Category: Trauma/PTSD

Bret Moore on Military Psychology and Getting the Mission Done*

Posted on by rezendevknowfully.com

Challenges During the Pandemic

Lawrence Rubin: Good afternoon, Dr. Moore, and thank you for sharing your time with us today. Much has obviously changed in the world since the time we scheduled this interview. My understanding of the role of the military psychologist is that they serve the mental health needs of veterans and active personnel. What clinical challenges have you noticed in light of the COVID crisis?
Bret Moore: We often think about service members deploying and helping overseas, fighting wars and those kinds of things. But they actually have quite a strong mission stateside as well. So, in episodes like the COVID-19 pandemic, many military members are tasked to help support local response efforts in states like New York and California that have been been hit the hardest. You have probably seen the news where certain units have been activated to support those efforts — whether it be quarantine or getting supplies to individuals that are sometimes done by National Guard service members or active duty service members.

In the case of the COVID-19 crisis, one of the challenges to military clinicians is having to shift our practice to telehealth
In the case of the COVID-19 crisis, one of the challenges to military clinicians is having to shift our practice to telehealth, just like civilian practitioners are having to do. Obviously you have to be concerned about privacy and not violating HIPAA, and other related issues like what if the video's not working. Can you do the session over the phone, and how much good can you do without seeing each other and having that visual interaction, those visual cues? So, again, not so much unique to military psychologists, but it's something that we're struggling with. You did mention at the beginning that military psychologists provide mental health care to military members. But that is really only one small part.

We also provide consultation to commanders about morale and unit cohesion. In a way we also function as consultants and industrial organizational psychologists. We not only focus on individual wellness; we focus on unit wellness. We focus on organizational functioning. That's what I really like about military psychology. It is a very diverse field, and it is very difficult to get bored being a military psychologist. 
LR: Telehealth is a transition that military and non-military clinicians are making right now, feverishly trying to catch up, get up to speed, so to speak. Do you think that providing telehealth to military personnel, either active or veterans, is a different challenge at this point to military clinicians than it might be to non-military clinicians?
BM: I think the transition to telehealth may be a little bit easier from the standpoint that the VA has been doing telehealth for over a decade. All branches of the military — but primarily the army seems to have had the most sophisticated behavioral telehealth infrastructure for at least a decade, so we are somewhat used to it. Even clinicians within the VA and military systems who don't provide telehealth on an ongoing basis are certainly familiar with certain aspects of telehealth. So, providing telehealth during this crisis is not a shock. It's not a huge amount of adjustment for clinicians within those systems as it is to some of my friends and colleagues who were practicing outside of the federal military system and who are asking questions like, “What system do I use?” “Is it secure?” “How do I get paid?” “How do I bill insurance companies?” The nice thing about the VA and the DOD is that they are really somewhat of a socialized healthcare system. We're not billing insurance companies per se, so clinicians aren't really having to struggle as much with answering those kinds of questions that our civilian counterparts are.
LR: Is telehealth something that a military clinician might use for someone who is deployed, if that clinician is not deployed with them?
BM:
Telehealth has been provided in places like Afghanistan and Iraq, and we have telehealth services that are being provided currently to Germany. Wherever there's a connection
Telehealth has been provided in places like Afghanistan and Iraq, and we have telehealth services that are being provided currently to Germany. Wherever there's a connection, theoretically you could provide services. I think the VA has done very nicely, and I do believe that the Department of Defense is going to be coming online with providing care from federal hospitals, VA clinics, or Department of Defense clinics to patient's homes. Now the VA has been doing that for quite some time and I think we are going to be moving toward in the future. It's important for the VA mostly because so many veterans live in remote areas. When I worked in North Dakota for two years and when I needed to go see and check in, have a physical with my doc at the VA, I literally had to drive four or five hours. So, it is important to be able to provide these services in the home, and hopefully the Department of Defense will come online with that at some point.
LR: What advice might you offer civilian clinicians in our audience about what may be gained after this pandemic passes as opposed to what will be lost?
BM: Well, that's a tough question. It is an excellent question, but it is a tough one because that is something I have been thinking about over the past several weeks. What I hope to see is a deepening of relationships, maybe — certainly within the immediate family. We're spending all this time together and you see memes and jokes like, “We're going to end up killing each other because we're spending all this time together.” I think the opposite is probably more likely, in that people are starting to reconnect and rekindle some of the things that brought them together in the first place. And dads are learning more about their daughters, and mothers are learning more about their sons.

Hopefully, we are developing deeper bonds. But what I really hope is that we develop some compassion and connection with people we have never even met, with larger society in general. We watch the news and we see everything that's going on and it's hard not to feel some kind of connection to the people who are suffering the most right now. So, I am hoping we gain a sense of greater compassion. And I just really wish that we would stop fighting each other. And I wish our politicians would set a good example by showing how we can all play together nicely and respect each other and get along with each other.
But I do hope that we see a deeper connection between individuals once this is all over
But I do hope that we see a deeper connection between individuals once this is all over. 

Trained to Solve Problems

LR: If we want to call the battle against the pandemic a war, would you say that from the standpoint of a military psychologist, service men and women are uniquely prepared to address some of the mental health challenges that crises such as this one create? 
BM: Oftentimes I am asked if there is a certain type of person who joins the military. And the short answer is no. I mean there are a lot of shared characteristics, but there is a lot of individual variability. There is a strong sense of public service and patriotism that you see obviously within the military population. And those individuals who join tend to have people within their immediate family that have served in the military. So, there is a sense of something that is passed down from generation to generation. I will also say, to generalize, I think individuals who join the military already tend to be fairly resilient individuals. And I think that the hard work and training they do in boot camp strengthens their resilience, whether or not they are eventually deployed.

You're probably aware of some of the research that Martin Seligman has done with comprehensive soldier fitness, and how the military has made a strong effort to strengthen the cognitive reserve, cognitive strength and emotional, psychological, physical and spiritual strength of service members. I am not going to speak for that particular program, but I think in general,
our men and women in uniform are some of the toughest individuals you'll ever find. and probably are more equipped to deal with the anxiety and stress that comes with something like the pandemic we are dealing with now
our men and women in uniform are some of the toughest individuals you'll ever find. and probably are more equipped to deal with the anxiety and stress that comes with something like the pandemic we are dealing with now.
LR: Would you anticipate that the levels of anxiety, depression and fear that have been reported in the civilian population might be lower in the military because of their preparation, resilience and the skills that they bring to service?
BM: I would think so. Even though we're not in necessarily active conflict right now, many service members have done deployments, and in some cases, multiple deployments in some of the most stressful environments that you can imagine, where every day is filled with new anxieties and new tensions and new fears. So, yes, just based on that, I think from a larger standpoint or from a broader standpoint, these individuals would be better equipped to deal with the anxiety and tensions that we see today. Absolutely.
LR: Do you think that this preparation and hardened resilience might make it difficult for some military personnel to address the potential lethality of the pandemic? Might they downplay it or minimize the risk because they are accustomed to being ready and prepared for war and death?
BM: No, I don't think so. I think it is more of understanding what the challenges are, because military members and veterans are trained to be problem solvers. You identify the problem and you come up with several solutions. You pick the best solutions, implement them, and then if that doesn't work, you implement something else. So, it is really a calculated approach to things. But no, I don't think that they would under-appreciate the significance and the risks that are associated with something like this. If anything else, I think they may appreciate it more.
LR: So, although not prepared to handle pandemics per se, you're saying that military members, by virtue of their training, by virtue of the resilience and problem solving skills are uniquely prepared to help each other and civilians to address the challenges of the virus.
BM: Yes, absolutely.

The Caretaker’s Perspective

LR: During this crisis, what concerns do you have for the mental health of military clinicians?
BM: There's been a few studies out there looking at provider burnout, compassion fatigue, vicarious trauma.
In general, the stress for clinicians comes with managing their large caseloads, which are made up of trauma
In general, the stress for clinicians comes with managing their large caseloads, which are made up of trauma. A third or a half of their cases are post-traumatic stress. I think it's not so much which area you practice in. I think it's the kind of disorders and presentations that you see, just like a social worker who treats child sexual abuse cases nonstop. If you have clinicians that are constantly treating post-traumatic stress disorder, combat-related trauma, military sexual trauma, whatever the case may be, I think that's going to take a toll more so than someone who's treating adjustment disorders, or even depression or panic disorder. So, I don't think it is any different, but I think it is something that is shared across the profession. So, you know, working with trauma survivors can be very challenging, and I think we probably have a similar rate of burnout and compassion fatigue that you would see across the system.
LR: You had mentioned earlier that by virtue of their training and resilience, service men and women are perhaps better suited than the average person for dealing with crises like this one. Do military clinicians bring a unique blend of characteristics into their role during times like these?
BM: You have military psychologists who, like me, were in active duty for five years. I did two and a half years in Iraq providing services to service members. And then I transitioned back to the civilian world as a civilian psychologist for the Department of the Army. So, my experience is going to be a little bit different than someone that comes out of internship from a university and has never worked with this population, and steps into an internship working with combat veterans. You know, I think over time there is a strength that these clinicians build if they stay within the system long enough.

I do think that those who choose to enter the VA to work as psychologists or the Department of Defense oftentimes have a strong sense of public service and a strong sense of patriotism. One of the webinars I provide is on military mental health and how to treat PTSD and related conditions. I get a lot of clinicians saying that they like working with veterans because “my dad was a veteran.” “My uncle was a veteran.” “I used to sit on my grandfather's lap, and he would tell me stories about what it was like serving in World War II.” So they come with their own experiences, even though they may not be direct experiences. 
LR: When you made that transition from a combat to non-combat military psychologist, did you notice any changes in the way you practiced, or what you brought from the combat sphere into the non-combat sphere?
BM:
I trained as an Adlerian, which involves insight-oriented work and a focus on the past; but I had to shift. You do not get to spend six months doing in-depth insight-oriented work with veterans.
I trained as an Adlerian, which involves insight-oriented work and a focus on the past; but I had to shift. You do not get to spend six months doing in-depth insight-oriented work with veterans. A lot of times, at least with active duty military personnel, you may get four to six sessions. So, I had to shift my approach and, when needed, to be solution-focused. I had to work collaboratively with the service member and identify what it is that we needed to correct, to “fix,” so that they could continue to do their job.

