced we would take them on a spelunking tour through the entire "cave" of the digestive system. I turned on the tappers, and we "led" the boys through the "cave" from the throat, through the esophagus, to the stomach and all the way through the twisty-turny intestines. I told Elizabeth "tell the boys that they may not attack the walls of the "cave", or the "good" bacteria bugs that were around. These bugs are needed to help digest the food. You can pet them and play with them, but not hurt them. However, the bad bugs, like e-coli and C-Diff, are fine. You can stomp those bugs to death and have fun doing it." She felt even better, though still tired.

After that she had rapid improvement, but got traumatized by one of the doctors. He had been off that floor for a few weeks. When he saw Elizabeth with color in her face, walking the halls with a bit of vigor he was shocked. "You're still here."

"Yes, but they're going to send me home in a few days." 

"No, but I mean, you're still here."

"What do you mean?"

"People don't survive what was happening to you."

When Elizabeth got out of the hospital, I did a home visit and we cleared her response to that distressing conversation.

She's been home for months and is exercising, driving, able to hold her granddaughter (she couldn't before with depressed immune system.) And the "boys" are behaving in their new body, just as they should.  When she's got more energy, we think we'll write a journal article about GVHD and our work with it.

(I wrote a chapter about Multiple Chemical Sensitivities in EMDR Solutions II: for Depression, etc.)

 

 

 

 

Treating Racial Violence and Harassment in the Trump Era

In mid-June, a woman with a young son returned to the park-and-ride in a suburban Seattle town. On the car was a note: "Kill all Niggers! I'm gonna kill you the next time I see you. KILL KILL KILL. KILL OBAMA." The woman called her white husband, who told her to get out of there and call the police. The police said it was a hate crime and that she should never go back to that parking lot. "Take another bus to work, that's dangerous." At that point, the terror for herself and her son and her two other sons at home arose. Within weeks, two black men were killed by police, one in Minnesota, on in Texas, and the woman came to see me for awful PTSD: nightmares, anxiety, flashbacks, fears for her kids.

At the first session, the intake showed a good family: white mom, black dad, 2 siblings. Good parents. Raised on a farm, the only black people in the county of a northern state. Advanced education, great job, good husband, great kids, well attached at home, at work, and with friends. We used a modified EMDR protocol, EMD, with finding the note, and her distress cleared from a 10/10 to a 4/10 fairly quickly, and then stayed stuck--"What if it happens again?" "What if he figures out who I am and where I live and comes after my boys?" "And by the way, I've been thinking about things I never think about" including

1. My black grandfather was shot to death by a white man he didn't know, on the side of the road in the South, when my dad was 5.
2. My brother was shot and nearly killed by a white man he didn't know, in Eugene, when he was getting into a car. He has scars all over his body from the bullets.
3. When I was a kid on the farm, me and my cousins climbed over a fence to the BLM (public lands) where people used to do target practice. Some white men drove up in a truck and aimed their rifles at us and kept them aimed until we ran far away, back to the farm.
4. All the times I was called the "Nigger", or sneered at, or left out of things, or harassed on the street. . . .
5. Etc.

So we did EMDR on all these targets and a few targets that had to do with death that weren't directly about race. The trauma has cleared beautifully, and in these few sessions we have bonded wonderfully, laughed together, and I've shared her anger at what's happened to her, what's happening in the country, and her fears for herself and her kids.

She had already told me that I could tell her story. At Monday's session, When I told her that her anxiety was all PTSD, and that she wasn't wired for anxiety disorders, like Generalized Anxiety or OCD, she sobbed louder than at any other topic. "All my adult life people have told me I have GAD. Doctors have given me medication for anxiety."

I said "Look at the trauma you have experienced! I don't anyone else outside of Syria, Iraq, or Afghanistan that has so many losses and near misses, in these years. . . Yes, you have anxiety, but you are a solid woman without the ultra-sensitive body that the born-to-be-anxious people have. This is trauma!"  

She cried some more, smiling. Then she said, "Thank you. I didn't know that the generational and cultural stuff had had this much effect on me. I try not to pay attention to that stuff. I always thought that there was something wrong with me, which was why I was suspicious of people, especially white men. Now I get it. It's trauma. Thank you!" 

She sighed, and dropped her shoulders. I told her that the danger to her and her kids was real, and that it might help to use awareness of the "now" to notice when she was safe. If she felt fear, look around. If there was no threat, let herself soften and notice the safety. Notice the good. And notice the exits. We're not done, but we're a way down the road.

