Central Iowa Therapy Solutions

Therapists: Are you READY?

3/12/2015

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 own 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 believe in helping others develop their dreams and answering questions honestly. These are the areas I can assist 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. Prior to 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 very fun 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'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.

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Moving!

2/4/2015

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I'm sorry for the lack of posts over the past few months. It has been a busy few months in the office. I'm so grateful for the referrals and continued support of CITS.

I'm lucky enough to have found a more convenient location and will be moving my office closer to downtown Des Moines. Birdie dog is still invited to sessions in the new office, for the bird lovers out there. She will be starting to make more appearances when spring hits.

My new office address as of March 1 will be:

431 28th Street
Suite 204
Des Moines, Iowa 50312

The office has a large parking lot (free). I think you'll love the new space.

Thanks so much for an exciting year.

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The Body Bears the Burden.

9/4/2014

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I'm currently reading (for a second time and it's now playing more of an impact after a recent training I've completed) "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 trauma.

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 an amazing 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 accidents. However, after litigation proceedings and settlements were received, 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 dedicates 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 important. 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 are 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 response of a brain to trauma.

In both PE and for Scaer, the premise that the brain separates from human awareness during or after a 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 fully experience. 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. which releases the energy (ever heard of anyone say "play dead like a possum"?) 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 prior to 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 prior to 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 in a systematic way. The term used for this is "in vivo" exposure. For example, if a person is afraid of 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 tell, 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 important part of the protocol along with doing some work outside of the sessions. The more exposures to the fear in the 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 find 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.

What is also true is that by understanding how our very "old" parts of the brain which are in our evolutionary core for protection and serve the flight/fight/or freeze responses try to protect us to avoid pain - they can also fool a person into believing that the fear is as intense as when a traumatic event happened and even grow in it's 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.

Jill

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Shame and Recovery.

8/21/2014

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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.

Bradshaw states:

"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."

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Relapse Redefined

8/15/2014

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Relapse? What is it?

photo courtesy of projectknow.com

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.

Jill

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Gender Identity Therapy Group Starting!

8/14/2014

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Support, empowerment, acceptance, and community.

I wanted to let everyone know I'm starting a gender identity strengths-based group for individuals age 25 and under beginning August 25 from 5:30-6:30 p.m. at my office location.

During the last few months I've noticed the limited options for young people struggling with gender identity. The importance for strong human connection is desperately needed and I'm hoping this one small step will help some people. This group will be a psychotherapy-orieted group with some education and may have guest speakers in the community from time to time.

I do request a face to face screening for interested participants prior to inclusion of the group. The group needs safe and supportive individuals attending who are invested in creating better lives for themselves and open to sharing experiences, struggles, and accomplishments in their lives. I'm so excited to be a witness to the growth and resiliency of people and hope this encourages voice and compassion in our community.

Send me a message if you would like to attend.

Jill

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Radical Acceptance

7/24/2014

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cc photo credit: goldene zeiten berlin

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.

photo courtesy of elephantjournal.com

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suicide - The "thing" we don't talk about

7/21/2014

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· A suicide attempt is made about once every 40 seconds [1], and a suicide is completed once every 15 minutes [2]. 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 [3].
· Suicide was the tenth leading cause of death in 2011 [4].
· The rate of suicide has been steadily increasing since 2000 [2], and is at its highest rate since 1991 [5].
· 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 [6].
· Suicide rates are highest for females aged 45-54 and males aged 75 and older [6].
· Men are 4 times more likely to die by suicide than women, but women attempt suicide 3 times more often than men [2].
· Native Americans are most likely to die by suicide, followed by Caucasians [2].
· 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 [2].
· More Americans suffer from depression than coronary heart disease (7 million), cancer (6 million) and AIDS (200,000) combined [7].
Source: http://livethroughthis.org/resources/

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.

Jill

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Letters to New Therapists - Part III

7/17/2014

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Letters to new therapists – Part III

Dear Therapist,

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.

Read Yalom.

-Jill

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A NEW DAY IN Treatment

7/16/2014

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Medications = hope

slide courtesy of Nida.org

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:

Campral (acamprosate) is one of the medications specifically for alcohol and reduces cravings for use. There is less risk for people with liver disease than taking naltrexone.
Suboxone/buprenorphine (partial agonist) to reduces euphoria for opiates and is what is called a partial-agonist. There's a blocking effect within the medication that reduces the risk for abuse while still occupying receptors that crave opiates.
Naltrexone (antagonist) - Blocks receptors and seems to work both for opiates and alcohol.
Methadone - (agonist) - Used for opioid dependency (must meet criteria for). Has a long half-life so that a person can avoid withdrawal. It should be noted that methadone is carefully monitored and if you seek this medication you'll need to present to a clinic daily to receive your dose. Opioid clinics do not generally accept those with co-occurring pain management problems and doctors sometimes use methadone long-term for chronic pain which doesn't require daily dosing in primary or palliative care settings. After a period of successful dosing along with treatment involvement, take-home doses of the methadone can be granted with team and doctor approval. Because methadone is a full agonist, there is a risk of abuse. Medicaid often covers methadone fully. In rural areas, traveling to clinics in larger cities may be an obstacle. You may want to discuss options with your primary care doctor and see if there's a primary care doctor certified to provide suboxone instead.