My job as an active duty army psychologist was to care for the wellbeing and emotional health of the personnel, but it was also to make sure they could continue in the fight. You know, a soldier's job is to fight, to win wars. So, if they are not psychologically and emotionally healthy, they cannot do their job. So, not only do I have to take care of them emotionally and psychologically and help them, but also, I have to get them to return to the mission so they can finish what they started. And sometimes people who don't understand the military all that well have a deep conflict with that because they ask, “How can I as a psychologist try to patch people back up just to send them back out to fight?” Well, what is the alternative? Just send them back out to fight and not patch them up? They're soldiers. They're going to have to go to war. So, I need to be able to do whatever I can to make sure they can do their job to the best of their ability. 
LR: If you thought a particular combatant was not fit to continue, did you have the flexibility to send them back stateside, or was there a mandate to patch him up, get them back? In other words, was the threshold lowered because the mission was the mission, and your role was to get him back into the battle?
BM: No, I didn't experience the pressure at any point in my active duty days. The psychologist, the mental health professional in general, has a lot of power, a lot of control and influence over what happens with service members who may be struggling and are not mission-ready. Ultimately, it is usually the commander's call to decide whether to send a soldier away from the fight, maybe back to the States so they can recover. But in general, a commander,
a good commander will listen to his docs and say, “okay, if my doc is telling me that sergeant so-and-so is not fit, I am not going to put him back out there
a good commander will listen to his docs and say, “okay, if my doc is telling me that sergeant so-and-so is not fit, I am not going to put him back out there. Because not only does that put him at risk, it is going to put the rest of my unit at risk.” So, yeah.
LR: Did you ever feel caught between that conflicting obligation toward the military to continue the mission versus the person who might not be ready to get back in the fight?
BM: Near daily. Over two and a half years of being deployed, probably most every day I wrestled with that to varying degrees. Brad Johnson and Jeff Barnett have written a lot of great stuff about that. There is always that push and pull, and you have to find a balance, and you can't be overly rigid. This is not a black and white game. You have to think in various shades of gray and you also don't want to work in a vacuum. So, that's why if, when I was an active duty army psychologist, I got on my high horse and said, “all right, I'm just sending this person home, this person home, and that person home, I don't care what you think,” I wouldn't have lasted very long. There had to be some trust that developed through consultation and education, which oftentimes was an important part of my job, was to educate commanders about the impact of mental illness and mental health conditions on functioning. With that proper education, I was able to resolve most all conflicts in a rapidly short period of time.
LR: So, that moral conflict servicemen and women experience can also be experienced by the military clinician who struggles with the morality of where to send them in or send them back.
BM: Absolutely. I trained as a psychologist. I wanted to help people. If it would have been up to me, we would not have been there in the first place. But it was not up to me, and if it were up to me, I would send everybody home. But I knew I couldn't do that. That is not my job, not my responsibility. So, yeah, it was a challenge.

Military Clinical Competencies

LR: I would like to drop back to some of the core questions I had initially prepared because many of our readers will not have experienced military psychology. I recently did an interview about multicultural competence, and since the military is its own culture, I'm wondering if there might be core clinical competencies that a military clinician must have or develop in the course of their training and service?
BM: The core clinical competencies include being a generalist. The military and the VA definitely have specialists, including neuropsychologists, aviation psychologists, as well as behavioral medicine specialists. But to be a military psychologist, you have to be a generalist because, for example, you may find yourself deployed or in a remote location where you may be the only person available. So, you do not have the luxury to knock on the door of the specialist down the hallway.

There are some good articles and chapters out there about this notion of the distinctiveness of the military culture. In 2008, Greg Reger and colleagues wrote an article in The Military Psychologist in which they talked about the ethical challenges that military psychologists face that are not fully understood by the average clinician. The military has a unique language and a certain class caste system, a socio-economic status of sorts within the military that distinguishes the officers from the lower enlisted.

The lower enlisted have different responsibilities from the senior enlisted versus the officers. So, there is a hierarchy that must be understood.
Sometimes things in the military are not about fairness and it is not about the individual, it is about collectivism and working as a team
Sometimes things in the military are not about fairness and it is not about the individual, it is about collectivism and working as a team. You know, if you think about our current society, we put a lot of emphasis on individual rights and what is best for us. You know, what is best for me. If I take care of myself, I can take care of other people. You hear us say that as clinicians quite often. But in reality, that is not necessarily the mentality within the military. You take care of your group and then as you take care of the group, you are also taking care of yourself. 
LR: So, a commitment to a more generalized approach to intervention and an appreciation for the collectivism that is part of the military. Are there any other core competencies that you can think of that distinguish military clinical competence from non-military clinical competence?
BM: I think comfort with and being well trained in the treatment of trauma-related conditions. Combat trauma is a lot different from civilian trauma, meaning motor vehicle accidents or natural disasters and sexual assault. Combat trauma is more along the lines of complex trauma and multiple traumas. There is generally not one specific incident that leads to post-traumatic stress. For a combat veteran, it could be a year or years-long worth of traumatic events. So, it is about having a comfort to work with very trying and difficult cases, presentations and diagnoses, and being versed in evidence-based treatments. You know, the VA and the DOD are very focused on providing manualized evidence-based therapies for PTSD, like prolonged exposure and cognitive processing therapy. You also must be comfortable with a solution-focused, problem-oriented approach to care. Again, a psychodynamic psychotherapist is going to struggle a bit more than someone who is more of a behavioralist or cognitive behavioral clinician.
LR: Might a non-military clinician working with military personnel be more susceptible to compassion fatigue or vicarious trauma more so than a military psychologist who has worked side by side with these military personnel?
BM: I think that is a reasonable assumption to make. I'm not aware of any data to support that, but
plenty of friends and colleagues who have never served in the military or have never even worked within the military system, but who are private practitioners who take veteran patients, tell me, “Oh my goodness, how do you deal with this on a day-to-day basis?”
plenty of friends and colleagues who have never served in the military or have never even worked within the military system, but who are private practitioners who take veteran patients, tell me, “Oh my goodness, how do you deal with this on a day-to-day basis?” Some of the cases are very overwhelming, as they must listen to the horrific traumas that some of our men and women experience. And the military can be a difficult environment to work in. You know, there is no eight-hour shift for the most part. You work until the job is done. The mission comes first, whether it’s to complete training or to win a war. And that means everything else must come second, third, fourth and fifth, including family, friends, socialization and even self-care.

Non-military clinicians may say that these types of conditions and stresses are an unfair position to put clinicians in. How do you expect them to be happy when they are living in such a stressful environment? And so, I think compassion fatigue and an increased level of frustration are certainly going to impact the non-military clinician. And I think that is normal and to be expected that you are going to find yourself frustrated not only working with this population but with the system that you have really never been a part of. They may be hearing second hand the difficulties of working within that system, but not necessarily the benefits of working in the military. 
LR: It almost sounds like the clinician, whether military or non-, who is working with military personnel has to readjust their relationship with Maslow’s hierarchy of needs because in active military combat, there's not a hell of a lot of time for self-actualization.
BM: No, that is way down on the list.

The Privilege of Prescribing

LR: You are in a unique position because you are a prescriber, one of an elite group, so to speak, in a nation where very few states provide prescription privileges to psychologists. How has this added privilege been a benefit in working with the folks you have had to serve?
BM: It has reduced the number of referrals I have had to make. I will tell you that. I do a lot of medication management as well as administration. About half of my time is research and administration and half of my time is clinical work. I am not a huge proponent of medication and believe in using it sparingly, smartly and only in cases where psychosocial interventions have not worked. But as a clinician who trained initially as a psychotherapist, I know that sometimes psychosocial interventions don't work, or they don't work well enough, and then medications are warranted. I might at times have to refer to somebody else and lose that patient because they resist psychosocial intervention, but also resist having to start over and believe that they have to tell their stories over and over again, especially trauma victims.

So, I might lose patients once I attempt to refer, or if I could obtain a referral while convincing them to stay in treatment, it could be three months before there's an appointment. But, as a prescribing psychologist, I get to do both my therapy and medication management. I have the ability to provide a level of continuity of care that you don't get, I think, in any other mental health profession — even psychiatrists. You know, psychiatrists obviously can do medication management, but very few choose to or can do psychotherapy. So,
I really think prescribing psychologists are in a good position to show that continuity of care is important, that collaborative care is important, because we do best as professionals when we collaborate
I really think prescribing psychologists are in a good position to show that continuity of care is important, that collaborative care is important, because we do best as professionals when we collaborate. I collaborate with primary care physicians and other healthcare professionals. I do not operate in a vacuum. But I have become more effective, I think, as a clinician, and I have grown to truly appreciate the complexities of human nature and psychological presentations and have come to appreciate how powerful psychotherapeutic interventions can be as well. 
LR: Have you found any particular challenges prescribing to service men who are either predisposed to substance abuse or who have histories of substance abuse? Or who are actively using substances while serving?
BM: Not so much substances. My guess is that the rate of true substance use disorders in the military is probably equal or a bit lower than you would see in the general population. The challenge you tend to find as a prescriber within the military system is that there are medications that are not conducive to serving in a harsh environment. So, medications that require careful monitoring and updated laboratory values might not be the most appropriate during times of active combat. Medications like benzodiazepines — Valium and Xanax — can reduce a person's focus and concentration and can lead to drowsiness, so you don’t want someone who is rappelling off a tower on high doses of one of these types of drugs. But there are mechanisms in place if you put someone on one of these medications. Commanders are alerted that hey, these are some limitations that you need to follow while this or that soldier is on this or that medication. That is the biggest challenge.
LR: Are there difficulties certain service men or women have who are prescribed during active combat, and then return home or are transferred into a non-combat area?
BM: I kind of see it as the opposite. The need for meds is limited in a combat environment except for sleep meds. Sleep meds are very, very useful for service members who are working very long shifts in a very noisy environment where it is very difficult to sleep even when allowed to. So, what I find stateside is there's more time to ask the existential questions, even though you would think you would be asking these questions on deployment. But it's so busy and the operational tempo is so fast that you don't really get a chance to sit back and do a lot of introspection about the meaning of life, and why am I not happy, and what's this anxiety that I'm dealing with? When deployed soldiers return home to relative comfort and regular days, we start to see more anxiety and maybe more dissatisfaction with life.