-------------------------------------------------------------------------------------------------------

Another thing. Two other women have been threatened and one beaten in liberal Seattle. 3 guys got off the bus and grabbed another black woman who had a little kid. One held the child while two beat the woman to a pulp.     A white woman with black kids was chased home and had "Nigger-lover" written on her house. My client has contacted these women, to support them and be supported. This stuff has not been happening as much, until now. We're blaming the permission that Trump has given to show racism, anger, hate and violence. What do you think?

Update and New Workshop

Dear Readers,

(It appears that the many links in this post aren't working. You're going to have to drag and drop into your browser if you want to see anything online. Sorry!)

It's been a busy year since I've posted anything. I blame Facebook and work in many other areas. Since my last book, Easy Ego State Interventions, was published, it and I have been getting a lot of attention, and many invitations to do workshops based on the material. At this point, I'm scheduled for Seattle, Edmonton, Omaha, and Rome. (That Rome!) And people are asking me to speak at conferences next to some of the big names in therapy. 

People and reviewers are telling me that the book is accessible and usable. They read it, and then go into session and are able to use the techniques with their garden variety clients, traumatized people, couples, and DID people. This is what I wanted, and I had to fight my publisher to do it. "It's not long enough!" "It doesn't have research!" "Ego states aren't a 'thing' anymore." (Oh yes they are, a BIG thing!)

I'll be doing a Easy Ego State Interventions Workshop on September 16 & 17, 9 - 4:30 in Seattle. If you'd like to see what the fuss is about, you can sign up at http://emdrsolutions.com/events/ . Or you can download or even buy the book at https://www.amazon.com/Easy-Ego-State-Interventions-Strategies/dp/0393709272 . I did the first workshop, in Ottawa, without EMDRIA credits. This one will give EMDRIA credits to people who do EMDR, and can work very well, and give credits to people who don't know EMDR, if you can stand a little talk about a therapy technique you don't do. I included some case consultation in the workshop, the first go-round, and it worked very well, so I'll be leaving a bit of room for some in this workshop.

The more therapies I learn, the better therapy I do. I'm still enjoying my studies with the CIMBS technique (Complex Integration of Multiple Brain Systems). http://www.complexintegrationmbs.com/ I'm in my third year of training and learning even more how to collaborate with clients to rewire their brains for better attachment, more directedness, less shame, more motivation, and a more positive outlook. Terry Sheldon and Beatriz Winstanley Sheldon have developed an amazing therapy and are teaching it to people in Seattle, Vancouver, and ever more places. I mix their technique with EMDR, Ego State and Somatic therapies, the hypnotic stuff I started with, and more, and am loving this work even more!  And please don't send me new clients. After 35 years in practice, I get way too many referrals and hardly ever can take any new people.

What else am I up to? I'm consulting to a bunch of groups and individuals, mostly EMDR-oriented, in person, and on Skype and phone with people from all over the States and Canada. I think it's the most fun--supporting colleagues to do help their clients. I love watching therapists grow. And in the groups, facilitating the supportive environment that helps that growth to happen. 

I'm still teaching the Washington State mandated Suicide, Assessment and Treatment class. Some people have taken my class two times, or come to mine after taking others. Their feedback is that mine is more user-friendly, practical, and, somehow, more fun. I enjoy doing it, and try to tailor each class to the special client populations of the participants. (That's easier when there's 20 people, harder when there's 60.) The next one is in Seattle on October first: http://wacoalition.org/suicide_prev_wkshp.html  

People are asking me about another book, but I'm not feeling one asking to be written. I'd like to get back to this blog and to write only when I feel like it. Every book, becomes "that #$%&ing book", near the end. I want to stick to the short form, before I put my schedule and my body through the contortions of writing a fifth book.

I hope you all are having a great summer! 

Expect posts!

Robin

 

 

"Love and Mercy"

I just saw the bio-pic about Brian Wilson's (of the Beach Boys) genius, decline, and fall into the hands of a sociopathic psychiatrist, who became his legal guardian.  It's a good movie and a hard one to watch, especially for a therapist.

Wilson is portrayed as a genius by Paul Dano and John Cusack (at different ages.) We get to see how his obsessive brain honed the music in the studio over take after take, until it perfectly matched the sounds in his brain. We see how the awful physical and emotional abuse he suffered from his father impacted his later life. And how his anxiety disorders, PTSD, drug use, and dissociation drove him crazy, for a time, and made him a docile target for an unscrupulous doctor, who over-medicated, berated, and threatened Wilson into signing over his finances and power of attorney.

Spoiler alert: Love saves the day. Whew!  And the doctor is thrown out of the profession. And if you watch the credits, you'll see the real Brian Wilson playing with his current band, looking healthy, alert, and present.

