Anyone can publish on Medium per our Policies, but we don't fact-check every story. For more info about the coronavirus, see cdc.gov. Acute Stress Disorder, Small Joys, Fire trucks, and Lessons from Sufferring The firetrucks, ambulance, police cars, and other city workers came by for a surprise parade tonight for our twins.
Another one that might be helpful regarding COVID-19.
I speak out after a recent autobiography I read from a psychologist I admire. Marcia Linehan. She struggled with the question her client's would directly ask her for 60 years. "Are you one of us?" She took the advice of other clinicians to never answer that question directly.
I contend that this increases stigma. I'll be brave and will answer this directly. Yes, I'm one of you.
I can still help and am a wounded healer in the middle of this with you. I am also proudly proud of those of you who speak of mental health and reducing stigma. I'll do my part, too.
I'm human with you and in this together.
Hi everyone, in the middle of the COVID-19 Pandemic, I turn to writing and thought I'd share my thoughts as a fellow human, capable wounded healer, mom, writer, and human.
We are witnessing a political scene experiencing confusion and anger about why and how people are unable to recall specific details after traumatizing events. Questions float: But she didn’t remember (insert __________?) She didn’t know where she was? Didn’t she know which house she was at? She remembered the bed or the hallway but not __________? Why didn’t she remember who turned on the lights or who drove her home? She remembered drinking one beer but didn’t remember_________?
It all seems obvious to a person who isn’t trauma-informed to make these conclusions. For those not understanding trauma, are curious about why the gaps in memory occur or are not looking through a lens of the brain this does seem sketchy at first glance. It sounds confusing at best and fraudulent at worst that a victim doesn’t remember parts of events that they “should,” in fact, recall.
Therapists working in the field understand hormonal responses, neurotransmissions including adrenaline and norepinephrine surges during an event along with the impacted neuropathways of brains following a traumatic event. We also have excellent supporting research from the Department of Veterans Affairs in the aftermath of the Vietnam War and adverse impacts from soldiers struggling upon their return home and why. We DO have a pretty good understanding of the gaps in memory and responses after trauma occurs and it really is a real thing. We also know it can be treated. Thank you to the Veterans who helped us understand what worked and what didn’t. I am deeply sorry to those who suffered so long before we knew what we know now about how to help.
We have a responsibility as a society to understand the science and stories of our survivors.
To a society first being introduced to these concepts this probably seems foreign. For someone who hasn’t experienced trauma or learned about why things stay online or offline in a brain, it might look like psychobabble or jargon trying only to take “sides” with the victim. I want to make an argument that is based in science and why this might be confusing for people who haven’t been educated or experienced trauma themselves to wrap their brains around. I hope your curious part sticks around for a minute if you're open to what I have to share.
1. After or during a traumatic event part of the brain goes online and parts go offline. Movies depicting “multiple personality disorder” haven’t helped to understand this phenomenon and people often think that you have to have very “split parts of the self” to have moments of what we coin “dissociation.” Dissociation is very common after a traumatic event and most of the time doesn’t lead to various parts of the personality “switching” over like the movies or dramatic TV shows depict. It doesn’t mean dissociation isn’t real and it is much more common than we think but doesn’t look like what mainstream media portrays. It does look like a person has disappeared emotionally. Glazed over, back to their experience or almost in a trance. It does look like time has stopped. They do often look frozen in the middle of a discussion, and it could be directly related to the trauma we are discussing, or a feeling state that suddenly rushed over them making them feel like vomiting Rarely do they "switch personalities" as we commonly see on TV.
2. Dissociation is a genuine part of the experience. An excellent book to read to understand it at a higher level better is by Dr. Bessel van der Kolk, M.D. – The Body Keeps the Score. It will go into greater detail than this writing about the hippocampus, cortisol levels, and what scientists have discovered as a result of adverse experiences following terrible events a person has witnessed or been a victim of. We can also see some of these same responses in other animal species experiencing threat watching them fight, flight, freeze, collapse, or surrender.
3. Our bodies often remember tastes, sounds, smells, feeling states, or random seemingly insignificant details after an event. Our brains were never meant to deal with horror and witnessing the worst of the human condition. Our minds do an outstanding job of going “offline” during these worst moments and frankly, we would not survive emotionally (or sometimes physically - think of John McCain's capture) if they stayed “online” during some of the very worst moments. Sometimes the brain stays online and occasionally offline and what the brain picks up on can be related to hormone levels and cortisol in the brain. For Post Traumatic Stress Survivors, we are certain levels of cortisol (the stress hormone) that modulates stress responses varies quite differently from those who have not experienced a traumatic event. The brain can become hypo-aroused (feeling numb) or hyper-aroused (feeling on edge producing re-creation or re-enacting of the experience.) Many times people experience both at different points.
4. Triggers. People can be triggered by reminders of the event.
Examples of triggers:
The smell of someone’s breath
the sight of a car where the trauma occurred or make/model of an accident
A feeling state that happened in the time of the event
Intrusive thoughts of rage or self-harm
The racing brain that just and can’t stop leading to insomnia
The brain will resort to “psychic numbing.” If the numbing doesn’t work, a person may turn to drugs, alcohol, or impulsive behavior to make this numbing turn-off or sometimes even to turn on. I hear people telling me “I just want to feel something again and alcohol lets me do that,” or more often, “I can’t get the sounds or smells out of my head and marijuana just makes it more bearable.” This makes total sense as a clinician, but they can be ostracized by others for their actions which don't see these behaviors as purely functional and how they are trying to stay alive. People experiencing this condition often feel a sense of shame and helplessness while also desperately wanting to run from these hauntings of their past. I hear “why can’t I control this? I’m so strong in every other part of my life?”
That is because you ARE strong in every other part of your life and you are not broken. Your brain has experienced events that you were not supposed to suffer from, and the mind does not know when or what to turn on and turn off at times it’s supposed to now. It’s not your fault.
It is also not your responsibility to convince naysayers of your story or why it’s valid. Your account is valid because it just is and how you experience symptoms are probably similar to others and also different than others. No two people are the same. Gaps in memory are common and feeling states you attempt to avoid is probably your brain’s way of trying to make sense and coping with what shouldn’t have happened to you.
I’ll be writing a bit more of a treatment called “Eye Movement Desensitization and Reprocessing” soon and why we think it works and I have asked a few of my clients to share some of their examples (with names and experiences changed to protect identities) and how it has been helpful on their journeys. Some treatments can help center the brain, so the numbing, agitation, reminders, and triggers become a memory and not a current state of panic or numbing.
However, before I write about the components of this treatment and as a therapist who provides it, I wanted to establish something else:
A. It is not your fault that your memory processing network was disrupted by an event that happened to you that you did not choose. Any painful memory is worth discussing and just because your experience may not have "been as bad as _______ (I hear this a great deal) this doesn't mean it shouldn't be treated. If it's bothering you and creating the above symptoms, treatment can likely help you.