I think transitioning medication from non-deployment to deployment is the bigger challenge — getting them off the medication so that they can be aware, alert and not have any cognitive deficits related to medication so they can really focus on the task at hand
I think transitioning medication from non-deployment to deployment is the bigger challenge — getting them off the medication so that they can be aware, alert and not have any cognitive deficits related to medication so they can really focus on the task at hand. I'll give you a concrete example with nightmares. There is a medication called Prazosin that’s used for nightmares. It's been shown to be really effective. And if you're taking that stateside, that's fine. But when you deploy and take it, one of the side effects is that if you get up too fast, you can faint and hurt yourself. So, yeah, if you are sleeping and a rocket comes in, you hop up out of bed too fast, you could fall and hurt yourself. There are just some medications that aren't conducive to a combat environment. 
LR: It sounds like in your training for prescription privileges, there were specific components of that training that addressed the issues of transitioning from deployment to non-, from non- to deployment, and to the use of medications in combat. Is it that specific during your prescription training?
BM: Not during the formal educational/clinical training. On the job training, yes. One of the nice things about the military is they tell you what they want you to do. There is no shortage of regulations and memos and guidelines to follow. So, there's definitely guidelines for which medications are a go versus no-go, and for what to do if a person is on a medication and they're getting ready to deploy or transition from one base to another base. So, there's definitely plenty of guidelines out there to help clinicians make those decisions.

Myths and Misconceptions

LR: Are any popular misconceptions about the military persona, the military psyche? 
BM: There are some popular misconceptions out there, likely based partly on some truth. Back in the day, the only people that went into the army were the people who went before the judge who said, “Hey, you either go to the army or you go to jail.” But it's not like that anymore. Actually, there are more people joining the military right now who are from the middle class. People tend to think that they’re from lower SES groups. So, it is more of the middle class, middle America that really serves. And the military can be a springboard for very successful careers, not only in the military, but after service ends. You can serve 20 years and get out at the age of 38 with a full retirement and then have another career set aside for you. I guess my point is the idea that people join the military because they don't have any other options is no longer accurate. It's just not true.
LR: Choice versus default. And it is the default conception that leads people to think that military personnel are unstable or simply do not have anywhere else to go.
BM: Sure, there is going to be a segment of military people that join because they do not have any other options. They may come from a small town where either they work at the sawmill or they go into the military. College isn't always an option. And the great thing about the military is it has a very robust college opportunity where if you serve, you basically can go to college for free. And there are some people within inner cities that say, “You know, I've got to get out of this. This is an opportunity for me to make a life of my own.” I don't want this to sound wrong, but it's not the bottom of the barrel of our country that joins the military by any stretch. It is people who come from hardworking families and the middle class, from across the country. And again, many who have a strong patriotism, a love of the country and want to serve others.
LR: You'll probably find the most misconceptions coming from those who are most removed from the military.
BM: Absolutely. Another misperception or conception that I think that some people have post- 911 or post-Iraq and Afghanistan, is that our soldiers are broken, busted, unhinged, crazy. It really, really troubles me. I know they've made great stories for media, but anytime a veteran does something that's not good, you know, a shooting or a high profile crime, they always lead with “combat veteran does this” in the heading — they don't lead when a non-veteran that does something bad, they don't lead with “non-combat veteran does this.” I think it's done to create some of the sensationalism. But I think it feeds into that wrong narrative that our service members are busted and broken, and they are really not. If you look at the vast majority of service members, they don't return home with post-traumatic stress disorder.

And if they do, they go on to lead very healthy and successful lives with symptoms of PTSD. We look at our World War II veterans, you know, the level of post-traumatic stress that these men and women dealt with — primarily men — they helped build this country into what it is today. And they didn't get a lot of treatment. They didn't get a lot of services, but they still found a way to live with those experiences. And that has led me to another area that I am really interested in, which is post-traumatic growth. Working with Rich Tedeschi and Lawrence Calhoun, we have found that
not only do returning soldiers experience symptoms following trauma, they experience growth
not only do returning soldiers experience symptoms following trauma, they experience growth. You can actually become a stronger, better, person following trauma and lead a more rewarding and fulfilling life because of what happened to you. 

Challenges to Military Families

LR: What are some of the challenges that military clinicians typically confront when working with the children and partners or spouses of deployed personnel when they come home, when wheels go down, as you say in one of your books?
BM: When the spouse stays home, it’s typically the female partner. The military member maybe took care of everything when they were home. But again, each household differs. What I found is that the stay-at-home partner or the partner that didn't deploy, the non-military partner, has to take on the responsibilities previously handled by the military member of the family, which creates a significant level of stress, feelings of being overwhelmed — “I'm doing this by myself. I'm having to raise the kids, but now I also have to take care of everything else that you were taking care of.” So, there can be a bit of anger, frustration and animosity toward the service member who is deployed, and when they return home.

But, I have also seen the transition from that frustration and animosity to a new sense of independence. After a year of paying the bills, after a year of making sure the home was being maintained and the cars were maintained, the partner who remains home might feel something like, “I'd like to keep doing this” or “I want to keep doing this.” So, now when the service member comes home and believes that they are going to take over their former responsibilities, there can be a bit of a conflict, as the stay-at-home partner feels, “I don't want to give this back up. I am more capable than I originally thought. I can actually handle a lot.” It's hard to turn that back over. I think non-military clinicians who want to work with couples, especially couples that had at least one party deployed, should understand that this kind of military-related conflict may be a common occurrence. 
LR: What are some of the issues that you've noticed in the parent-child relationship between the deployed and now-returned veteran and the child(ren)?
BM:
One of the complaints I hear from the returning service member is feeling disconnected from their family, especially if they were away for a long time
One of the complaints I hear from the returning service member is feeling disconnected from their family, especially if they were away for a long time, and the only previous contact was through Skype or phone calls. There is a sense of disconnection, and sometimes it is connected to post-traumatic stress, while other times it is outside of the realm of post-traumatic stress. I am not really clear on where that disconnection comes from. It probably has something to do with being separate for so long. And sometimes the children mature and develop in their own ways. So, that tends to be a struggle.

This is certainly true from an adolescent standpoint, particularly if the service member was a strong disciplinarian before deployment, and returns to an older and more independent child who feels something like, “They come back and tell me now what to do,” or “I've been taking care of mom or the sister or brother for the last year while you were off at war, so don't come home and start bossing me around.” The same thing may occur for the spouse, who feels, “Don't come home and start bossing me around. I'm the one that's been taking care of the household for this long.” But again, the nice thing is that with good counseling, marriage counseling, couples counseling, family counseling, this can be corrected. That is because a lot of times it's just a matter of understanding how expectations have changed and understanding how people are feeling, and helping these individuals discuss what they're feeling and what they would like to see happen going forward.
LR: So, is being a well-trained family or couples therapists enough to work with families of returning veterans, or is there additional training they should have in order to work with military families that are reunited after deployment?
BM: I think being a grounded and solid couple or family therapist is important, but also having some additional training. It doesn't have to be formalized training. It could be a CE activity or even reading a couple of books on military culture. Family therapy is family therapy is family therapy.
If the clinician can pair their skills as a couples therapist or family therapist with their newfound awareness of cultural, military cultural aspects, then I think they will be just fine
If the clinician can pair their skills as a couples therapist or family therapist with their newfound awareness of cultural, military cultural aspects, then I think they will be just fine.
LR: If, as we close, you could send a message to those military psychologists, military clinicians working in the combat theater or at home, what would you say to them?
BM: Well, first of all, thanks for doing such an incredible job over the years, and that's directed toward those that have been doing this for a while, because I think we have had a challenge providing for the many needs that our families and our service members have experienced over the past decade and a half. And for those that are new to this field and are just starting to work with veterans and military members, don't give up. You are going to feel frustrated. At times you are going to question, “Why in the world am I doing this? Why would I work with families or individuals that I really don't have a strong connection to?” Because as a civilian provider, you can oftentimes feel like an outsider if you don't have military experience.

Military experience and military service is valued by service members and military families, but it is not a requirement for helping them. But in honesty, in all honesty, it is valued. But for the non-military clinician or clinician who has no experience in the military, ask when you don't know something — don't try to fake it. If you don't understand what the terminology means, let the service member teach you. Let the family teach you. Develop a collaborative relationship, and don't give up. Just work through the frustration, because we have plenty of veterans and families that need the help of good clinicians. 
LR: Stay in the fight.
BM: Stay in the fight. Get the mission done.



* The views expressed herein are those of the interviewee and do not reflect the official
policy or position of U.S. Army Regional Health Command-Central, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense or the U.S. Government.

Integrating Technology into Mental Healthcare: Theory and Practice

Posted on by Psychotherapy.net Team

Recent Trends

A recent review by the American Psychiatric Association (APA) found that there are currently over 10,000 mental health apps on the market¹.

At first glance, that number is astounding. However, “technology in mental health is not necessarily a new concept”. The 1966 advent of the Rogerian artificial intelligence therapist named Eliza marked the first formal introduction of technology’s application to mental health in general, and to the process of therapy in particular. Although the limited technology that built Eliza was far from a meaningful contribution to the course of mental healthcare in America, it nonetheless represented an important milestone that has since snowballed into our current ecosystem of mental health applications used by billions of people worldwide.

While there are all kinds of mental health-related applications that service a wide range of functions, most of which are of the “self-serve” type, what has drawn my attention most are those that are used to supplement or enhance my own work as a therapist. Truth be told, my skepticism around the prevalent use of self-serve apps — particularly those with largely unfounded clinical outcome claims about producing a quick fix for [insert any diagnosis here] — has limited my interest in recommending these apps as an alternative to face-to-face therapy. However, technological innovation in the context of supporting, rather than replacing, the work that we do in therapy has piqued my interest for quite some time.

In this context, I have found that technology used to enhance the therapeutic process can be clustered into three overarching domains, which are detailed in brief below.

1. Technology for improving access to care.

It’s no surprise that the largest impact that technology has had on the mental health and wellbeing of individuals across our world is the advent of online telehealth platforms. Individuals who previously were denied care due to a lack of access to qualified health professionals (e.g., those in rural areas, with disabilities, or with limited resources for transportation) can now access quality care in a matter of minutes. Telehealth companies such as Regroup and Ginger are changing the way in which we understand the therapeutic relationship, and the process of therapy more generally, through the addition of a computer screen separating therapist and client. Although there are certainly several noteworthy factors that warrant consideration regarding providing telehealth services (client safety, confidentiality and boundaries come to mind), “even the technology-wary therapist has a hard time arguing against the profound benefits that come from increasing access to care for those who need it”.