If you see the movie and have a different diagnosis, I'd love to see it. Here's a trailer for the movie: http://www.loveandmercyfilm.com/

The Science of Inside Out

I'm done with writing books, after finishing Easy Ego State Interventions last week, and going to the movies. Here's my favorite movie this week:

Inside Out is a Pixar's delightful film about the inside of 11-year-old Riley's brain. Riley has just been dragged from her beloved Minnesota, house, school, and hockey team by her dad's job change. She's living in an unpacked mess, in a strange house, going to a strange school and very, very sad. The movie shows how Joy, Anger, Disgust, Sadness, and Fear personified by a bunch of great actors organize Riley's experience. The moral of the story is the moral of the therapy I do: "Feel everything!"   When Riley finally has Sadness run the show, she can connect, be soothed, and work through her losses. It's a lovely movie, worth sending every affect-phobic client to. Go yourself. Take the kids. It's Pixar and it's great.

The writers interviewed real brain scientists about emotions and 11-year-old brains. Here's what one of the scientists wrote after seeing the movie: The Science of Inside Out

 

Theodicy: Spiritual Views of Evil and Abuse That Help or Impede Healing

This article arose from a discussion on listserve that deals with clients who have suffered unspeakable abuse and torture. Rev. Lynn James wrote a wonderful response on the subject of Theodicy: Spirtuality, Evil, and Suffering, that is the best thing I've seen on the subject.  She expanded it for Ellen Lacter's blog. Here is the link, http://endritualabuse.org/healing/spirituality-2/ 

It's a must-read for every therapist, since these issues come up every day with abuse survivors.

Steps To Take When You Suspect A Family Member Is A Victim of Abuse

Written by Josh Anderson

One in four women has experienced domestic abuse at some point in their life, according to statistics from The Centers for Disease Control and Prevention and The National Institute of Justice. While not all abuse is physically apparent at first, over time signs of abuse become more difficult to hide. When these signs appear and you suspect a family member is a victim of abuse, there are several steps you should take. 

Warning Signs
Before approaching your family member about potential abuse, learn to read the warning signs of an abusive relationship. The most obvious signs are physical, such as cuts, bruises, broken bones and other injuries that occur on a consistent basis without reason. However, not all signs are as visible. Watch for changes in character or appearance. People who are being abused often isolate themselves. The development of anxiety, depression and low self esteem, especially when coinciding with the start of a relationship can also signal abuse. The dynamic between the family member and the potential abuser also shows signs, such as feeling anxious or afraid to please the abuser, and a negative or verbally abusive dynamic when together. 

Investigate
If you suspect a family member is being abused, talk to them. Silence does not help the situation, and knowing that someone else knows may provide the bridge necessary for your family member to get out of the abusive situation. In many cases the family member may deny the presence of abuse out of fear, denial or even shame. In these cases, continue to be present and allow opportunities for your family member to confide in you for support. Point out specifics details of what you have seen and describe why it's wrong. Do not approach or investigate the abuser yourself. In the case of suspected child abuse, skip this step and move directly to reporting. 

Report
If you have reason to believe your family member is in imminent danger or you witness the abuse, contact the proper authorities. In the case of child abuse, report your suspicions immediately to your state child protective services agency or law enforcement. Do not investigate the situation yourself, leave it to the professionals to determine whether or not abuse is occurring so the child can be removed from the situation without incident. In many states you are required by law to report child abuse, especially if you hold positions such as nurse, doctor, teacher or daycare worker. Not reporting the abuse can result in you serving jail time. 

Support
Continue to support your family member regardless of the decisions they choose to make. While they may not leave the abuser right away, knowing they have a supportive family member may turn into the catalyst needed to end the relationship. Do not pressure them, blame them or judge them as this can have the opposite effect of what you're looking to do. 

While it's difficult to step forward when you suspect a family member is a victim of abuse, not saying something allows the potential abuse to continue. Unfortunately, it's not uncommon for abuse to escalate, which can end in injury or worse for your loved one. Do the right thing and help your family member by starting the process of removing them from a harmful situation. 

Domestic Violence Resource Center: Domestic Violence Statistics 
http://dvrc-or.org/domestic/violence/resources/C61/

Jeremiah Granier wites all about health, self-help and happiness. His recent work is on the Top Online Masters in Counseling Programs.

Roy Kiessling's Belief Schema Perspective for EMDR

Roy Kiessling, a prolific EMDR trainer and innovator, has come up with a great idea for EMDR. Instead of coming up with a different negative and positive cognition on the fly, right before processing, find the general negative belief or beliefs that underlie the client's life during the first stages of therapy. During the history-taking phase and the preparation phase, when there's no hurry, and you can delve deeply into the clients' perspectives and overarching schemas, you can find a sentence that brings tears to their eyes and sense of being truly understood to their hearts. When it's time to do some processing, you can say, "does 'I'll never get it right" (that core belief) still fit this situation?" Then go to the already configured positive belief and your off and running.