B. Your brain was doing (and probably is doing) the best it could and hasn’t learned it doesn’t need to go offline or to overdrive at the most crucial times for you. Be nice to yourself. Your brain and parts of your personality are doing the best they can with the circumstances they were dealt.
C. You deserve to be believed, and it isn’t your fault that society doesn’t understand what clinicians know.
D. It can get better with appropriate help and care. We know this. We have research supporting this.
Jill Lehmann-Bauer, LISW, ACSW
Clinical Social Worker, Central Iowa Therapy Solutions, LLC.
I’ve been asked countless times by clients, how do you cope with the ups and downs of the craziness of our politics?
Indeed, this is a question that is personal but also one of scientific significance that has to be understood on a trauma level but also one to explore on a human level.
Emotions have various reasons for being activated within someone. Feelings can give us a lot of information, but you must first be able to label and understand what you’re feeling and what the function of the emotion might be underneath. For example, you may be faced with a person on social media who disagrees or becomes verbally aggressive with you. What emotion do you feel? Is it anger? Fear? Generally, the first emotion you feel is something we call “secondary” and is often the one that is felt the strongest. You may feel rage at this person on social media who might be attacking you. While there is a reason to feel this rage, we can often peel it back a bit and notice something else happening that might even be truer. Fear.
I see clients coming in with great deals of rage in the political system, and I often ask them if other feelings are coming into the room with them or other “parts of themselves.” Most can usually identify with the rage and know where they feel that in their bodies. However, as we begin talking, fear is, and sometimes a feeling of helplessness follows.
I think all emotions can be helpful and potentially motivating. I believe there is a place for all feelings. A time for anger and a time for fear. I also think there is a time for two emotions to co-exist at once but knowing which one is driving your bus is paramount in knowing what to do next. If you mostly act out in rage in political discussions, you’ll likely not be heard. I contend one of the most challenging things happening in our communities is the break down of really being “heard.” It is complicated if your raging part comes to the table and cannot access the part that is also afraid but willing to hear.
You do not have to agree with your political opponent to hear them. Civil discourse while allowing the opinions of others to be understood is often challenging when things feel so unjust. However, to engage with another who is not also willing to enter into a civil dialogue and blended with their rage may be triggering to you, especially if you have had a history of trauma. Hearing someone may be creating a bridge but also doesn’t mean you have your voice taken away. You can listen to and also be heard if the other person is also willing to agree to the same standards. I don’t often find this to be the case online but can happen more frequently in person.
There are a few responses in the face of fear for trauma survivors. Fight, flight, freeze, surrender or collapse. Many people don’t know the last two or three. The first two we often hear of often but the last three are also still essential and given your history may explain some of the responses you may be having. Do you find yourself being triggered by the news and feeling angry, disconnected, numb, distracted, raged, impulsive, or looking to substances to escape? Our brains are remarkably helpful to us trying to do their best to protects us and have some socially learned response and some that are just hard-wired into who we are. It doesn’t mean to go down a 12 pack to drown out your fears, but the brain might want to do that as a way to cope and hasn’t learned other ways to deal with painful emotions and triggers.
For many, these political times are a constant trigger. I hear people feeling helpless. I tease out the fear underneath their helplessness or their anger in therapy. Below are things clients have found to be most helpful in the times of social injustice and reducing the apathy, rage, or numbing they go to.
A. Decide how much social media you’re going to consume. Latest research shows the more social media accounts you have, the more of a risk there is for depression. YOU get to choose when you engage online, WHERE, and HOW long. Have you gone down a rabbit hole of comments on a forum? It’s easy to do. Before one even realizes it you are so far away from what you intended on doing that evening and probably unaware of what is happening around you. For some of my clients, limiting social media time and making time for other things they love allows them to connect in a more meaningful way.
B. You do not have to feel guilty if your “pedal” isn’t on social advocacy every day. Guilt is an emotion that is either justified or unjustified and in times of political unrest, it is easy for the feelings of guilt (i.e., I’m not doing enough, I am only calling the senators, I am not marching, etc.) to come into the foreground and there has to be a time of rest to be able to adequately present in however you decide to engage.
C. Realize your anger might be motivating. I see many people feeling angry and wanting to run from it before even seeing the value in it. Anger can be motivating and helpful to us in many ways. We can become change agents of a world. If people hadn’t been angry and horrified at Hitler would he have been held accountable? Probably not.
D. Connect to communities you identify with both politically and elsewhere. The greater sense of community we have around us and the levels of support we have in our lives makes the isolation and fear responses that automatically get triggered less.
E. Decide how you can or if you want to make an impact to change course. The most significant changes can come from the quietest voices. Rosa Parks wasn’t a loud woman and made a brave and bold move to refuse to move to the back of the bus. She was followed and supported by others who recognized injustice and encouraged her to the next level.
F. We are all not going to be or have to be like Rosa Parks. Small and meaningful steps can be helpful and the higher the numbers or calls to your representatives mean the less helpless you feel and doing anything that makes you feel like you have a sense of control in the face of an unjust world can be helpful. However, YOU get to decide how, when, and in what forum you feel comfortable doing this in. Some clients feel compelled to march, some feel an urge to send e-mails, some clients feel the need to join political groups. Some clients desire to increase prayer.
G. Read about non-violent communication and those who have gone before us. I would be surprised if you wouldn’t feel a sense of great relief and hope after reading Coretta Scott King’s autobiography and how her small steps to support others and “faking bravery” in a time of great political unrest. Read things that inspire you.
H. Create art. Any art. Create music. Any music. Walk. Research shows that any movement that activates the calming parts of our brains can help center us. If you desire a sense of empowerment, consider martial arts. If you feel anxious and cannot express yourself in words, learn to paint. While a guilt part might come up for doing such things in a world that seems very unfair and wrong, you are still surviving in it and need to figure out how to fight back with intentionality.
Jill Lehmann-Bauer, LISW, ACSW
Clinical Social Worker, Central Iowa Therapy Solutions, LLC.
Hello, world. It's been a bit (years actually) since I posted on my blog. It doesn't mean I have not been writing, just not updating my blog as frequently due to the demands of parenthood and managing my practice. I'll try to put up some of the things I think might be most helpful and useful to you as you are on your journey for health and wellness. For now, this is my story of my friend, Donna Red Wing.
My first lunch with Donna was at a local sushi restaurant in July 2012. It was a dreadfully hot day and I remember a large part of me feeling nervous because I knew the person walking in had a lifetime of achievement and I wasn’t sure if I was smart or worthy enough to have been asked to meet with such a person. This leader wanted to have lunch with “ME” and asked to hear my ideas and visions for a more inclusive and sustainable sociological world from a therapist paradigm. I didn’t want to disappoint her. Looking back, there was no way I could have done so because she led with her real self and all the parts that made her whole were in that room with me that day. She was present. I wasn’t totally present because I’m still on a journey of what it means to be fully present and noticing my own “parts.” I also had no idea she was about to teach me about life lessons through what she said but more about how she was able to “show up”. Donna taught me about “showing up” even during the celebration of her life just a few years later.