2. Technology for screening, assessment, and risk management

Leaders in our field have advocated for measurement-based care for decades, and countless research studies have confirmed that integrating routine screening and outcome monitoring into your practice in one way or another significantly improves your ability to detect client deterioration, make appropriate referrals and make better treatment decisions throughout the course of therapy, among other benefits. However, the implementation of measurement into practice has traditionally been halted by the cumbersome process of collecting relevant information and, quite frankly, the annoyances that inevitably arise when administering and making sense of paper-pencil assessments during your sessions. As a result, less than 20% of clinicians currently practice measurement-based care². Luckily, technological advances are solving these issues by making it easier than ever to routinely screen and assess client symptoms and progress in therapy. For example, companies such as Blueprint allow therapists to assign rating scales and screeners for clients to complete on their own time while at home. These platforms can alert you when a client’s data shows a spike in severity and can even link the client to local crisis resources for just-in-time interventions. Although seemingly simple, these advances can make a world of difference when trying to integrate measurement and screening into your otherwise busy clinical practice.

3. Technology as an adjunct intervention

The research around combining app-based interventions with face-to-face therapy tells a similar story to what is commonly found in outcome studies for psychotropic medication and therapy: they work alone but are better together. Many mental health apps are specifically designed to serve as a supplement to individual therapy by focusing on aspects of care that you want your clients to be doing anyway, such as learning new skills and practicing techniques outside of the therapy office. In fact, simply monitoring thoughts and emotions daily, which represents a fundamental component of cognitive behavior therapy (CBT), has been identified as a leading predictor of early positive change in CBT for depression and anxiety. “It’s no surprise that self-monitoring apps are also among the most downloaded mental health related apps on the market today”. As therapists, we should be encouraging our clients to partake in this type of behavior as a means of engaging more fully in the process of therapy and generalizing skills outside the therapy office.

A Lesson Learned

For some of you, the addition of the three domains of technology into your practice mentioned above comes naturally. For others, myself included, it does not. In fact, throughout my early years of clinical training I was vehemently opposed to introducing technology and apps into my clinical work. The foundation of my focus was (and still is) all about cultivating the therapeutic relationship; between this and my burgeoning passion for helping clients build a contemplative/meditative practice into their daily lives, I just couldn’t fathom why I would ever want to pull up a computer screen or bring out my cell phone during a session.

It wasn’t until my clinical training with Hasbro Children’s Hospital & Alpert Medical School at Brown University that the integration of technology into quality mental healthcare was de-mystified. The psychologists I worked under had a wonderful approach to implementing the three domains of technology mentioned above in a non-invasive and rapport-strengthening manner, and in a way that enhanced the therapeutic work that was being done. I’ll share one small excerpt from this experience in the form of a case study to illustrate how technology can be integrated into your clinical practice to support your work and improve your clients’ mental health and wellbeing. Please note that all identifiable information and certain aspects of the case report have been modified for privacy purposes.

Case Study — Katie

Katie was a 16-year-old female who was referred to me due to PTSD symptoms following a traumatic experience with a family member. She initially presented as cautious, with flat affect, and with little ability for back-and-forth conversation. Given her presenting symptoms and overall demeanor, I used a trauma-focused cognitive-behavioral therapy (TF-CBT) approach to help her overcome distressing internal experiences that were holding her back from engaging fully in her academic, home and social life.

Following a few weeks of psychoeducation and building rapport, we started working on relaxation and grounding skills to help her reduce the panic and hyperarousal that she would experience in the face of trauma-related triggers at school and with friends. Although she would engage in exercises during our sessions, she had difficulty maintaining this practice outside the office. After reviewing several relaxation apps, we collaboratively identified the app “Stop, Breathe & Think” to support her independent practice of these skills. Katie found this app extremely helpful, particularly its feature to support paced breathing, as well as its daily journal function, where she could express her thoughts and feelings in the moment. Moreover, she enjoyed bringing up the journal entries during our sessions as a means of communicating significant events that occurred over the week with more detail than if she relied on recall.

Over the course of six months, Katie became increasingly able to manage her symptoms of PTSD and felt as though she was finally beginning to take back control of her life. However, an upcoming out-of-state move with her parents required that we make a decision regarding the remainder of her care. I felt as though she still required the support and assistance of a therapist, yet had progressed sufficiently to warrant holding off on transferring to a new therapist for continued care. As such, we decided on using a telehealth platform to continue having sessions virtually on a bi-weekly basis with the goal of ending services within the year.

Given that I would no longer be meeting with Katie face to face, I decided to implement a remote assessment and screening platform as an additional precaution for keeping an eye on Katie’s health and wellness as she adjusted to the move. Katie was assigned the Patient Health Questionnaire Adolescent (PHQ-A) and the Trauma Symptom Checklist Short Form (TSCC-SF) to complete through the mobile app on her phone on a bi-weekly basis. I would review the results with Katie during our sessions and bring up any noteworthy changes to her functioning for further discussion.

“Six weeks into her move, I met with Katie through the telehealth platform as usual and things seemed to be going just fine”. She was keeping up with her journal entries in the Stop, Breathe & Think app, which we would use as an additional source of communication. However, when reviewing her most recent assessment, I noticed that Katie reported “sometimes” to the suicide-related question on the PHQ-9. When asked about this response, Katie reported that she had been feeling “a little off lately” and that she had been experiencing suicidal thoughts that were like her experiences early on in our time together. Upon further inquiry and discussion, Katie and I jointly decided to make a referral to a trauma specialty clinic in the area that could better assess safety and set her up for a longer course of care with a local therapist. Katie and I had one final session before her transition to the new therapist, and at that time she was feeling hopeful and optimistic for positive change. Although Katie’s case doesn’t have a resolution for our story today, I hope that it is a helpful example of the ways in which technology can be integrated into clinical practice to support the process of therapy across the care continuum.

Looking Back, Looking Forward

 While the list of mental health apps entering the market is growing each day, the practice of psychotherapy is, and always will be, founded upon the uniquely human relationship that occurs between a therapist and a client – something that technology in and of itself cannot reproduce. As a result, it is our responsibility as therapists to adjust to this new culture and learn how to integrate these tools into our practice, while also being mindful of the limitations that technology may have in supporting our work.

For example, a primary area of interest in contemporary mental health app development is the ability to detect psychological disorders or pathological behaviors using complex data analytic techniques such as machine learning and artificial intelligence. Doing so would, in theory, enable better prevention through linking individuals to healthcare services earlier in the disorder progression, and would help therapists identify clients at risk for relapse before they exhibit observable symptoms or behaviors. However, despite this type of technology’s current availability the market, such innovation is far from obtaining widespread research support and validation. As a result, clients may be vulnerable to the effects of misinformation (e.g., being wrongly identified with a particular mental health disorder), and clinicians need to increasingly trust their clinical judgement amongst potentially opposing information from unvalidated sources.

In summary, technology can and should have a place in the therapy office. In particular, therapists should take notice of technology that increases client access to care, assists in screening and routine assessment, or can be used as an adjunctive intervention to support face-to-face therapy sessions. My own experience has taught me that cultivating a sense of curiosity and willingness for change, together with a healthy sense of skepticism, is the best approach to jump-starting a technology-friendly practice. I’m hopeful that with regard to integrating technology into your mental healthcare services, you all can get out of your comfort zone and do the same.

References:

(1) Torous, J., Luo, J., & Chan, S. R. (2018). Mental health apps: What to tell patients. Current Psychiatry, 17, 21-24.

(2) Lewis, C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglass, S., Simon, G., & Kroenke, K. (2019). Implementing measurement-based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324-335. 

Usha Tummala-Narra on Living Multicultural Competence

Posted on by Psychotherapy.net Team
Lawrence Rubin: I want to thank you very much, Usha, for being with us today and sharing your time and expertise with our audience of psychotherapists.
Usha Tummala-Narra: Thank you for inviting me.

Towards a Definition

LR: Multicultural competence seems to have become somewhat of a buzzword in the field of counseling and psychotherapy, defined differently by different clinicians; but since it’s the nexus of your own clinical and research work, can you tell our readers what you think it is and what you think it isn’t?
UT: Indeed, there’ve been many different definitions. I arrived at cultural competence from a psychoanalytic perspective. Given that, I think of multicultural competence as a way of understanding, a way of engaging with sociocultural context and how it shapes interpersonal processes as well as intrapsychic life and extending into the therapeutic relationship. How do the sociocultural context and dynamics that are evident in broader society get mirrored in the relationship between the therapist and the client? So, cultural competence to me looks at the various layers of an individual’s life, both intrapsychically and interpersonally.
LR: Irvin Yalom talks about the therapeutic relationship as a microcosm for the client’s interpersonal world, so I’m wondering if what you’re saying is that a multiculturally competent clinician strives to build a connection with the client’s broader contextualized experience.
UT: That’s certainly a part of it. I think the other piece is the person of the therapist in terms of their own socio-cultural history. This includes their own history of social oppression – what they find as positive and identify positively with in terms of their cultural background, their religious background or linguistic background. It’s about how all those sets of cultural and socio-cultural experiences shape the therapist and their subjectivity and how that in turn interacts with the subjectivity of the client. There’s this kind of interaction between multiple cultural worlds happening regardless of who we’re working with therapeutically. And this is not specific to working with clients from a particular socio-cultural background, but rather I see it as broader than that. It’s about engaging our broader context within the therapeutic relationship.
And so for me, cultural competence isn’t a specialty, it’s just part of professional competence. I just really see it as a regular part of psychotherapy.
LR: So, it’s more than just two people coming together, but it’s almost like two worlds coming together in the therapeutic encounter.
UT: Yes, that’s right.

Revealing Full Personhood

LR: Traditional therapeutic practice, particularly dynamically-informed practice, is built upon the premise of therapeutic neutrality; so how can a clinician bring their full contextual personhood into the relationship with a client and still be faithful to the ethics and the tenets of psychotherapy?
UT: That’s a great question. We should consider what neutrality actually looks like and feels like for the client. We’ve been socialized as therapists to put everything about ourselves to the side so that we’re not imposing our agenda onto the client. And so, therapists have this idea that “if I was to initiate a discussion about race or culture or gender, that it’s really my personal wish that’s being filled in some way, or my personal longing to engage in those discussions rather than the client’s needs and what might be actually helpful to the client.” But in fact, what I have found is that so many clients in fact need to talk about issues of race and culture and religion but have been told all their lives in one way or another that they shouldn’t. As a result, people’s experiences of racism are often kept hidden, are kept silent, and are more often spoken about within somebody’s home or with a circle of friends.
But, we should consider that psychotherapy is actually a place where we can talk about things that we have been told not to because therapy is not an ordinary conversation, as Freud himself pointed out. For me, then, we must think about what’s not being spoken about when we neglect to address issues of sociocultural context and background. If we’re not talking about something like social class and how it impacts our clients, then perhaps neither will our clients. I don’t see those particular issues as being separate from what may be going on internally for a person – what they might be struggling with. I just see the two as quite intertwined in terms of a person’s suffering and conflicts and relational issues. They’re very intertwined for me.
 