This weekend, during the training, every participant experienced a profound shift when they cleared the core belief/schema during processing. For some of us, the knowledge of the belief was sufficient to make some changes.  

If you're an EMDR professional, you may want to contact Roy and sign up for this training. He's also giving Basic EMDR trainings, that include this focus. If you don't do EMDR, you may want to organize a training in your town. You can find out more about Roy at http://www.emdrconsulting.com/

Why I love EMDR!

A friend of mine was home when her house was broken into last night. She got away, and the cops found the guy and arrested him. She posted the whole story on Facebook this morning. This afternoon, she posted this. I have her permission to repost. Please don't mention her name in the comments.

"Quite a day! I really appreciate everyone's support, it helps so much to feel cared for and connected. Got in a session of EMDR on this morning's incident, which was extremely helpful too. Both to discharge reaction and emotion that hadn't fully hit me yet because i was in "deal with it" mode, and to put the scary parts in context of the whole 'movie' along with "and i wasn't hurt and i'm ok and i handled it well enough, and it's over and extremely unlikely to happen again...". 

To top it off i get to go contra dance tonight. That's going to feel good! After EMDR i am feeling more like i could be ok with sleep tonight, and i would still welcome any prayers, holding in the light, thoughts and intentions for safety, that any of you would like to send my way for the next few nights. Thanks for your caring, friends! Wishing everyone a safe and comfortable evening."

I didn't do this session, but this is why I love EMDR!

Trauma is Curable: My letter to the NYTimes

When I read Mark Epstein's op-ed "The Trauma that Life Brings" in the 8/3/13 New York Times, I had to reply. Epstein, a psychiatrist said that trauma and grief are inevitable and that there's nothing to do about them but wait it out and suffer. I like that he was normalizing both, and I was horrified that he 1. Conflated grief with trauma; 2. said that there was no way to clear trauma; and 3. said both to the many people who see the Times as the "paper of record".

Letters to the Times can have no more than 150 words. To make the words count, I skipped issue #1. Luckily another letter writer picked it up. My letter is the second one in this link  Here's the letter, but you can hit the link to read the others:

"Mark Epstein’s essay does a grave disservice to trauma sufferers when he says people must live with trauma. There are many psychotherapies that heal trauma.

The most effective therapies for trauma that truly clear the shock, fear, flashbacks, bad dreams and emotions include eye movement desensitization and reprocessing, or E.M.D.R.; many somatic therapies, and Brainspotting.

In my work with grieving people, I first help them clear the trauma of the illness, accident or moment of finding out about the death. Then we target the grief. People still move through the grieving process but are no longer stuck in the past. When the grief resolves — and it does resolve — patients still miss the person who died but are no longer stuck in the moment of the death or in active, acute grief.

Trauma runs through everyone’s life. But unending suffering need not.

ROBIN SHAPIRO
Seattle, Aug. 4, 2013

 

The writer, a social worker, is the author of “The Trauma Treatment Handbook: Protocols Across the Spectrum.” "

Installing the Future

Dissociative people often lack coherent narratives of their pasts (Mary Main & Dan Siegel). I'm finding that they often lack coherent visions of their futures. Today I "installed the future" in a formerly dissociative client, who has given me permission to tell this story. 

When "Linda" was 6 weeks old, her mother became gravely ill and was hospitalized for several weeks. Linda was passed around to different relatives, none of them parents, until her mother returned home. After that Linda, was different, sometimes frantic, sometimes shut down. As a teenager, she was in and out of mental hospitals, overdosing on drugs, and acting out in big ways. Later she settled into a long-term relationship with some good earned attachment, became a respected professional and had two kids.  She came to me two years ago, functional, but prone to huge swings in mood, perspective, and ego states: DDNOS in presentation, possibly DID.  

After two years of intensive EMDR, Ego State Work, Brainspotting, and great therapeutic alliance, Linda, in her late 30's, is stable, adult, and integrated. A few months ago, after a violent death in her family, Linda had the normal reaction of fearing for her own mortality. In discussion, she revealed that she couldn't see her future. Her future felt like one second away, even thinking of herself as 90 years old, felt like a momentary blip. Her past, too, felt like a blip. Dissociation had stolen a coherent sense of time.

I stole a piece from Lifespan Integration (Peggy Pace), which leads kid parts up past years, year by year to the present. Instead of doing it in the past, I led Linda through the years from now until her 90's, including the changes in her body, her kids, her partner, her parents, her work life, her age-appropriate world view, and technology. In 20 minutes we visited developmental stages from now until old, old age, while I administered bilateral stimulation.