Donna walked into the quiet restaurant for lunch and she knew exactly what to order. She had commented that she had intentionally eaten a light breakfast so she could fill up on her favorite menu items during lunch that day. I nervously ordered the same because I didn’t care what I was going to eat and had an agenda I wanted to cover with an unsaid purpose of trying to understand her voice, courage, and bravery. I wanted what she had. I just didn’t know how to get “that.” I didn’t know how to experience fear and stand up anyway. Looking back, I didn’t know what or who the “enemy” was in that time of my life as well.
I was surprised she recognized me upon entering. We had talked through e-mails prior to physically meeting and I knew she had only seen my headshot. We were to discuss my new role on the One Iowa Board that day and how she thought I could help enhance their mission. Of course, my experience with the LGBTQI population was of interest to her and I was filled with ideas and ways we could move forward. I was ready to fill her up with some of my ideas and my fast brain and cart before the horse was ready to run. I suppose the “other side” would call our meeting the “gay agenda” and we would laugh about that idea during our subsequent interactions. Donna noticed me right away I noticed the unique sparkle and life in her eyes and energy that seemed to fill the room. She was engaging and loveable. This human hugged me even though she didn’t yet really know me. She told me she was excited about our conversation and for our time together. I believed her. I also believed I mattered to her.
The early stages of civil discourse and an unlikely friendship between Donna and Bob Vander Plaats (historically an anti-LGBTQ affirming politician and director of the Family Leader) were forming at that time and Donna proceeded to share with me what she was learning. I remember her words, “I didn’t want to like him but I did. I really do.” My angry and confused parts were in the mix during that conversation but my real self and curiosity were still intact enough to recall the thought “what a courageous soul but how can she possibly sit with someone and not believe he hates her to the core? Isn’t she skeptical of his agenda?” I was curious and open enough to let my real self be part of this conversation that day. Interestingly, I wasn’t initially at her memorial. During our lunch, I didn’t know the future path of a new therapy I would learn and resonate with would be personally put into action. The model I’ve embraced over the last year is called “Internal Family Systems.” I certainly didn’t realize these concepts would come up during her celebration of life just a few years later. The constant irony of the therapist at play: teach these wonderful concepts and have no idea when they are smacking us right in the face in the moments we need them most.
The powerful and fearless leader I sat across from that day had no signs of slowing down. It seemed (and still seems) confusing and devastating that this powerful enigma who encompassed peace and a greater level of understanding is no longer with us in her earthly form. When she discussed her goal of eventually retiring in the next few years and enjoying her years with her wife I questioned her and it took the breath out of my spirit. How could we possibly carry on her leadership and legacy without her in the mix? That was the selfish and fear parts talking to me. My real self knew she deserved to feel the ocean breeze and enjoy the simple moments of the light she fought so bravely for. I didn’t realize at that time these would be limited in number for her. My angry red man tells me she deserved more of those days.
During the course of that lunch, we did talk about some concerns in the system from a mental health standpoint but we also talked more broadly about life. She wanted to know me. Of all the things she could be spending her time doing that day she chose to explore my life. Donna wanted to talk more with me about my wife, dogs, and photography. She wanted to share the joy she had in her marriage to Sumitra, and the pride she carried in her smile when discussing her son, Julian. Donna remarked, “you have to meet Julian sometime. He’s a photographer too. He shoots various political campaigns and he has asked I no longer call his images ‘pics’. He says they deserve the respect of the word photographs instead.”
Noted. Since that day I have never used the word “pic” on any image that tells a story. I tried my best to soak in what she taught me that day.
I found my place in her celebration of life in the middle to back of the room. My wife was at one side and my friends at my other. I felt my wife’s arm bump me to quietly grab my attention and she whispered in my ear, “do you see who that is in the front row?” I couldn’t. She quietly whispered, “Bob V.”
Have you seen the movie “Inside out?” The little red angry character that comes on stage and the real-self tries to soothe, understand, and validate but keep at bay? The little red angry man has reason to be on stage and is doing our best to protect us and actually links our reptilian brains to our foundational neural networks that have experienced pain, sadness, or discrimination from our experienced years. Mine wasn’t and isn’t any different than others even if I happen to be a clinical therapist. Most of us have one of those little guys inside of us and they can come out unexpectedly, especially when the world as we know it seems unfair, unreasonable, and tragic.
My little red man came on stage after that nudge from my wife and the angry part said, “How dare he sit so close at the front of the service?” I remembered the past open dialogue I witnessed just a couple of years ago between Donna and Bob each discussing how they would attend the funeral of the other but Bob’s comment related to rejecting and attending her wedding (should they have known each other at that time at which they did not) because it would have been disingenuous. My little red man was fuming about that and the part was furious it was Bob talking at Donna’s because it wasn’t her time yet. I didn’t mean that it should have been Bob’s time but it wasn’t right, fair, or reasonable that he was there, in one of the front rows, and in Sumitra’s line of sight.
Yet, Donna was in the room, still teaching us.
I heard the drums. The systematic rhythms beat into my chest. I felt the energy and the vibrations and saw the little boy in front of me who covered his ears because the energy inside the walls linking all of us flooded our senses. That was Donna. It was her energy. I looked around at the diversity of the room. I was able to notice all people sitting together in peace even with the differences between us that I historically knew we shared. I looked around all my parts were astutely aware of political affiliations, runs for office, and those who have experienced the most struggle out of social despair. However, our common humanity was present in the room. We all loved or had been impacted by Donna. We all listened to the same drums. We all felt pain in our hearts.
The little red angry man part I carry softened when I heard and saw Donna’s grandson in the back of the room and the struggle her son was experiencing trying to reign in a toddler. I get that struggle with my whole body. I was reminded of my own family and our similar stories of prematurity that weave us together like a seamless quilt. I was reminded of the uplifting messages she sent while I was in the hospital on bed rest and how her grandson Jasper overcame all odds and that she was hopeful for us, too. I noticed the thought that we share more to this life and the common theme that binds us all together at the end is suffering but triumph within. We likely all suffer and grieve in similar ways if we are able to let real self come to the table and direct the parts of us who are afraid, angry, sad, and lonely we can exist peacefully.
Initially, I didn’t notice the part of me that was flared. I was just in it. The belief that suffering shouldn’t happen on “our end”- especially for the good guys - and that it wasn’t fair she was taken was driving my thoughts and grief. I watched a few people on the screen speak of Donna and her impact. We watched clips of Donna speaking throughout the years and her passion was alive as though she was still in the room. Present and agitating in the most productive way possible, even after death. Donna was still ever present in this world.