LR:  It’s interesting how you’re saying that people who differ from the so-called mainstream are taught to be invisible, to homogenize themselves and hide the rich context of their life. And the same seems to go for therapists who are taught to blend into the background, to neutralize the rich cultural, racial, gendered, religious aspects of themselves so they may be fully available. But you’re also saying that both client and therapist need to step out of that invisibility and reveal themselves to each other.
UT: Yes. If we’re interested in exploring a full range of experience within our client’s lives, then we must actually explore all of those different aspects of our own life. And I don’t see how we can separate the individual from their context. One other thing that comes to my mind is how we might even from the very start think about developmental history. When we do an intake assessment and ask questions about a person’s development, we typically ask questions about their family, school experiences, work and health history – things of the like. But we tend not to ask more specific cultural, racial and contextual questions like, was the family struggling financially, did they have resources in the community, what was it like growing up in this particular family?
It can be so important to ask about the immigration history not only of the client and their immediate family, but of the extended family. Deep and culturally-informed questions can be so valuable like, was there any bullying related to racism or to sexism or homophobia? These are the kinds of questions I think that could extend what we already do, but into a realm that considers the fact that development is occurring in multiple contexts and that we ought to know and learn about what’s happening in those contexts, especially for kids. But also for adult patients, who have been internalizing all sorts of things as a function of being in and living through those contexts. 

Becoming Culturally Competent

LR: It goes back to what we talked about before—the need to de-neutralize the relational encounter with our clients. What are some of the challenges that you’ve seen clinicians deal with, or that you want to caution clinicians to be careful of?
UT: Actually, something you said pointed to part of my response to this in that I don’t see cultural competence as necessarily an outcome, but as a process. It’s a journey, as you say. And I think one of the things that clinicians are challenged with is this idea that somehow cultural competence only relates to certain outcomes related to people of color, or people holding some kind of minority status, rather than this being relevant to all people of all backgrounds. And so, I think that an important challenge to overcome is the assumptions we make about what is cultural competence and who it is relevant for. If we don’t see it as relevant to all of us, then it becomes a situation for certain people at certain times rather than thinking more broadly. I also don’t see it as only a professional endeavor, but a personal endeavor as well, because if we are not learning to listen to issues of context and culture in our everyday lives, then it’s very difficult to know how to listen for that in our professional work. So, to think that we just need a set of competencies to apply in a technical way in the therapeutic relationship, that’s really not what I think of as cultural competence. To me that’s a mechanical way of being rather than investing the self into the work.
LR: A more fluid way of living multiculturally rather than simply turning on the multicultural switch when in therapy! What do you see as some of the blind spots clinicians may have in working with the “other,” basically someone who’s different from yourself in any regard?
UT: I think that’s a great way to phrase it because so much of the time, the assumption or presumption in our literature is that the clinician is white, and the client is the racial minority person or something like that. Whereas certainly in my case, it might be reversed or there are two racial minority people in the room. So, you can have any combination. I think one blind spot may have to do with our human tendency to overgeneralize about groups or our conceptions about certain, if not all, socio-cultural groups. It is the notion that if someone is affiliated with or identified with a particular group, then they carry certain characteristics or that they have this or that particular set of values. I do think it’s important to have some working knowledge about the history of different cultural groups and a good working sense of that. To me, those form just a beginning framework, a beginning sense, rather than a story or rather than really understanding what belonging to that particular cultural group means for and feels like to the person.
Everybody has a unique experience of their own culture or their own religion or belonging to a particular racial group or being multiracial. I think this is why for me, a psychoanalytic perspective is particularly well-suited to this line of inquiry, because it does allow us to think about experiences that are deeply embedded in relationships, within early life relationships, but also throughout one’s lifespan and one’s evolving relationship with the broader context as well.
Another blind spot that comes to mind has to do with working with somebody who is, in some way, of similar background and making an assumption of sameness, which can get in the way of differentiating ourselves from the other. This is the flip side of overgeneralizing about the other, sort of more about merging – two people whom you think might be similar in some dimension which may not necessarily be true. 
LR: Overgeneralizing about the other and undergeneralizing about someone we perceive to be like ourselves or with whom we share certain demographics. Like me working with a white Jewish male and not inquiring into their whiteness, Judaism or their maleness and as a result, missing out on a lot of potentially good information about what it is like for them.
UT: And sometimes the clients are making assumptions about the therapist, too. So, you might hear a client say, “Oh, you know what it’s like to be Christian,” or biracial, or gay? And I could say, “Well, I know what it’s like for me, but I’m still learning about what it might be like for you and trying to understand that more.” And certainly, with some of my white clients, I routinely ask about their ethnic background. I will ask them to describe it. Some of these clients will say, “Well, I’m just white you know; that’s just who I am.” And to me it always reflects how we’re socialized around race, particularly in this country, to believe that some people don’t have a history beyond just being white. So any previous family history is really kind of disavowed, which people may actually have a lot of complicated feelings about.
LR: And if we don’t allow that into the conversation, then it just continues to be a force of oppression. Just out of…
UT: Disavowal of some kind.

Bearing Witness

LR: Along these lines, what have you learned about social oppression, racism and trauma in working with immigrants and refugees that could help our audience of therapists along their own journeys towards multicultural awareness and competence?
UT: The journey I’ve had has been an incredible one. I feel very grateful for the opportunity to have learned from the people I’ve worked with in therapy. They have been an incredible resource in transforming my understanding of immigration and trauma. One of the things that I have learned along the way is how incredibly complicated the process of immigration is psychologically.
Immigration is rife with hope and optimism and resilience, but also with deep separation and loss. And the ways that people reconcile this are unique to that individual and depend on so many different factors. It depends on their families, the quality of their relational life, their own personalities and what they bring to those relationships. It also very much depends on the traumatic experiences, the support they’ve received and the willingness of people to listen to them and to hear their perspectives. So much of what’s happened in more recent years, certainly since Trump’s election, is we have enormous anxiety among immigrants and refugees.
This anxiety is not only about status, the fear of deportation and separation from loved ones, but also related to the underlying anxiety that immigrants have always felt around not belonging and not being wanted. You know, feeling as though one must find other ways to sustain the self. And that’s been important for me to understand and bear witness to. So, listening to the stories of immigrants and refugees is not just about hearing what happened, but about witnessing and bearing what is happening now and what has happened in the past. There’s tremendous transformation that occurs across the lifespan for immigrants and refugees, as well as developmental points and junctures where their kids and their grandkids are also challenged. And that itself transforms one’s own experience of what it means to be an immigrant or refugee. So, there’s a lot that we still have to understand and learn and research. Actually, I think about these changes that occur as a function of time and cultural shifts and political context and social oppression – all those things.
LR: On a more personal level, if I may, how has or is being an Indian, Hindu female, informed your own multicultural journey as a clinician and a researcher?
UT: Well, certainly it informs a great deal of my whole self, which you know, I bring to my work as well. I immigrated to the United States when I was seven years old from India and grew up first in New York City and then in New Jersey and then moved to Michigan. And we traveled around quite a lot while growing up in the US as well. So, I think that one of the things that stood out to me in that process of adjusting to being in America was how incredibly resourceful my family as well as people in my community — my Indian community, the Hindu temple — were. We really found ways to take care of each other and be very present with each other in one sense. And yet in another way, people also have difficulty talking about painful losses and traumas, so there was this really interesting paradox within the community where I grew up.
I think it’s true for many communities that there’s this sense of cohesion and an incredible connection that feels positive that brings a great deal of strength for people. And yet at the same time, when there are issues of trauma such as violence in the home, racism, sexual abuse, or political oppression that people might have faced prior to immigrating, these things become much more complicated to talk about openly and become stigmatized. So, I became increasingly interested in figuring out what can we do about that and why is that the case? A lot of what I do in my research and in my practice has to do with trying to figure out those gaps and try to make mental health care more accessible to people who typically wouldn’t seek it out or who may not trust the typical mental health professional to understand their context, their values and their families.
I think anything that’s not considered mainstream American is not necessarily considered positive or normal in some cases or normative. People within immigrant communities have a lot of concerns. Racial minority communities as well.
I have concerns that if an immigrant sees a therapist, are they going to be seen as abnormal, or are their families going to be devalued? Is their culture going to be devalued in some way because of the very theories that we use to conduct psychotherapy? And so, there’s a lot of concern around that for people in addition to around providers’ not having awareness of the impact of trauma or the impact of emotional suffering on individuals and families. This is one way I think about my own journey interfacing with and guiding my professional life and is clearly very important to me. 

A Different Worldview

LR: What are the elements of the Indian and Indian American worldview that psychotherapists need to understand?
UT: I think there are some common shared elements. But I think that it’s also important to point out that, as you say, there isn’t one worldview. Somebody may say something like, “what’s it like to be an Indian person?” Well, you can ask a million Indian people and you’ll hear different things about what that means. So, I would say that there’s no one thing that’s definitive. There are many things, but I will try to narrow it down to a Hindu Indian perspective — but again, it depends on how much a person identifies with a particular religion or a particular ethnicity, and even a region within India and language, all those things.
One of the things that comes to mind as a common or a shared element of Indian culture is the ways in which families interact with each other. There is traditionally a respect for older members of a family, in a way — a deference.
And this leads us to think about conflict within families. While there is the tradition of deference to older members of the family, younger members may want to do something that’s not approved of by the older members, but they may then go ahead and do it. But in this instance, they tend to avoid speaking about the conflict. So, there are ways of communicating that are more culturally accepted or valued.
From a Hindu perspective, there’s also a belief in Karma, or a belief in the inevitability of suffering in human life. This is very interesting to me because it parallels psychoanalysis in a particular kind of way in that there is an acceptance of the fact that suffering happens and that there’s value in bearing suffering, at least to a certain extent in service of others, in service of a greater good. So, this feeling of being a part of something greater than yourself or bigger than yourself is something that I think a lot of Indians more broadly, but certainly Hindus, tend to value as well.
These are a couple of more common types of shared elements. There’s also a third thing I could highlight, which is a different sense of ideology around parenting. Parents are typically pretty involved in their children’s lives throughout their lifespan. The Hindu Indian notions of parenting don’t necessarily follow the same developmental lines of being 18 and going to college or being 21 and experiencing a definitive separation from the family. And so, in a lot of Indian families the separation may happen later, or it may take a different form in some other way later in life. So, that can look a little bit different from Western notions of parent involvement. And sometimes it’s extended family too, like aunts and uncles who play a significant role in the attachment and separation experiences within families. 