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.

Jill

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Letters to new therapists - Part II

7/15/2014

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Letters to new therapists - Being Brave.

Dear Therapist,

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.

Keep reading

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:

Trauma and Recovery by Judith Herman, M.D. is a wonderful read for those really wanted to get an overview of trauma.
Motivational Interviewing by Miller and Rollnick
Becoming Solution-Focused in Brief Therapy by Walter and Peller is one of the first books I read that gave me a handle on what I was doing and why. Learning exception questions and capitalizing on what is going well can be a great avenue for motivation
The Power of Losing Control – Joe Caruso
Drinking: A Love Affair - Caroline Knapp
On Grief and Grieving…. Good stuff. Anything by Elizabeth Kubler-Ross will help you understand complex grief and more than just the stages of death and dying themselves
Read Man’s Search for Meaning by Viktor Frankl
The Body Bears the Burden: Trauma, Dissociation, and Disease by Robert C. Scaer
Healing the Shame that Binds You - John Bradshaw

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.

Jill

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Letters to new therapists

7/11/2014

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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.

Dear Therapist,

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.

Jill

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The Coming out Process- Cass 1979

7/6/2014

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Photo courtesy of psychologybenefits.org

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.

Jill

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Dialectical... Diabolical, what?

7/1/2014

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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

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The language we use matters.

6/30/2014

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Decrease Stigma.

One of the things I try to be careful about in my work with people and other clinicians is paying attention to the language we use. Language is powerful - it's loaded with meaning. When we work with people, are we referring to "addicts", "alcoholics", "schizophrenics", or "clean/dirty" both inside and outside of sessions? Why would it matter?

It matters because it influences how we think about things. I was called out early in my career by a loving colleague who discussed the ramifications of my noting in reference to a "dirty ua". Does this imply people are dirty? That use is dirty? Does it imply a judgment? You bet it does and I wasn't even aware of the implication. How we think and communicate recovery and our perspectives matters. If you are precisely defining a behavior without judgment, you can feel a lot more hopeful when discussing a situation. For example, if someone is struggling with use and we use "they continue to be dirty for their urinalysis" vs. "they are testing positive for _____" - it takes the emotional and negative perception of a behavior right out of the equation.

In addition, when we label someone as in "denial" we are judging a very real stage of change that is needed for anybody considering a change in their lives... We make it something ugly when we've all been there. Denial is just feedback, feedback a person isn't at a point they are ready to make changes or aware of the need to make changes and respond accordingly with our clinical intervention. Respecting autonomy and stage while having open/honest discussions without judgments can get a person a lot further in your work with them.

When people say "that's so gay" - what does that really mean? It means it's bad, ugly, stupid, and results in hurt and perpetuation of stigma. People who say things like this usually aren't even aware they are doing it because it's ingrained in our culture - until we stop it.

I challenge both helping professionals and those we are serving to avoid labeling yourself or others. Be specific. There's a lot more to a person with alcohol dependence than being labeled an "alcoholic."
They are often fathers, Veterans, artists, children, and someone for whom it is worth defining things differently.

Communication can make or break a relationship. Be aware.

Read more about this: http://www.unleashthenoise.com/2013-summit-findings

http://www.theguardian.com/science/brain-flapping/2012/sep/06/crazy-talk-language-mental-illness-stigma

Jill

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This is a big deal.

6/29/2014

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1 in 4.

1 in 4 people have a mental illness and suicide is the 3rd cause of death in this country. This is unacceptable. Mental illness and suicide are both areas that can be treated and it is disheartening to me how many people give up before they have sought help. I get it though - the stigma and shame of admitting we need help and admitting something might be more than we can handle is difficult. What does it say about a person who needs a little help? I think it says you're incredibly strong.

I've seen people get better and regain their senses of self and find a life worth living again. We have abilities even in the most discouraging situations. The clients I see are heroic - all of them are on their own path, each different but all courageous.

Generational poverty, addiction, and stigma in our society can all lead to despair and many people aren't even aware how the old thoughts and situations influence who they are today. When someone realizes what oppression is, they can fight back in healthy ways against it.

I am so grateful I have the opportunity to help people overcome their pain. There is nothing better than to see healing right in front me.

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Therapists: Are you READY?

Moving!

The Body Bears the Burden.

Shame and Recovery.

Relapse Redefined

Relapse? What is it?

Gender Identity Therapy Group Starting!

Radical Acceptance

suicide - The "thing" we don't talk about

Letters to New Therapists - Part III

A NEW DAY IN Treatment

Medications = hope

Letters to new therapists - Part II

Letters to new therapists

The Coming out Process- Cass 1979

Dialectical... Diabolical, what?

The language we use matters.

Decrease Stigma.

This is a big deal.

1 in 4.

Jill Lehmann, LISW, ACSW, CADC

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