Donna’s face came on the screen. She looked different than our lunch we had a few years earlier and from the last time we saw each other in person. I noticed the same sparkle in her eyes just a few weeks prior to her passing in that video. Donna died with dignity and a message. She spoke of her unlikely friendship and building of bridges without compromising her integrity or self. She spoke of what mattered and how to have difficult conversations but that we were all more alike than different if we can get beyond our egos. Donna was speaking in a language I now understand as “real self”. Little red angry man doesn’t have to drive me but can sometimes come on board when I see, feel, or perceive a threat. Thanks, little red man. You’ve helped me out in my life but the last word is not yours. You can and will always exist within me but at that moment, you can step off the stage and hear Donna again. It doesn’t mean to step down. It means you can dialectically see humanity and fierce advocacy in the same spirit and vein.
The angry red man stepped further off the front of my stage as I watched Donna’s face fade from the screen and Bob stand up. He stood up with confidence and candor to speak. I held my breath. As he spoke, I actually believed his grief. He was dynamic and kind with his words. He was also funny. He didn’t sway from his beliefs but at that moment, I felt he actually did love my friend. I could see why she was confused about liking him.
There is no doubt in my mind that Donna had planned this. This was her statement, her memorial, how she wanted her legacy to continue. The little red angry part of me knew better and also recognized that was the purpose but didn’t see it in the time I was blended in it. She was still teaching us even after moving to a new dimension.
The gay men’s chorus sang. The drums and rhythms were back in my heart and I was present. A fleeting thought ran through me wondering, “Does this change Bob’s heart at all? Seeing the love and witnessing the grief of Donna’s wife, friends, family, and community? Even if he fundamentally sees the world through a religious lens will this moment somehow make a difference in how he lives, continues to speak, and if he should see me with my family on the street?” My real self hoped so. My angry side is still a bit tainted but more out of sadness than anything.
I am sad the angry part can so easily blend with me when I think injustice is happening. There is often a greater story and a story of humanity it doesn’t want to see. We all live through the narratives we enter into this world and experience what life brings our way. Under no circumstances were we dealt hands that assured us no suffering in life.
During my first lunch with Donna, I had prepared the agenda in my head and wanted to build a plan of attack for the community but she had a different idea on how to engage me and the first step is by slowing down knowing each other. We can be interested in the parts that make our lives whole. It isn’t just one thing and each deserves a place at the table. All of our parts deserve a place at the table, even the little angry red man that will serve as an aware agitator from this point forward and speak in a more intentional way. We can still learn and embrace her courage today.
Once the angry part left my body, I wept and couldn’t stop. I was no longer filled with anguish and anger that Bob had sat so close to Sumitra but honored that it was their decision and that Donna was still teaching me from a different capacity.
We may not be able to have lunch together again but we can look for our real truths by asking parts of ourselves to step back and allow each to have a voice. They can all exist in the same space.
Thank you for being my friend and wanting to know me. I desperately needed to know you that day too.
***Special thanks to Donna's wife, Sumitra for allowing me to share this with the world***** <3 I love you.
Also, if you'd like to watch something that shows how Donna impacted lives and put everything on the line, here's a link to a documentary that is very powerful:
Jill Lehmann-Bauer, LISW, ACSW
Clinical Social Worker, Central Iowa Therapy Solutions, LLC.
One of the most rewarding experiences I've had over the past year is helping a few therapists bolster the courage to take steps forward building their private practices. I decided to formally offer this as a service to others who might be considering taking this step for their careers.
I know it can be anxiety-provoking and overwhelming for independently licensed therapists to "take the jump" into private practice work and over the past year, I have learned a great deal to make things work. I continue hearing the same concerns from therapists I'm working like:
Where do I even start?
How do I get referrals?
Will I be able to make it? What are the REAL costs?
How do I use an electronic health record and get reimbursed by insurance companies?
How do I manage the business end? I know how to provide therapy, but I'm not an entrepreneur!
How do I build a website? Can you help me with that?
How do I pay taxes?
I believe I can continue to help other therapists in the area strategize and develop plans. Consulting is very rewarding for me, and I think in assisting others to build their dreams and answering questions honestly. These are the areas I can support with:
Offering a packet of "first steps" and a "how to" guide of considerations to make the process less overwhelming.
Developing marketing materials + website design. I remember a professor in grad school stating that all past experiences can be a useful tool in your future as a social worker. This comment has served me well. Before my work as a therapist, I built websites and took many classes in graphic design and computer science. I still enjoy this part of my life, and it's been enjoyable to mesh this skill set together in my life.
Networking you with others in the Des Moines community to help you get this off the ground. You don't have to do all of this yourself, and the costs are reasonable.
Cutting costs. With a little ingenuity, you can go a long way. I have some tricks to help.
I've spelled out details on my services page if you're a therapist and interested in consultation work with me, shoot me an e-mail on my contact page.
I'm currently reading "The Body Bears The Burden" by Robert Scaer, M.D. I have found this book to be exceptional for those wanting to understand trauma and how the body and mind work to preserve our well being and how it also can be hi-jacked after experiencing a significant emotional injury.
People can overuse the word trauma. I get it. Your butter falls on the floor - it's traumatic. You cut your finger on a nail, it's traumatic. Your dog growled at you- trauma. We don't want to look for trauma and treat something that is not there. However, as clinicians and informed clients, we need to be aware of it. This means accurate assessments and evaluations on the front end. One commonly used tool is called the "PCL checklist."
But in all seriousness, trauma is subjective to the person who experienced it and for those with lasting memories (in psychobabble we call it intrusive thoughts) that interfere with day to day life -- we must understand as behavioral health providers what is likely happening. Scaer does a fantastic job looking comparing trauma survivors and whiplash victims both experiencing problems functioning that have no explained physical abnormality. To elaborate, Scaer is a neurologist who researched reporters having whiplash from motor vehicle accidents. During his work in the area, Scaer found that treating professionals believed victims were malingering symptoms to receive compensation from the collisions. However, after litigation proceedings and settlements were collected, these victims still weren't getting much better and continued to report pain even when there was no further compensation possible. Scared couldn't see any neurological or physical abnormalities in these patients but believed there was still something going on.
Scaer states dedicated his first book to his English teacher who taught him that "the diagnostic truth lies more in the uninterrupted stories told in its entry by the patient than in a dozen diagnostic tests." This is not to say that diagnostic tests are not necessary. As clinicians, we need to administer tools to be able to see whether or not a person is getting better from the treatment they are receiving. Do not forget about the Rogerian importance of human connection and the basic dignity and respect your clients need in getting better. However, within this relationship, the untold stories are what is most important. Stories that may never have been safe enough to put words to before.
I recently attended a prolonged exposure workshop focusing on the treatment of post-traumatic stress disorder that fits nicely with Scaer's hypothesis. I found myself relating back to this book I read a couple of years ago which introduced me to the response of a brain to trauma.
In both PE and for Scaer, the premise that the brain separates from human awareness during or after trauma and stays "stuck" is interesting. While some researchers refute Scaer's empirical backing, both theories seem to hold value and by integrating what we know about the brain we have found ways to treat PTSD and/or trauma that hold promising empirical support. Prolonged Exposure (which is a best practice in the VA for trauma victims) is about accurately educating patients about the fight/flight/or freeze responses that occur during a trauma which is based in survival. We are wired to protect ourselves, and our brains protect us from things that might just be too difficult to experience fully. Most people are familiar with the fight or flight, but I believe that not many know about the impact of the other part. The freeze holds the key to understanding what is really going on.