Sitting with Suffering

LR: Along these lines of differences in worldview, I understand that in Hinduism, as in some other religions, suffering for the greater good is seen as a virtue, as aspirational. Western psychotherapy, in contrast, seems bent on eliminating suffering, resolving irrational thoughts, helping the person to regulate themselves, helping the person to change their behaviors so they don’t suffer. And even though the third wave of cognitive behavior therapy incorporates mindfulness and acceptance, do you still see a tension between traditional Western psychotherapies that are designed to eliminate suffering and therapeutic orientations that embrace suffering for growth?
UT: To see some type of suffering as a normative part of life feels very aligned to me with the reality of what I see every day. But the idea that somehow to live a happy, fulfilled life you must eliminate all suffering, just doesn’t add up. I think it’s sort of a setup for people to actually feel even worse, and it creates more suffering because there’s a way in which this expectation creates the unrealistic expectation that one should never feel bad or one should never have negative experiences. And in fact, we all do and we all will and that’s sort of a foundational idea. So, I do see it as a problem of trying to eliminate the suffering as quickly as possible rather than trying to understand what’s happening. I do see that as a big tension.
LR: I wonder then if Western psychotherapists need to be aware of the intrinsic pressure of our models to sanitize living. An example, perhaps, is our seemingly uncomfortable relationship with death, dying and grieving. We remove people to facilities. We don’t talk about death. We have special grief counselors, which is okay, but what about conversations in families around loss and death? I worry that many therapists in our audience may be too caught up in that need to sanitize and cleanse the person of suffering.
UT: I think we probably feel some pressure to have to relieve people of how bad it feels. And I understand that. And of course, there are certain situations where that suffering is so overwhelming that we do need to help and relieve people. But if it’s something that is a natural part of a loss or separation that happens, we can help people to bear those and know that they will come through it. And so, you’re certainly instilling hope. But you’re not also giving this false hope that somehow everything will be fine after this. Because in fact, it often isn’t, you know?
LR: I wonder if therapists working with refugees and immigrants who have been trafficked, tormented or brutalized simply find it so hard to be in the presence of someone who’s suffered that they try purge them (and themselves by association) of their suffering? Or might some therapists simply not be cut out to work with these clients for reasons related to countertransference?
UT: I do think there are certainly some types of suffering that feel too much to bear for therapists, but that varies for each of us. Some things are going to just feel harder. And perhaps it’s because we’ve been through something similar or that we just don’t want to imagine, you know, and bear witness to that. And certainly, that happens. I’m thinking also of situations where a therapist may not know what to do with that suffering, so they minimize it or push it aside.
LR: Ignore it.
UT: Ignore it. I’m thinking of a situation where clients will talk about experiences of racism at the workplace or at school and wonder within themselves, was that racism? Was that why I feel so badly?
LR: It goes back to something we were talking about earlier in the conversation — core competencies of a clinician who is aspiring to cultural competence. So maybe we should add to this conversation the willingness and ability to sit in the presence of pain, someone else’s pain, our own pain, and bear witness to it — to embrace it, to allow it into the conversation. And in doing so, honor the client who has been oppressed, who’s been trafficked, who’s been marginalized, who’s been hunted.
UT: You’re right. You’re mentioning situations of extreme trauma like trafficking that feel, in some way, so foreign to so many people, as though it’s happening out there somewhere. And in fact, it’s happening in our own neighborhoods and in our own microcosms. I think that it speaks back to that earlier point we touched on which has to do with our own personal investment in these issues. If we don’t take the time to learn about what’s happening to people within our broader society, then it’s going to be very hard to listen for these experiences.
LR: You speak about our broader society. I worry that some psychotherapists consider our broader society maybe a few states away, or “all the way” out to the Coast. But when you expand the definition of “our broader society” to humanity beyond borders, then it’s really a commitment to considering that there but for the grace of Allah or Brahma or Yahweh, go I — that we are all potential sufferers.
UT: Yes.
LR: I wonder if certain therapists would actually benefit from working with such clients and to consider doing so to be a gift of enlightenment for them. A potential gift of the opportunity for awareness and growth.
UT: I think it’s so pivotal to growth as a human being and as a therapist. It’s transformative when you listen to people’s stories from various places and contexts; it is unbelievably transformative.

Final Thoughts

LR: Given that patriarchy and the masculine worldview have historically infused psychotherapy and religion, how does male privilege impact the practice of psychotherapy for you? What are some of the learning lessons we need to learn?
UT: It’s a big framework kind of question. When I think about male privilege more broadly, I see it in the context of our traditional theories that I think hold so much weight over how we think today. I don’t think, oh, well these were some of the older theories or theorists and that was a long time ago. But in fact, I think about how we’ve all been and continue to be socialized under certain models of thinking. In the research world, for example, there is still a valuing of a certain type of research which is quantitative and includes randomized clinical trials as the gold standard. Only certain types of methodologies fall under that umbrella, whereas qualitative research such as case studies are actually more feminized and seen as less valuable. Storytelling and listening and witnessing and participatory action research, which is not valued as highly as quantitative research, is really rooted in community psychology and feminist psychology.

So, I’ve been really interested in using the feminized methodologies and rethinking the issue of being privileged, how it applies to our research paradigms and ultimately to our clinical practices. You know, what narratives and whose narratives are being privileged, and why? Not to say that there isn’t value in all these different paradigms. I see great value and I learn a great deal from each of them, but I do think that the issue of male privilege brings up a broader question about privilege in terms of what therapies are available to different communities. I think about what research is considered to be gold standard and acceptable, and how that all translates to public welfare and people’s wellbeing. I think there are many ways to challenge the status quo in terms of that.

LR: A dichotomy between quantitative and qualitative as masculine and feminine. It seems that the newer therapies are much more relational, inter-psychic, narrative and contextual than the traditional therapies. This makes me wonder about you as a psychotherapist. When a client walks into a room with you, a Hindu, Indian female, what can they expect from you based on the intersectionality of you, of your Usha-hood?
UT: When someone comes to me for psychotherapy, I think they can expect someone who is really interested, curious about their life, about their perspective, how they make meaning of things in their life, and what’s important to them. And I want to hear their story. I want to know who they are as fully as I can know them and as they will let me know them. I want them to understand that we’re all vulnerable in some way or another, but also that being in psychotherapy itself can feel really precarious and that I understand that. I hope to make it a space where they can connect with as much of themselves as they can and make decisions that feel more fulfilling.
LR: So, you are curious, and you are caring, and you are contextual, and you are collaborative.
UT: I would say so, yeah. That’s what I try to be.
LR: Well, it’s about the journey, not about the destination. Right?
UT: True. Very true.
LR: Do you have any questions of me before we stop, Usha?
UT: I have one question. I am curious about how you’re finding this mode of interacting with your audience and what you’ve been learning from that.
LR: This mode of communication, the interviews I conduct, is the pinnacle of the work I do for Psychotherapy.net, because each interaction expands me as a teacher, clinician and as a person. Learning from some of the experts in the field, those who are passionate and committed has ignited my own passion and commitment to learn and grow. It has also made me painfully aware of my biases and limitations, but also of my gifts and strengths. It has made me all the more sensitive to stories, to context, and to the importance of deeply felt personal experiences. I hope that answered the question.
UT: It does and very much aligns with how I’m experiencing you. So, I just want to say that. It’s really been lovely to talk to you.
LR: Same here, Usha. I hope we can speak again.
UT: Me too.

© 2020 Psychotherapy.net, LLC

Trauma and the Reproductive Story

Posted on by Psychotherapy.net Team

It’s morning. The alarm goes off, the coffee pot goes on, you decide what to wear, and ready yourself for the day. Consciously, but most likely out of your conscious awareness, you expect today will be similar to yesterday, and tomorrow will be like today. The day’s events may differ, but most likely the routine will be pretty much the same. There is comfort in that.

But suddenly something changes. When a traumatic event occurs, your world is no longer the same, no longer the safe place you could count on. It can feel as if the rug has been pulled out, everything is flying in the air and has yet to settle into place again. And as I will discuss, one’s internal world, one’s sense of self, also can feel dramatically off kilter.

Trauma and the Reproductive Story

Trauma, as defined for the diagnosis of PTSD in the DSM-5, is “exposure to actual or threatened death, serious injury or sexual violence¹. We often think of it as a one-time horrific event—a car accident, an earthquake, a shooting. But reproductive trauma, specifically infertility and/or pregnancy loss, is cumulative in nature. For most patients, by the time they set up an appointment with a fertility doctor or with a mental health professional, they have already gone through a year of “trying” to conceive, and multiple losses. As one patient put it, every menstrual cycle felt like a “mini-death.” And indeed, the losses that patients experience—of their hoped-for baby, their own adult development as a parent, their hopes and dreams for the future, of what we refer to as their “reproductive story”—significantly affect their psychological well-being².

Another way to define trauma, and one that fits with reproductive patients, is to think about infertility as an event that causes the disintegration, not just of a would-be pregnancy, but of one’s entire inner world. It affects every aspect of one’s life: feelings about the self, questions about one’s purpose, concerns about relationships—with one’s partner, friends, family, the world—and worries about the future—how does and will one fit in, what is one’s legacy, what is the meaning of one’s life? These are clearly not minor concerns. Trauma, in general, can be thought of as an event that overwhelmingly shatters core beliefs and assumptions³. For reproductive patients, the narrative that they once held, often as an unconscious guideline for the creation of their family, is no longer tenable as originally imagined. The core assumptions they held about having a family are demolished.

As a clinician who specializes in reproductive issues, I have heard a wide range of stories from women over the years, some of whom proclaim, “I always knew I wanted to be a mom. Even as a little girl that was what I wanted to be. I even decided to become a teacher so I would have the same schedule as my kids;” some that are more vague, “I just thought I would have kids someday;” to some that were more ambivalent, “I didn’t think I wanted kids and then one day it hit me. I hope it’s not too late.” These stories often begin in childhood, as we ourselves are parented. The stories evolve over time and the subtle changes that are made to the narrative become subtly yet implicitly assimilated. It is when the story abruptly goes off course, when a woman can’t have children how and when she wants to, that the traumatic loss occurs.