When we were done, she said something like, "Wow, that was great! You've given me the future. I feel much calmer. For the first time in my life I can imagine what it would be like. It's not just a blank, like my childhood. . . I feel safer and less afraid of dying, since I can imagine living. I know that anything could happen, but I had no alternative in my mind to something happening. Thanks!"

At the end of session, we agreed to go back and use Lifespan and the bilateral stimulation to bring coherence to her life, up until now.

A Highly Sensitive Man

Years ago, when I read Elaine Aron's The Highly Sensitive Person, I could recognize the HSP people around me with the innate ability to sense, revel in, or be overwhelmed by their external and internal worlds. These folks (I'm not one) are the best cooks, among the most creative artists in any field, and make with their ability to track both minute changes in their clients and the corresponding responses in themselves, some of the best therapists. They also can be over-loaded by too many people, too much noise, too much light, too much commotion, and their intense awareness of their own internal states. See Aron's website with her books and other information, here. 

I just read a lovely post by an HSP man, Rick Belden, coming out as Highly Sensitive and exploring issues of maleness as HSP. Every therapist and every HSP and interacter with HSP's (that would be everyone) should read this lovely post.  http://rickbelden.com/blog/2012/11/16/i-am-a-highly-sensitive-man/

Related articles

Are you a highly sensitive person?

The Highly Sensitive Person and Creativity

CPT Codes: Professionals Only

"Here's the latest about the CPT codes from NASW. I'm so glad I haven't tried to bill yet:

***ALERT CPT Code Snag***

  The use of the new Psychotherapy Codes became effective on January 1, 2013.  However, many Social Workers have encountered problems in being paid under the new codes.

 The reason for this is because many insurance companies were slow to update their systems with the new codes.  If your payment was denied, please resubmit using the new codes.  The companies have updated their systems with the new codes." 

And I hear that most people are being paid for 037 (one hour) codes. And that there is no code for 90 minutes that doesn't involve a certifiable emergency.

 

Defining Rape and Sexual Assault

I've been working with survivors of rape and sexual assault since I started in the mental health field. Here are my definitions:

Rape: The sexual use, involving penile, digital (fingers) or objects on a woman's, man's or child's body without that person's consent, with forced consent (threats) or if that person cannot conset due to age, mental disability, state of drunkeness or druggedness, or relative social position to the rapist (employee, slave, patient, lower rank, parishoner, etc.)  

Rape can include penis in vagina, anus, or mouth, or forced masturbation. It can include objects. It can include rubbing genitals on a person with clothes in between. Women can, but rarely do, rape people by forcing them to touch or otherwise sexually interact. People of any age can be raped. People in an otherwise consensual sexual relationship can be raped, if they say "no" or are asleep or passed out, and their partner is sexual with them without their consent. 

Sexual Assault: Unsolicited, unwanted touching, grabbing, or other sexualized physical utilization of another person. All rape is sexual assault. Not all sexual assault is rape.

Molestation: See Sexual Assault. Often used when describing either the Sexual Assault or Rape of children. I wish this word would go away. I'd prefer "Child Rapist" to "Child Molester" since it's the true definition of what happened.

Effects of Rape and Sexual Assault: It depends on what happened, by whom, and to whom.

• Adults who are raped by strangers tend to experience full-blown Post Traumatic Stress Disorder. No matter the circumstance, they tend to feel dirty, culpable, and ashamed. It ruins, at least for a while, their healthy sex lives, their sense of safety and trust in the world, and their image of an autonomous, safe self. If the adults had a history of childhood sexual abuse, the new rape often brings forth the same feelings, ego states, and flashbacks of the earlier time. Sexual situations with beloved partners can bring up flashbacks of the rape. Men who are raped can have a sense of loss of maleness and a whole other level of loss of self.
• Children who are raped by strangers tend to experience all of the above including a pervasive sense of "badness", and without treatment may carry that sense of shame and fear of sexual situations to adulthood
• Date rape: Rape by someone in dating situation, when the victim has said no or cannot show consent, brings another layer of self-blame, lack of trust, questioning of "fault", and social complications. ("I shouldn't have worn a short skirt; drunk so much; gone out with someone I didn't know well; etc.") along with PTSD.
• Rape of a child or teenager by a parent, coach, teacher, older sibling, uncle, step-parent: Kids can't give consent, even if it's "friendly", it's rape. The worst thing I often hear is "It's (being an object of sex) what I'm for." Child rape by a person on whom the child relies for protection creates huge issues of identity, safety, goodness, worth, and sexuality.  Some kids, after chronic sexual abuse/rape, become prostitutes. 75 - 95% or prostitutes were sexually abused as children.  http://www.womenslaw.org/simple.php?sitemap_id=148. Many have flashbacks for the rest of their lives, unless treated. Many are not believed by their families. (The response of the family and/or institution in which the abuse occurred is strongly correlated with healing, or not, after the rape.) Kids who are raped tend to freeze, then go limp during the act. Afterwards, any sexual threat or even solicitation can bring the same passive, obedient response, making further exploitation more likely. Some re-enact their role with sexual acting out, a warped attempt of mastery of the situation. Most, but not all, people involved in sadomasochist "scenes" were sexually abused/raped as children. Child rape by trusted adults is a factor in most serious dissociative and Borderline Personality Disorder diagnoses. 