In the animal kingdom and in other cultures, we can actually see the releasing of energy - sometimes shaking, crying, but nonetheless - energy right before a near-death experience or after. Some animals detaching from their experiences during or following a trauma seem to shake, flutter, kick, etc. that releases the energy. Have you ever heard of anyone say "play dead like a possum"? This might be where that comes from. The thing is, when this release of energy doesn't happen in humans naturally, the brain can become hard-wired and hijack a person into thinking that future events are as significant and fearful as the one they experienced during the trauma. In essence, the memory gets stuck, and people come out of it with a range of symptoms like:
A) feeling emotionally numb
B) over-reactive to things that weren't bothersome before the event
C) avoid people, places, and things because they no longer feel safe
D) experience agitation, loss of sleep, etc. which were not difficult for them before the trauma.
There are many other symptoms related to trauma that we have seen too. For purposes of this blog (and to avoid clinical jargon, I won't get into these and encourage you to google PTSD diagnostic criteria.)
What we do know is that the more a person avoids (the hallmark of post-traumatic stress) - the more the brain is rewarded. It finds relief in avoiding and distracting. The brain likes it, it makes sense to a brain that has not been able to process an event. However, the more it avoids and is reinforced, the more things grow and the more anxiety that is present.
Part of trauma therapy (scary, right?) is about moving the person towards the situations they are avoiding through planning and tackling experiences systematically. The term used for this is "in vivo" exposure. For example, if a person is afraid of the airplane, we can't expect a person to jump on a plane to go to Hawaii tomorrow after this fear has been growing for a great deal of time. First steps might be to look at a picture of a plane for thirty seconds, to sit on a plane and get off immediately, etc... with a goal of eventually flying on the plane. You see, many people aren't as distressed after they have successfully moved toward what they are facing vs. escaping (what the brain really likes). All makes sense, right?
The second part is through imaginal work --- which means telling the story over and over in a safe spot until the brain recognizes it is safe to say, put words and feelings to -- to experience the event as though you were again in it and able to cope (thus, getting "unstuck"). We are resilient human beings, and we can and do great things. It takes bravery and patience. Homework assignments related to breathing and relaxation and some really cool applications (look up PE coach - it's free in the iPhone app store, and there's one for Android users too) are an essential part of the protocol along with doing some work outside of the sessions. The more exposures to the fear in mind, the better.
What's most important as a therapist to understand - is that there is a brain/body connection that happens in all we do. The problem is the problem, and the people are not the problem. The good news is ---there's a medical explanation in the brain we know, and you're not crazy. Finding ways to move towards the fear and looking at the ways we see meaning in our experiences is paramount. There are lots of ways to get better, and PE is just one of them. However, one that shows excellent empirical research for individuals who continued to be bothered by their symptoms.
Our brains are evolutionary to their cores. These "old" parts of the brain serve the flight/fight/or freeze responses try to protect us to avoid pain, yet, they can also fool a person into believing that the fear is as intense as when a traumatic event happened and even grow in its avoidance.
If you're a therapist or a client interested in learning more about Scaer, check it. It's worth a read and some thought.
Shame is often the catalyst for someone to engage in psychotherapy (whether or not they are aware of this shame or not.) A classic book I often have my clients read - "Healing the Shame that Binds You" by John Bradshaw does a great job explaining what shame is and how it can manifest in a human being. Sure, it's a book geared towards addiction but most often, underlying addiction is a great deal of shame. Whether or not you suffer from addiction, this book can be really helpful.
Let's face it, most people did not grow up in a perfect home. Actually, I contend that none were perfect and many had elements of shame. We learn what we are modeled and the first 4 years of our lives the personality is developed. Neurobiology now explains how the brain is formed and adapts to environments in the developmental years and how the brain is forever changed with the modeling, care, and attention children receive early on.
What happens when parents who are shame-based have the responsibility of the development and nurturing of a child in their hands? Our brains do the best they can do cope and protect. Sometimes this protection is on overdrive based on what has been conditioned and leads to problems later on. Our brains are working to protect us but can also be hi-jacked based from past learning and modeling. For example, if you witnessed a parent often becoming enraged with the slightest bit of anger, your response when witnessing angry feelings might be to get the heck out of dodge. This may lead to feelings of anxiety and discomfort when you or anyone around you might show anger.
Most often, parents are doing the best they can with what they have got and probably even needed to do better (a dialectic). However, it is unavoidable for this shame to creep into the person they are assisting with differentiation and development if the parents have a great deal of shame. The key for many people is to understand how generational shame and self-perception leads to the depression or anxiety they may be faced with.
"The job of parents is to model..." "How to relate intimately to another person; how to acknowledge and express emotions; how to fight fairly; how to have physical, emotional, and intellectual boundaries; how to communicate; how to cope and survive life's unending problems; how to be self-disciplined; and how to love oneself and another. Shame-based parents cannot do any of these. They simply don't know how."
Bradshaw continues to write: "Emotions are a form of energy in motion. They signal us of a loss, a threat or a satiation. Sadness is about losing something we cherish. Anger and fear are signal of actual or impending threats to our well-being. Joy signals that we are fulfilled and satisfied. Whenever a child is shamed through some sort of abandonment, feelings, of anger, hurt, and sadness arise. Since shame-based prints are shame bound in all their emotions, they cannot tolerate their children's emotions. Therefore, they shame their children's emotions. When their emotions are shamed, children numb out, so they don't feel their emotions."
It's important to understand how your parents reacted to sadness. Did they show you what it was like to feel sad? Did they become enraged, distant, or dismissive to themselves when they were sad? How about anger? Did they become overwhelmed, fearful, or aggressive when anger arose?
Our emotions are indicators of being alive. They sustain us and they matter. When a person can't feel a full range of emotions they can often feel depression and a sense of "not really knowing who they are." Sometimes people share with me they feel like they live in a fog, are not really present, and have a strong fight or flight response in the face of an emotion. I find that this is often linked to very early conditioned responses of modeling.
Part of therapy is about observing, describing, participating (tenants of dialectical behavior therapy) in emotions. You may not even be aware you have certain emotions and these need to be re-learned (i.e., I never get angry, it's not in me or "I'm so frustrated and angry" - when the underlying emotion is sadness and grief that feels very uncomfortable. Our emotions help keep us alive.
Taking steps to fully understand, feel, and experience emotions with another human being is what recovery from depression, addiction, anxiety, etc. is all about. It takes a willingness to go into places that may be uncomfortable or foreign. It takes courage. Take some time to reflect on what emotions make you uncomfortable and how your brain has wired to avoid feeling or experiencing certain things Do you feel guilt when you feel joy? Do you become angry when you start to feel sadness?