As I have listened to my patients’ reproductive stories, I have taken note of their core assumptions about pregnancy. The more I, as a therapist, can understand what it means to them—how it enables them to fit into their cultural milieu, how it can make them feel they are on equal standing as an adult—the more I have been able to appreciate and begin to understand the depth of their losses. “Acknowledging their own internal narrative, I have witnessed how patients can begin to heal by attempting to “rewrite” their reproductive story”; they may not know exactly how the story will end at this point, but navigating and choosing how they move forward—especially given all the options that current reproductive medicine offers—gives them back a sense of control.

Allison and Core Belief Disruptions

Allison, 38-years-old, had experienced a recently failed IVF cycle. With only one other frozen embryo, she was planning to try another transfer, but was not sure what would happen if that one was unsuccessful as well. Financially maxed out, she and her husband were faced with some very challenging decisions. Should they try another retrieval using her eggs? Should they consider using an egg donor or embryo donation? Should they adopt?

Today, though, she came into session in tears and in a rage. As she grabbed for the tissues and started piling them up on the coffee table between us, I realized that before I even knew what was causing her such pain, “I was feeling helpless and overwhelmed by her emotional state”. I recognized that this was most likely how she was feeling as well. We sat silently for a few moments while she dried her eyes, and then she blurted out that one of her best friends just announced that she was pregnant—and did so via Facebook for the world to see. “She didn’t even have the decency to let me know privately. She knows what I have been going through. It would have been hard enough to find out she was pregnant, but to find out like this? And all the time I opened to her about my struggles, I thought she cared! I feel so betrayed. I don’t even know how long she has been trying for.”

As I comforted Allison by affirming her feelings about her friend, I began a mental list of all the assumptions she had held, and how many had been shattered by her fertility struggles. First and foremost, and a core belief nearly all people have before they start to try to conceive is, “everyone can get pregnant; it’s easy.” Many people assume that all they have to do is stop using birth control and voila! Indeed, it is so drummed into young men and women to “be careful” that it seems as if getting pregnant happens effortlessly. So often women with no fertility issues, and no sense of how their joking comes across, declare “all he has to do is look at me and I get pregnant!” Clearly this is not funny to people in the midst of a fertility work-up or a miscarriage.

Allison assumed that her friend had gotten pregnant on the first try. Whether this was true or not did not matter; to Allison it was simply unfair. One of her core beliefs, that “life is fair,” and that “the world is a just, secure, and reasonable place,” was disrupted by her friend’s pregnancy. Additionally, the belief that “my friends understand me and are supportive of me; I can trust them” was crushed. The challenge for Allison was to make sense out of this threat to her fundamental beliefs. Not only had she not been able to easily become pregnant, but a trusted friend had, and in the process, betrayed their alliance. Could it be mended? Could the earth right itself again and the pieces fall back into place? As a therapist who has observed the great strength and growth that reproductive patients exhibit over time, I knew it could. But right now, as the tissues continued to pile up in our session, things were not logical, the world was not fair, and I needed to listen to more of Allison’s shaken world. While I wanted to be present to the current dissolution of her reproductive story, I also wanted to encourage her to think about her strengths and resources.

Allison went on to talk about her last IVF cycle. “I don’t understand why it didn’t work. We chose the healthiest looking embryo—I didn’t care if it was a boy or a girl. In fact, I told them to just pick the best one and not tell us the gender. We had all the embryos tested. These were the two that came back normal, so it should have worked. Now we’re down to one.”

Allison and her husband had opted for an additional procedure after the embryos began developing called pre-implantation genetic screening or PGS. The test entails removing a cell from the embryo prior to transferring it to the uterus and checking to see if the chromosomes are normal. There is some controversy in the literature about this procedure, as it does not guarantee the embryos will develop normally. It certainly can weed out embryos that won’t develop, but there are some conditions in which the embryos can self-correct as they develop in utero, even with an abnormal result. The test is often very useful if the woman is of advanced maternal age (considered to be 38 and older) or if there is a known health risk.

“And I did everything!” Allison continued. “I went to acupuncture; I stopped eating gluten and loaded up on pineapple. And I was so good about resting for 48 hours after the transfer. I basically only got up to pee!”

I validated that Allison did do everything she could that was within her control. She did do everything right. Only, with pregnancy, doing everything right is still not a guarantee. This brings us to another core assumption, what I call the Santa Claus theory, and a significant part of people’s reproductive story: “If I am good, I will be rewarded for it (Santa will bring toys)” or, stated slightly differently, “if I work hard at something, I will succeed.” In our core belief system, the opposite of these assumptions is also true. So, as it goes, if I am not rewarded, I must be bad, or if I didn’t succeed, I must not be working hard enough. When people mention this in their reproductive stories, they often reference other people who they feel didn’t do everything right. I have heard numerous versions of how unfair it is when someone had kids and couldn’t afford them, or drank, or had them too young, or wound up getting divorced. I can recall one patient talking about her older sister who got pregnant as a teenager, had the baby, and then wound up living back at home as a single mom. My patient was adamant that she would never do it that way. She and her husband got married first, waited until they had finished college and had a steady income, waited until they could afford a house. In their minds they were doing it the right way, and “when they were diagnosed with age-related fertility issues (commonly known as old eggs), they were naturally devastated”. The assumption, “what did I do wrong to deserve this,” is one that runs deep.

The facts are that a woman between the ages of 20-25 has about an 85% chance of getting pregnant; by 30 years of age, the rate drops to approximately 60%; by 40, it drops to about 35%, and when a woman is 45, there is only a 5% chance that she will naturally conceive. People are delaying having children for many reasons, such as pursuing higher education, the ensuing student loans and financial debt, needing to move back in with parents because of debt, not finding the “right” person and many more. Many people also assume that reproductive medicine will be available to them, and are astounded by the cost as well as the rates of success. For women under 35 going through IVF, there is about a 40% chance of pregnancy; for those over 40, it drops to about 11.5%. So, although waiting until one feels established and able to take care of a child is smart, it also can come with risks if one waits too long. At 38-years-old, Allison’s ability to produce healthy eggs was definitely in decline.

When All Else Fails, Blame Yourself

Because reproductive trauma disrupts one’s fundamental beliefs about how the world is and how it should be, the search for reasons becomes paramount. This is especially true for individuals or couples who have “unexplained infertility” or a pregnancy loss for unknown reasons. Generally speaking, about 20% of infertility cases are unexplained, while the rest can be equally divided into female factors, male factors, or a combination of problems in both partners. In my clinical experience, the bulk of the feelings of responsibility fall on the woman when a pregnancy fails. This is likely due to the fact that she is the one carrying the baby and feels in charge of its care. Whether it’s an early miscarriage, an ectopic pregnancy, a stillbirth, or an unsuccessful IVF cycle, women not only feel like it’s their fault, but also want answers. Unfortunately, there are times when there are no answers.

“Allison’s failed IVF cycle was unexplained”. The embryo had tested “normal” and according to her embryologist, it had thawed well and was “hatching” when the transfer took place. Her uterine lining was in great shape. All systems were go. In a follow-up meeting with her fertility doctor, she was told that these things just sometimes happen, and that it was not her fault.

“How could it not be my fault? It was my body, after all! I wonder if there are things wrong with me that they just don’t know about. Or…if I’m just not supposed to have children.” She was crying again and pulling out more tissues.

In a desperate search for reasons, Allison was blaming herself. The assumption was that she had done something wrong. My impulse was to reassure her that she did not cause this loss, but I wanted to hear her reasoning. So, I asked why she thought she was not supposed to have children. “I know I never brought this up in here,” she began. “But when I was in college…well…” she hesitated, “…I had an abortion. I don’t know how you feel about that. That’s why I never brought it up. I know it was the right thing at the time. At least it was the right thing for me. He was not the right guy, or the right time. I mean, I was in my first year of college. I was just, well, experimenting. Can you imagine? It would have if completely changed my life. But now when I think about it I wonder if that was my only chance, that somehow I am being punished. That because of what happened then, I shouldn’t have children now, when I am really ready to be a mom.”

At this moment, Allison revealed another of her core assumptions: you get what you deserve. It is not uncommon for fertility patients to blame their current reproductive issues on what they perceive as past indiscretions. Whether it’s about partying too much in high school, or promiscuity, or as in this case, a previous abortion, their self-blame is not always rational, and almost never accurate. Searching for reasons, it felt more reassuring for Allison to blame herself for her current loss, than to believe it to be some random event. As paradoxical as it may seem, self-recrimination may actually bring some relief to the internal chaos of a shattered schema.

So many times, when couples are struggling with conception, they are given well-intentioned, but inaccurate advice to “just relax” or “my sister-in-law went on vacation and came back pregnant; maybe that’s what you need to do.” For fertility patients, this popular notion translates into: “you’re not doing it right.” Whether it’s about not being relaxed enough (and who is when they’re giving themselves shots!) or for having negative thoughts (i.e., “I don’t think this is going to work”), women may absorb this into their self-narrative. If only one could control conception through one’s thoughts! There would then be no need for birth control! And throughout history, women have conceived under extremely harsh conditions: during war, famine, following rape. These are clearly not times when women are relaxed. It can be helpful for the clinician to remind patients that conception is not a skill, but a biological process that has nothing to do with thinking.

“Self-blame that accompanies reproductive losses can be destructive and promote a downward spiral of negativity”. Depending on the strength of the blame and feelings of punishment, these adverse attributes can become incorporated into the very core of one’s being, leading to negative self-worth, an all-encompassing feeling of meaningless, and depression. Although important for patients to give voice to their deepest feelings of guilt and shame—doing so can actually provide relief—it is equally important that they are able to regain control and process their self-deprecation in a constructive way.

Grief-work, Coping, and the Reproductive Story

With gentleness, I addressed Allison: “You’ve really got a lot going on right now. Not only are you grieving the loss of this pregnancy, you are trying to make sense of your friend, and you are thinking back to decisions you made in college and wondering if you deserve what’s happening now. No wonder you’re feeling awful.” The message here was clearly supportive, but it was also meant to remind Allison that a failed IVF cycle is something to be grieved, compounded by the questions she has about trusting her friend and her own past decisions. Sadly, losses involving failed cycles and even early miscarriages are commonly treated as non-events by society at large, and sometimes even by medical staff. Because of how medically frequent these losses occur, they can become easy to dismiss—but clearly not for the particular woman it’s affecting.