Complicating factors:

•     Not all rape is violent or actively coercive. When attachment bonds are used to manipulate kids or adults into sexual activity it confuses the issue of desire, identity, and fault.
• People can be physically aroused and even orgasm during a rape -- by the mechanics of the act. It still doesn't mean they wanted it. This is a huge issue in therapy.

Treatment: Many psychotherapies are helpful with rape and sexual assault survivors. My favorites are EMDR, Somatic Therapies, and, with victims of child rape and long-term abuse, Ego State Therapies. With permission, my favorite phone message from a client, after 3 sessions of EMDR for childhood sexual abuse: "Robin, I just called to tell you that I had sex with my husband today and it was great. After 12 years of marriage, this was the first time we made love and my grandfather wasn't in the room! Thank you!" 
 

Politics: Misinformation by the anti-choice people has muddied this issue. Some of them don't want women to have abortions. Some don't want women to be able to get pregnant from rape, necessitating the need for discussion of incest and rape exceptions in laws. Women who are ovulating can get pregnant from rape. It's a fact. "Legitimate Rape" appears to mean a violent rape by a stranger, only one kind of rape. 

A Song: Illegitimate Rape. the only good thing to come out of this political kerfuffle: http://youtu.be/mg_4O6XmKAQ

Psychotherapy Works! And Not Enough People Use It.

According to a meta-analysis of over 50 studies, psychotherapy works better than medication and (Suprise!) has less side effects. Drugs have better promotion and are easier to get, so more people use meds. Read about it here: http://www.sciencedaily.com/releases/2012/08/120809190641.htm

How Not to Get Referrals

Mike Langlois explains "How to Get Taken Seriously as a Mental Health Professional" in a mild rant about the uses and misuses of LinkedIn, etc. at  http://gamertherapist.com/blog/2012/08/08/how-to-get-taken-seriously-as-a-mental-health-professional/

I get a referral a day from my website and many consultees from this blog. I tell other therapists, "If you want any clients under 65 years old, make sure that people can find you online.

I follow Mike on Google+. If you are an online-gamer or have clients who are gamers, you must follow him. I don't play online games, but do treat people who do. It's nice to have a clue about their experiences.

Stalkers: Classification and Treatment

Stephanie Rhys wrote a helpful article about Stalkers on Robert Muller's fantastic Trauma and Attachment Report blog right here: http://trauma.blog.yorku.ca/2012/06/29/in-the-mind-of-a-stalker/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+trauma-report+%28The+Trauma+and+Attachment+Report%29

Research: CBT FAIL!

Huge study in Sweden finds that CBT often doesn't work on anxiety and depression and can make the problems much worse: 

REVOLUTION IN SWEDISH MENTAL HEALTH PRACTICE: THE COGNITIVE BEHAVIORAL THERAPY MONOPOLY GIVES WAY

Please don't flame me, I'm just reporting the study.

Lessons from a Dying Cat

Lila, our 18-year-old long-haired cat had a message for us all about how to live one's last day, so I let her ghost-write this post.

1. Try to keep a normal schedule.
2. Stay hydrated.
3. Connect with the people you love.
4. Accept help: it's nice to have someone else brush your hair, when you can't do it.
5. Be assertive about what you want and don't want.
6. Meditate.
7. Keep engaged in what interests you: bird-watching.
8. Take naps.
9. Have no regrets.
10. Stay in the moment.
11. Accept all the love offered you.

Love, Lila

Trauma and Grief Explained and Self-Help Instructions

A few days ago, there was a shooting in my neighborhood. An unmedicated bipolar guy shot up a cool hipster cafe (Cafe Racer), a woman in another part of town and himself, leaving six people dead, and the extended community around the cafe in shock and grief.