Insight is power, understanding and forgiveness towards parents is paramount. While they needed to do better for you, they might have been doing what they learned and the best they knew how. You have the opportunity to change the generational shame by first being aware and learning to experience things again.
One last quote from Bradshaw --- "We cannot heal what we cannot feel."
Relapse? What is it?
re·lapseverbverb: relapse; 3rd person present: relapses; past tense: relapsed; past participle: relapsed; gerund or present participle: relapsingriˈlaps,ˈrēˌlaps/1. (of someone suffering from a disease) suffer deterioration after a period of improvement.synonyms:get ill/worse again, have/suffer a relapse, deteriorate, degenerate, take a turn for the worse "a few patients relapse"
Lots of people are mixed about how to define relapse - what does it mean for recovery? I contend relapse is related to any behavior and something normal with any change. Think about relapse in terms of cancer - someone could re-experience symptoms and the remission status ends. Are we judgmental of this? Generally not. It's difficult for a person with mental health or addiction to return to use and it's viewed based only in choice. Granted, there's choice involved whether or not to discontinue medications, take the first drink, crumble in the face of grief. and return to former eating habits. It's understandable - dare I say even common. Some people experience significant shame after re-experiencing symptoms and this doesn't help the cause of the problem. Addiction and mental health are both rooted in shame and I wonder what life would be like if this could be viewed from a compassionate, medical perspective?
If a person re-experiences symptoms, there needs to be a degree of acceptance and desire to change course. With cancer, it might mean consultation with physicians to change plans. Most often, the cancer is not a disease of the brain and the person can get back on track with treatment immediately. With addiction and mental health, the brain is what is hi-jacked and makes it more difficult.
Let me explain - If a person has a broken arm, their brain says - this hurts, I need to go to a doctor and a cast is put on and medications to relieve pain are taken. What happens when a person starts using drugs or alcohol again and the brain is what is the cause of the problem? They can't always make a rational choice to immediately begin exploring a treatment plan review and change course. It often takes more patience and compassionate friends, family, and providers to help the person get back on track.
I was lucky to have learned about relapse from Mark Dodd (Life Change Solutions) from a motivational interviewing framework. He was monumental in me understanding the difference - paying attention to language and being sensitive to judgments. Let's re-think this together. Take the shame out, look at the plan. There are lots of medications, outside support groups, treatment facilities, and interventions that can be use to help the person suffering.
A concept from the DBT skills manual I have found particularly useful mirrors an old 12-step slogan in the serenity prayer. "God grant me the serenity to accept the things I cannot change and the courage to change the things I can." Many models of treatment all encompass similar philosophies but present ideas in different terminologies. In my experience, clients have found "radical acceptance" a little easier to grasp and something helpful with practice.
Many people are aversive to the language of "God" and "radical acceptance" removes this as a criterion. Accepting life on life's terms is another catch-phrase that mirrors radical acceptances..
But that's really what it is about. Accepting life on life's terms. It doesn't mean agreeing with it. It doesn't mean liking it. It doesn't even mean you won't kick and scream initially about the unfairness, or lack of justice. Radical acceptance is for YOU and not for the situation or the other person. Marsha Linehan says "suffering is optional, pain is not." Being human is to have and experience pain. Suffering occurs when pain continues based on the lack of accepting the pain. It takes practice, it takes being mindful, it takes courage.
It also takes practice. A lot of practice.
It can be very helpful for a person to begin by learning to "sit with themselves". Slowing down, reminding yourself that in this moment you're alive, you're breathing. The thoughts you have are exactly them - thoughts. The feelings you have are exactly that... feelings.. Work on noticing and describing them, non-judgmentally. Sit with your breath and open your palms to the world. Let whatever needs to come in move through you and notice. You can feel any amount of pain, any amount of annoyance - notice your thoughts.
Mindfulness is simple but not easy and it takes practice. Digging your heels in and "cutting your nose off to spite your face" is what causes misery. You can't change pain but in time, you can learn to sit with yourself and notice without judgment.
This is a good article explaining more on "radical acceptance" and defines exactly what it is and how to use it.
· A suicide attempt is made about once every 40 seconds , and a suicide is completed once every 15 minutes . That breaks down to about 2,160 attempts, 96 completions, and 23 attempts per completion in a single day.
· Each suicide intimately affects at least 6 people .
· Suicide was the tenth leading cause of death in 2011 .
· The rate of suicide has been steadily increasing since 2000 , and is at its highest rate since 1991 .
· Suicide is the third leading cause of death in the 15-24 age range; the second in the 25-34 range; the fourth in the 35-54 range; and the eighth in the 55-64 range .
· Suicide rates are highest for females aged 45-54 and males aged 75 and older .
· Men are 4 times more likely to die by suicide than women, but women attempt suicide 3 times more often than men .
· Native Americans are most likely to die by suicide, followed by Caucasians .
· 90% of people who die by suicide have a diagnosable and treatable psychiatric disorder at the time of their death, most commonly depression (or bipolar disorder), alcoholism, or both .
· More Americans suffer from depression than coronary heart disease (7 million), cancer (6 million) and AIDS (200,000) combined .
Losing a loved one from suicide is unbearable. Unthinkable. Devastating. When there's complexities to this (and there probably are) - whether from anger, confusion, frustration, sadness, and problems adjusting afterwards, I understand. We can do more as a community to fight against this. I saw a cool project of people speaking out of the elephant in the room - there's so much shame when someone has attempted and fear of hospitalization that people don't speak up. Education alone doesn't do it - but connection with another human being can.
Check out the empowering site I'm referring to called: Live Through This
For those who have had a loved one die by suicide - it's important to talk. Not tomorrow, next week, or year. Now. People can't fix it, take it away, but they can bear witness to your pain and carry some of it with you. Nobody should have to bear this burden alone and it is not shameful to admit you need to talk. Talking about the loss over and over helps expose you to the pain so that you can get through it. Your story makes a difference and the meaning of the loss will change over time, only if you talk it through (over and over and over....)
This day is important to me. It represents people can get better and face hard things.
Letters to new therapists – Part III
It’s important to remember whatever happens in a session is a microcosm and valuable information that represents the outside world of a client. We begin to see how the person relates to his/her environment within the therapy session. The subtle and more overt difficulties and strengths the person might have can come out and this is a powerful experience! Do you notice they urge to take care of you? Do they have problems with completion of tasks you've requested? Do they distance themselves when “tough” subjects come up and laugh when their affect and discussion don't match? Do they attempt to push/pull on the relationship in ways that might be damaging to your continued work with them? If you notice it, talk about it. How does this impact the relationship at hand?
The relationship with your client can and should affect you– it’s a microcosm of many years of conditioned experiences (from both sides!) and we can learn a great deal about what is happening in the “here and now”. A big part of me as a social worker has been trained on resources and advocacy. The other part of me as therapist recognizes how that can also be unhelpful when the timing is wrong. The challenge is to balance both. Resist the "righting reflex" -- to give advice without permission, to solve the client problem immediately (see more on this subject of the righting reflex).
Offering and suggesting resources when a person isn’t ready or you’ve ignored what is happening in the current therapeutic transaction may provide a temporary fix or might be unwanted by a client while the underlying relationship might be ignored. I’m not saying to avoid EVER giving resources as options to client. Always ask permission before doing so (a component of Motivational Interviewing that elicits respect, dignity, and autonomy.) Example – “I have some thoughts about what you might want to try and I’m wondering if you are interested in hearing about a group I know in the community.” If a client says they are not interested hearing this information, respect this at all costs. Use your intuition when the right time to suggest an outside option is appropriate and always attend to the relationship first.
“The importance of using the here and now is based upon assumptions of the importance of interpersonal relationships and the idea of therapy as a social microcosm. Our interpersonal environment influences us and our self-image is formulated to a large degree based upon what we perceive important figures in our lives appraise us to be. “ - Yalom
“The interpersonal problems of the patient will manifest themselves in the here-and-now of the therapy relationship.” – Yalom
What does this mean for you? Seeing things more analytically between sessions. Remember when I said graduate school taught you how to think about things? This is where that molding comes into play. Dig up and review what you learned about regarding family systems in grad school. You might need to go back and gather a better social history and revert back to the basics with a genogram (thanks, Jeannie Shanks) to learn more about unspoken rules and communication patterns that may be generational. History and relationships often repeat themselves and can be wonderful information about what others might be struggling with in a client life. What you are feeling might exactly be what others have felt in the interaction and the relationship is the most powerful indicator you have with your client NOW matters. Ask your client frequently, how are we doing? What is helping in our sessions? What could be better? What directions are we going that you are finding most helpful? What might we be missing?
It also means to have thick skin. Not taking something personally is something we all have to work on. Central to assumptions and agreements in the DBT world is that the relationship between client/therapist is a real relationship and this means that the relationship can affect you. Let it to a certain degree while also understanding this is probably some of the difficulty the client has had in their lives from a long history and quite possibly, your own. It’s a therapy interfering behavior if you’re not honest with a client and also therapy interfering (Linehan) if you’re not looking at parts of you that may be carried forward and triggered from your own past relationships. Ask yourself, what is happening that I am afraid of? What is making me push away from this client? Is it my stuff or something that is happening in the relationship?
Because the relationship is real between two people, it’s important to talk about it with them after you’ve done some reflecting. How you talk about these things equally important as what you say. It’s difficult to bring up subjects that might cause some tension. It’s necessary for the person in their quest in developing a life worth living. It’s also important for you to accept feedback from a client when you’re doing something they might find unhelpful.
Precise communication full of honesty and dignity leads to the real relationships you’re modeling, teaching, and instilling. We all know Maslow’s hierarchy of needs asserts that safety/security is necessary for good things to happen. Create the safety to discuss what is necessary and how the relationship is progressing. Being genuine, honest, direct, and respectful are staples for this to happen.
Medications = hope
Many people cringe at the thought of having to take medications. I get it - along with the stigma from society implying that taking medications means weakness along with an over-medicated population that panics when any pain is felt equates to many needing psychotropic medications questioning their value.
That being said, I also know how powerful some of the new medications to treat a wide range of mental health and addiction related problems are. I previously worked in a clinic that offered methadone maintenance. With all of the ups and downs, medications save lives if used appropriately and are closely monitored. Medications + psychotherapy produce the best outcomes. Medications alone are generally less effective. The mind, body, and spirit are all connected and need healing.
We are on a great path on the medical path to treat both alcohol and opioid dependence. Medications to reduce cravings and produce a non-euphoric experience following use are evidence-based and a tool.
Some medications are "agonists" - meaning they actually provide the addicted substance in measured and longer half-life doses to avoid the pain of withdrawal. Some medications are "partial agonists" - they provide some of the medication to occupy the receptors while also having a blocking effect to avoid euphoria if a person slips with use and some that completely block and occupy the receptor eliminating any euphoria that comes from use. Antagonists completely block a brain receptor and "fills" it so that getting high is not rewarding because it is bypassing the pleasure centers of the brain that likes addiction so much.
Some of the medications I've seen people significantly helped by:
I have seen many people who also have a significant mental health concern that needed medications to help tackle their addiction. Some clients have had an untreated bipolar disorder which cycled into mania making them more at risk for use during these cycles. Because of the delicate balance for both addiction and mental health, treating both at the same time along with psychotherapy results in the best outcomes.
Interested in learning more? Come see me and we can talk about your options and I can refer you to a physician or psychiatrist specializing in both areas. Let's tackle this together.
Letters to new therapists - Being Brave.
It’s less about what you say and more about what people feel when they are with you.
Go into waters that may be scary. I’m not suggesting you operate out of your scope of practice. For example, you don’t want to try EMDR when you’re not certified and comfortable with a treatment approach. However, you can get into the Seeking Safety curriculum and modify it to something you can teach and discuss as an alternative. There's more than one way to approach something or a problem. It’s important that you don’t create more damage to a person – go with your intuition and gut and know your limits. However, pushing yourself and trying new things is what learning and growing means. You’ll fail, you’ll succeed, you’ll walk away feeling like you learned something new regardless. Hopefully your clients will see this in you as well. You want them to be brave, right? You've got to be brave yourself.
I remember being thrown into a DBT group and imploding in my head when the therapist wanted me to teach a chapter to the clients. I had to memorize the material - every little bit of it when getting 50% of it would have been more than what my clients came in with. I put more pressure on myself than what my clients were expecting out of me. Our clients don’t expect us to be perfect and are generally more accepting of our mistakes than we are. It’s also empowering to acknowledge the mistake, name it, ask for forgiveness. They will likely forgive you because they ultimately know you're doing your best and trying to help them. There is grace on both sides but carefully analyze if you’re doing harm.
Whatever you’re trying for the first time will be uncomfortable. Any new skill or strategy is going to feel awkward and this is what we are most often asking our clients to do. Throwing yourself in and moving forward while holding your head high and laughing when you make a wrong move is ok. You’ll make wrong moves. You’ll apologize to your clients when necessary and this will be healing and modeling to them about what being a human being really means. We don’t know all of the answers, we know how to “be” and “think” about oppression and that’s a great starting place.
Find things that interest you. Be curious. Ask other therapists what they have found helpful. You may not feel like you have the time with the stress of work and you’ll also probably think you’re tired after work and can’t take anymore “psychology stuff”. I promise it will be worth it and energizes you, even if you read 10 pages before bed.
My list of most helpful books:
Be you. You're good enough, you're talented and you have the right spirit. For those I supervise, you have it in you and your compass is strong.
I'm lucky enough to supervise the clinical practice of graduate students and hear some common themes from them. During my time in practice, there have been many things I've learned from wonderful mentors who I deeply appreciate and they guided me into the courage and confidence it takes to be a solid clinician. Some of these lessons come directly from their guidance and wisdom. I view them as their gifts to me. For the therapists I supervise or those just entering into the world of therapy, these are for you.