I was asked to present a bit about trauma and grief and to find therapist to volunteer their services for survivors. Here's a handout I made, based on handouts I'd made for clients:

Reactions to Trauma

1. Anxiety/Fear  2.Anger  3.Weepiness  4.Self-Blame or Shame 4.Numbness/Shutting Down  5.Feeling out of control 6.Startle Response 7.Nightmares 8.Flashbacks 9.Depression                  10. Avoidance of thinking about what happened by Not talking about it/Substance Use/Getting “busy”/Isolating

 

Stages of Grief (May occur in succession or over and over.)

1. Shock and Disbelief
2. Anger and Blaming: Self, the one who is gone, doctors, fate, God, et.al.
3. Sadness, Depression, Hopelessness, Yearning
4. Integration, alternating with all of the above.
5. Over the acute grief and still missing your person.

 

Rules of Grief

1. It always hurts more than you think it should.
2. It always last longer than you (and others) think it ought.
3. It makes you tired, cranky, stupid or feeling hopeless.
4. Avoid it and it stays terrible, creates depression and/or useless busyness.
5. Feel it all and it gets better.

 

What can I do on my own?

• Exercise, especially aerobically: walk, run, dance, ride a stationary or outside bike, do the elliptical machine at the gym.
• Take fish oil at least 3 grams a day. 3 big capsules. Carlsons is a good brand.
• Eat well, but not too much. Some people starve themselves to not feel, some soothe with too much food. Both ways bring up the endogenous opiodes (our very own biological heroin) and keep you from working through the trauma.
• Give your body more time to sleep.
• Talk about it. It helps.
• Alcohol and pot slow down the healing. Trauma and grief may push you to do more, but it doesn’t work in the long run.
• Remember that the trauma response is a normal reflex, not a sign of being crazy.
• Hang out with people who like you. Humans’ emotions are regulated by being around other people. Don’t isolate, especially if you feel horrible.

If people need more help, Seattle trauma therapists are volunteering their services. I'll post the list tomorrow.

 

Kristof on Chronic Traumatic Encephalopathy, the Brain Disease Plaguing Veterans

Nicholas Kristof writes about the brain disease that may be underlying the suicides of Iraq & Afghanistan war veterans: http://www.nytimes.com/2012/04/26/opinion/kristof-veterans-and-brain-disease.html?_r=1

Therapeutic Texting with Teenage Clients

I've never been much of a texter, but I have a 13 year-old client with PTSD and a few anxiety disorders for whom texting is an important part of her therapy. Both she and her mother gave me permission to share some texts.

Therapist=T. Client=C.

Last night: C :-(    T: What's happening?  C: I feel spacy. (She can be dissociative, but it was almost 10) T: Spacy or Tired? C: Both  T: What tipped off spacy? C: Like when I am spacy and scared. T: Scared of what? C: That someone might kidnap me. T:% of likelihood? C: 3  C: I think I am so spacy that I can't think. :-(  T: Feel the anxiety in yr body and calm it down. Then sleep. C: How? (How many times have we practiced this in the office!!!): T: Tap under eyes, on sides, on collarbone. Remember? Breathe slowly & deeply.  (After a while) C:Yes! Thank you. T: UR welcome. C: :-D  T: Yay!  C: Wow it works! Next time I come can y write it down so I can remember. (For at least the 3rd time...) T: Yes  C: Thay u!! Ttyl! (Talk to you later.)

This took about 10 minutes, during which time I was doing something else. She texts about once a week and it helps her to know that she has access, when she doesn't have access to other supportive adults (due to a complicated family situation).

Sometimes the texting is brief. I've been working on her to promote connecting through positive affect. I asked her to text me if she ever felt happy. These texts go like this: C :-)  T :^)  C: <:-D T: @;^)--<--<  C:LOL, Ttyl.   Her mom says that she is starting to approach with positive affect more often.

Sometimes even the hard ones are brief. C ;-( :-(  :-(  T: What's going on?  C: I'm sad!!!!  T: Sorry!!!  (Minutes later) C: I feel better, cause I told you. T: Good! C: ;-) ttyl.

These texts mimic talking. Connecting. Responding. Responding to response. And a change in affect. The first one had a diagnostic phase, a therapy phase, and a resolution. With this particular client it cut down on phone calls and deep distress. She feels contained when there are no adults around. And she's learning a great skill for her age group.

NYT's Article: Stimulants given to soldiers may increase PTSD.

Dr. Richard Friedman in "Why Are We Drugging Our Soldiers" shows the correlation between Ritalin and Adderall prescriptions and increased PTSD. He cites several studies showing that these drugs enhance the memory of fear-provoking events. Scary and makes all kinds of sense. Read it!

Traumatic Brain Injury

Traumatic Brain Injury (TBI) is in the news again. Robert Bales murdered 16 civilians in Afghanistan. He has TBI, drinks too much, and just saw a friend lose a leg. Why does TBI matter? 