I'll be adding to these from time to time.
You may not feel like you’re ready, worthy, or trained to be what you have learned. A therapist! You have graduated from your program and you regret not being extensively trained in therapeutic techniques you were hoping for when you started. You worry the tools in your bag will not be enough.
I promise you won’t be the first or the last with these feelings. You do have a new world-view of strengths and an understanding of oppression that contributes to the suffering of humans which is a great start. You’re exactly where you should be at in your skill level. The following thoughts are related to my own experience sitting where you’re at when you are feeling unsure.
You have been thought to think.
Graduate school is more than learning about the specific interventions of Freud, Jung, and Rogers. I’ve heard many therapists regret their graduate program failed to teach them specific intervention and styles during their programming. While I don’t disagree this could be helpful, I believe they were in the process of challenging you how to think about the world and that’s not an easy task! It’s your job to develop your style and learn the “tricks of the trade” and interventions from mentors in the field now that you “think” like a mental health clinician. You are good enough with the right spirit. Spirit cannot be taught, intervention can. You are ready to begin walking the path with others even when you might feel otherwise.
Never lose your worldview you were guided into
Graduate school is a process of thinking about the world (you're right, Mark Dodd!). Understanding human behavior is a complex task. We walk along a journey with our clients and cannot underestimate our clients are the heros in the work we do together. We are not. It is less about our intervention and more about our style and rapport. Graduate schools generally attempt to mold a worldview so that you feel comfortable being able to sit with another human being and empathize with their struggles and find the strengths underneath any behavior that may seem illogical.
Too many therapists forget their roots and where they started. I remember my first restraint with a child and having limited understanding of human behavior and being thrown in. I was in panic-mode. I also remember throwing footballs with 12 year old behaviorally disturbed kids and the hugs at bed time they yearned for and how a little kindness went a long way. I remember seeing a client smoke cigarette after cigarette in an apartment building who suffered from active schizophrenia and what it meant to have me sit with her even if I couldn’t understand a thing she was saying. I remember seeing the sparkle in her eyes that she still mattered to another human being. That’s what this is about.
Most of us started our work in the field in another capacity which was less "glamorous" than a therapist you are now titled with. The moments that shaped you in the helping field cannot be forgotten and what drew you to the spot you're in today. The ability to sit with another human being and provide unconditional acceptance and being able to work through your own “baggage” is what this is about. Specific interventions take time, nobody expects you to have a style developed your first year out of graduate school. The good news is that knowing how to “be” with another human being now and the clinical interventions will build. I promise. Keep reading, keep learning.
In 1979, Cass articulated the process that many LGBTQ individuals have in the struggle to embrace themselves while transforming stigma. I was first introduced these stages during a SAMHSA training of trainers I participated in during my time working as a clinical therapist at Prairie Ridge Addiction Treatment Services. While there are many models attempting to explain the coming out process for people, I felt Cass nailed it on the head and briefly want to describe them. Some information taken from: A Provider's Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals.
Stage 1 - Identity Confusion
This is when people start to recognize their sexuality may differ from the larger populous. There is a greater risk for drug/alcohol use occurring at this stage due to the conflictual feelings people may face. In addition, much of the history of the LGBTQ population has centered on the acceptance people find in bars - which may lead to greater risks of addiction.
Stage Two: Identity Comparison
This is the stage where people are recognizing that their sexually is, in fact, LGBTQ and are attempting to find meaning and peace in this fact but may vaciliate between I am/I am not different. This stage can encompass a great deal of pain and vulnerability. Substance use disorders are prevalent in this stage.
Stage Three: Identity Tolerance
Identity Tolerance, people begin to notice the feelings they have towards same-sex feelings are probably not going away and the need for acceptance starts. People can still feel very isolated and alienated. At this stage, a person may seek out others in the community to find some sense of peace.
Stage Four: Identity Acceptance
The Identity Acceptance stage is characterized by increasing contacts with others identifying as LGBTQ. Normalizing experiences at this stage is common - many begin to socialize in bars leading to greater risks for addiction. The person can find some relief at this stage, however - feeling not so isolated and starting to recognize there are others who have similiar experiences as them.
Stage Five: Identity Pride
People now understand the injustice with homophobia and discrimination and set out against it. There is a tendancy to become very angry with the world and see things as "gay or straight". Many people become involved in activist activities but can completely reject supportive heterosexual people who may be potential support to the person. This is where you'll see the Ani flags flying (thanks, Sarah).
Stage Six: Identity Synthesis
This stage encompasses a sense of peace. A person's identity is no longer consumed by the definition of LGBTQ. The person starts to realize this aspect is an important part of the self but not the only self.
In stage six, Identity Synthesis, an awareness develops that the dichotomy of “them and us” is not valid. Addiction may be significant at this point due to many years of heavy drug/alcohol use.
Why are these stages important? It helps us understand where we are, what a person might be going through, and the struggle to develop the self when pressured with stigma. These stages may be applicable to many non-predominant populations. Knowledge is power - both for providers and for those who might be wondering what may be occurring within them. Communities can embrace people when you're ready.
A few years ago I was introduced to Dialectical Behavior Therapy. DBT is not just a set of skills or terms but rather, a way of thinking about the world and how people can be assisted by the therapist using both skills and structure of sessions to promote a life worth living.
Resolving trauma while learning a few real-life skills can make a huge impact for those that suffering with emotional intensity problems. The cool thing is -- the skills and learning a new thinking behind them can help those with a variety of problems, not just Borderline Personality Disorder. I have seen the similarities with DBT to various models treating anxiety, addiction, and depression (to name a few). The specific skills taught can help just about anyone wanting to live a better life.
Dialectical (to me anyway) really means that nothing is right, wrong, good, or bad. Usually ALL things have some truth to them and have served purposes in our lives just for survival. We have to learn to think in these terms and find a greater meaning to them. There's a higher "synthesis" with a situation and meaning behind all things. When we can withhold judgement and truly accept what is and validate all sides of the equation we are afforded the opportunity to find meaning.
The founder of DBT posted an article a few years ago outlining why she created the model and how she actually suffered herself from the same things the client she was working with were facing. Read that article here:
Expert on Mental Illness Reveals Her Own Fight
This was totally inspiring to me - here is this brilliant, strong woman who is a leader in the field exposing the rational underneath her model. No wonder why it's so powerful. Dr. Linehan's courage to write her own narrative, at her own pace, and in her own words is a powerful lesson. To be strong doesn't mean you can't be vulnerable. To be courageous doesn't mean having all the answers. To be brave is not without struggle.
I'll be posting a few different blogs on some of the DBT skills that have produced a great impact on their lives in the next few weeks. Some philosophy behind the model in addition to the skills will be discussed as well.
Click here to see Linehan's company/practice.
Jill Lehmann, LISW, ACSW
Clinical Social Worker. Photographer. Enneagram studier.