Traumatic brain injuries are head injuries that can occur from a direct blow to the head, in an accident, sports, or assault (how most civilians get them), or from the shock waves of an explosion (how many military people get them). People who have strokes or brain aneurisms or too many steroids may have the same symptoms. 

Symptoms can include disorientation, memory loss, difficulty learning things, headaches, and confusion. Some people with TBI get right brain damage that makes them lose control of their emotions. They can have outbursts of rage, uncontrollable weeping, major depression that doesn't quit, and even laugh too long and too loudly. When traumatized or provoked, they don't have the normal "off" switch. If you add alcohol to TBI, you add more disinhibiton. If you add trauma, which amps up emotions, you can have the human equivalent of a bomb.  

I don't know Robert Bales, so I can't say more about what turned a nice guy into a mass murderer. However, I have worked with people with TBI. My clients all had memory loss, headaches, and wild emotions. They all had increased startle response, out-of-control anger, low frustration thresholds, and lives that were falling, or had fallen, apart. All these bright people needed help organizing basic things in their lives: finances, schedules, social lives, medical care. All felt dissociative, but weren't: one person when not filled with affect, but like a whole other person when showing emotion. 

With each one, I used EMDR, lots of support, and lots of cognitive work. We always targeted the accident with EMDR. With one person, who had had a tree-limb put a big dent in her skull, we were able to halve the pain, recover a fair amount of memory (2 years of graduate school), and cut back "out-of-her-mind" affect(emotion) in about 10 sessions. With others, it went more slowly, but was still helpful. The EMDR targets for most included the day of the accident, the losses that accrued from the head injury, the daily frustration, and the targets that would bring up much affect. We would imagine emotion rising and cognitively and physiologically calming it down. I taught basic relaxation, refocusing, grounding techniques, and how to deal with others. We brought in family and friends to teach time outs. Either the TBI survivor or the other person could call a timeout and the other one would have to back off, until the injured brain could cool out. I used the future template of EMDR for survivors to image using these techniques when needed. 

I've had a few clients that I didn't know had TBI, until nothing worked with them. After scratching my head, I would finally ask the question: "Have you ever been hit in the head?" In both cases, TBI answered my question, and I knew what to do. When people exhibit TBI symptoms, I always ask this questions at the intake. When people don't exhibit these questions, I try to remember to ask.

Back to military people. I have been hearing that many active duty military and veterans aren't getting proper care for TBI. Why? Poor screening and institutionally not wanting to pay for the cost of extensive, long-term treatment. In my opinion, it's a crime to ignore this devestating injury in the people that are taking the hits for the rest of us. If our country won't pay for the treatment, we will pay for it in traumatized families, increased suicides of military personnel, and more chaos in theaters of war and at home.

An op-ed in the NYTimes: War is Brain-Damaging

TBI Website: http://www.traumaticbraininjury.com/

 

NBC's Awake: Creative Grief Avoidance

It starts with a horrible car crash. Jason Isaacs flips his car in a California canyon. Either his wife (in one reality) or his son (in the other) dies in the crash. Every time he sleeps, reality switches. He has two therapists, one for each reality, who are set on proving that their particular realities are the correct ones. Isaacs plays a cop who uses information from one reality to inform his cases in the other. He either has a grieving teenager or a wife (way too beautiful for any reality) who refuses to grieve. Somehow it all works.  

One therapist is pedantic, one more experiential. None of them do somatic work or EMDR or brainspotting. In all of the protaganist's sessions, I was itching to ask him where he felt the grief and what he was telling himself about his culpability in the death(s).  I'd love to see EMDR clear up this problem. But then there would be no series.

Prediction: At the end of the season, we'll find out that he is either 1. In a coma and dreaming it all and or 2. Grieving the loss of both his wife and his son.  I'm going to keep watching to find out. And I'm going to keep itching to see effective affective therapy in either reality.

P.S. The most emotionally true show on TV: Smash. And the most fun.

Francine Shapiro in the New York Times on EMDR Research

Three years ago, while I was at the at the Olympus Women's Spa celebrating the publication of EMDR Solutions II, a woman in the same jacuzzi interrupted my conversation to attack me about my obvious misperceptions about EMDR. "Everybody knows it doesn't work . . . it's woo-woo-bullshit . . . and it's just exposure therapy, anyway . . . and there's no good research about it."  She was a researcher of cognitive and exposure therapies. When I tried, gently, to refute her, she spit on my friend and me, in her rage. Today, in the New York Times Health, Consults blog, Francine Shapiro has brilliantly refuted every point. Read the article here.  HAH!

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