Feeling disenfranchised in her grief, Allison needed to be able to label it as such and to understand that grief of a reproductive loss is not simple. “If you had a favorite uncle who passed away,” I continued, “you would have a store of memories, lots of photos, and people around you would understand how sad you are. But lots of people don’t really get how significant a failed IVF is. You have put so much effort into this—physically, financially, emotionally—it’s got to feel awful that you don’t have anything to show for it. And you’re not only sad, you’re angry. It’s not fair that this is happening when other people like your friend can get pregnant so easily. It’s also not fair that you got pregnant at a time that wasn’t right for you and that now, when it is the right time, you are struggling.”

I could feel the room sigh a breath of relief. Allison’s shoulders dropped and she nodded. She felt heard and understood. But the next step was to have her consider how to cope with these changes in her narrative. She needed to be able to compartmentalize her grief and have it coexist and intermingle with her strengths and resources.

Here’s where the concept of the reproductive story can help. Our patients come to us in crisis. They are in the middle of their reproductive story and don’t know how it is going to end. They can look to the past, understand how the story began, recognize their assumptions, and see how their hopes and dreams got thrown off course. They are certainly aware of the enormous pain they are in at present. And the ambiguity of the future—will they become parents, how will they get there, what happens if they can’t become parents—is causing significant stress and emotional pain. What they can’t see is how the experience of reproductive trauma can actually enhance their lives in the future, and produce a new and revised life story.

The Importance of Telling the Story

One thing we know that helps people grow beyond their traumatic experience is grief work. This entails feeling the range of emotions that naturally occur and being able to tell their story—to select people. Sharing their story is the essence of narrative therapy. The process reduces isolation, increases the sense of connection with others and creates a feeling of being understood. Additionally, telling the story without feeling judged allows patients to unburden that which they feel most ashamed about. Whether this happens in therapy (as with Allison) or outside of therapy is less important than the issues of trust and safety. Allison’s loss of trust in her friend compounded her already fragile self-esteem.

It has been suggested in research on trauma that there are two systems of storytelling?. One is for public consumption; the other is the story that we tell ourselves. That story, the one deep inside of us, is the one that produces haunting, intrusive rumination, and with it self-loathing and self-doubt. In therapy, we try to access that deep story. In order to heal, that story needs to be befriended and looked at in a different light. Allison’s previous loss through abortion filled her with immense shame. Had she not been struggling with infertility, however, that part of her history might never have resurfaced. But the failed IVF coupled with the repeated attempts to get pregnant the old-fashioned way overwhelmed her. The fact that she could open up about it in therapy and have it be received without judgment was an enormous step for her. Instead of continuing to be self-punitive, Allison was on the road to replace her harsh and self-punishing inner narrative with a more tender, kinder version. This is a process that takes time, as all grief does, as the gradual acceptance of a new story emerges.

I had three goals for Allison at this point. Although laid out here in numerical order, these therapeutic goals are not linear; rather they co-exist as part of the ongoing process that occurs as one assimilates the trauma into a new narrative:

1. Manage her emotions and reduce her negative self-talk. I encouraged her to express her feelings without the harsh self-critic that was so deep-rooted. Labeling what she was experiencing as grief helped to validate that her loss was real. I also encouraged her to reach out to others for support—carefully. I suggested some local peer-led support groups to contact so that she could find other people who would really have empathy for her story of trauma and loss.
2. Work on ways to craft new narratives, new schemas. Allison found it helpful to think of her reproductive story as evolving. She thought about her remaining embryo; what if it didn’t work? While some people take comfort in focusing on the present and not delving into the “what-ifs,” Allison needed to have a plan ready in the wings if her next attempt didn’t succeed. Although she had yet to make a firm decision about anything, giving space to contemplate the future was allowing her to think about a new narrative.
3. Recognize that her core assumptions about pregnancy, her relationships, and feelings about herself were changing. Trauma can be thought of as a turning point. There was the time before, and the time after. Beliefs about oneself and how the world works can significantly change. And, as will be discussed, post-traumatic growth following reproductive losses can be quite life-altering in a positive way.

Out of Loss There is Gain

There have been numerous studies focused on posttraumatic growth (PTG) and the positive gains that can arise from challenging life crises?. Whether it’s recovering from a life-threatening disease, surviving a car crash, or witnessing a mass shooting, people can grow, change, and appreciate life in profoundly different ways.

As we have observed with Allison, trauma challenges fundamental assumptions—about oneself, one’s relationships, and the fairness of the world. The disruption to one’s narrative or schema commonly results in negative responses such as intense anxiety, depression, anger, intrusive thoughts, and/or feelings of numbness. Physical reactions are also common: headaches, gastro-intestinal upsets, fatigue, or a general sense of not feeling well. While the consequences of trauma result in psychological and physical distress, personal growth can occur in its aftermath as well. There is a cognitive restructuring that occurs in order to rebuild a sense of the future, and focus on what it takes to cope and find meaning. It’s important to note that the ability to grow does not signal an end to the trauma, the pain, or the distress, but they live alongside each other to create a new worldview.

A greater appreciation for life in general is a common characteristic of growth after trauma. There is often a newfound sense of gratitude for the everyday, a not-taking-things-for-granted attitude. For people dealing with reproductive trauma, research has shown that when they do become parents—however they get there—they tend to have a better relationship with their children, with greater emotional involvement?. The speculation is that the parent-child relationship may be strengthened because of the great lengths it took to become a parent, and the appreciation for their family becomes heightened.

From clinical experience, I have seen infertility and pregnancy loss patients grow in extraordinary ways, whether they are able to eventually have children or not. So many who have been down this road want to “give back” as a result of their experience. One couple made memory boxes for other parents and delivered them to the hospital where their daughter was born still. Another woman took to Facebook to educate the community as to what to say, and what not to say, when someone is struggling with fertility issues. Others have taken the opportunity to reevaluate their careers; I have worked with many women in healthcare, including mental health professionals, who decide to change focus and specialize in working with reproductive patients. One nurse opted to return to work in obstetrics so she could be there at the front lines and provide care to those in need.

“As people balance feelings of loss with a sense of growth, the strength that emerges is distinct”. Knowing that bad things happen, that we are all vulnerable, and that—most importantly—we can get through it, increases one’s resiliency. A new core belief can develop: “I am a person who is tough, hardy, and can handle just about anything!”

The Reproductive Story Ends

Our reproductive stories have a beginning, middle and end. As discussed earlier, patients enter therapy in the middle of their story at a heightened state of loss and pain. Using the story as a therapeutic tool addresses the inner beliefs and core assumptions of pregnancy and how it was supposed to be. Whatever the trauma or loss that has brought them in to our office, this experience is clearly not how their reproductive story was supposed to unfold.

One of the pluses of using the reproductive story in treating patients is that they immediately get it. Although there is a great deal of psychological theory behind it, it’s instantly recognized and understood without any psychological jargon. Knowing that they are in the middle of their reproductive story, gives them a sense of a timeline. Where they had felt a loss of control, they can utilize the idea of their story to edit, rewrite, and come up with new possibilities. They can try on different endings: if I use an egg donor, how will I feel? Can I emotionally and physically handle another miscarriage? If we decide to stop trying, how will our lives have meaning?

The reproductive story allows patients to understand the personal meaning of pregnancy and family, and the depth of what is lost when the story and their core beliefs go awry. I have the opportunity to explore these narratives, and the trauma they have experienced opens doors to explore new possibilities in creating a family, and in the broader context of their lives. Although their reproductive trauma has changed them forever, they also can embrace the ways in which they have grown through the process.

Postscript

As for my work with Allison, over the course of the next several months she continued to progress in a constructive way, between grief and growth. She was preparing herself for her next IVF transfer with the one remaining embryo. In looking at options beyond that, both she and her husband agreed to “wait and see” and keep the option of using an egg donor on the table.

The day she walked into my office beaming I knew she was pregnant. Her blood test results came back with a really high beta and had doubled, meaning that the embryo was developing as it should. We celebrated, cautiously, as we knew that there are never guarantees with pregnancy. She was trying to enjoy the here and now, even though it was filled with anxiety about all the things that could possibly go wrong. I normalized this for her; everyone who has had a reproductive trauma is anxious about a subsequent pregnancy, another loss. Gone are the days of that innocent assumption that getting pregnant and having a healthy child is natural and easy. As I welcomed her into the next chapter of her reproductive story—pregnancy—I reminded her that whatever happened, we would get through it together.

References
(1) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association: Arlington, VA, USA, 2013.

(2) Jaffe, J. & Diamond, M.O. (2011). Reproductive trauma: Psychotherapy with infertility and pregnancy loss clients. Washington, DC: American Psychological Association.

(3) Cann, A., Calhoun, L.G., Tedeschi, R.G., Kilmer, R.P., Gil-Rivas, V., Vishnevski, T., & Danhauer, S.C. (2010) The Core Beliefs Inventory: a brief measure of disruption in the assumptive world. Anxiety, Stress & Coping, 23:1, 19-34, DOI: 10.1080/10615800802573013.

(4) Van der Kolk, B. (2018). Trauma conference: The body keeps score. www.pesi.com.

(5) Tedeschi, RG & Calhoun, LG (2004) TARGET ARTICLE: “Posttraumatic Growth: Conceptual Foundations and Empirical Evidence”, Psychological Inquiry, 15:1, 1-18, DOI:10.1207/s15327965pli1501_01

(6) Golombok, S., Lycett, E., MacCallum, F., Jadva, V., Murray, C., et al. (2004). Parenting infants conceived by gamete donation. Journal of Family Psychology, 18, 443-452. DOI: 10.1037/0893-3200.18.3.443.

When the Grass Becomes Greener

Posted on by Psychotherapy.net Team

I feel fortunate to live in a climate where four seasons prevail. The first having passed for the year (ski season), we are on the precipice of entering the second: lawnmower season. Spring has sprung! And, with the recent rains we’ve had, our grass is taking off to new and varied heights! It’s about time to unearth the mower from way back in the back of our garage, get dressed in some comfortable work clothes, put on some old tennis shoes, and officially commence lawnmower season, week after week, one hour at a time.

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The usual routine involves noticing that the grass is starting to eclipse the stone borders around our blackberry and raspberry vines, and lamenting the development of dandelions and hard woody weeds that tend to shoot up above the rest. The latter of these are actually the persistent leftovers of a sour cherry tree that we used to have in our backyard, perennial manifestations of seeds haphazardly planted by the birds who used to steal the ripened berries straight off its branches.

After a long day of therapy, processing trauma with clients who have lived through the darker side of our shared humanity, I welcome the physical exercise that weeding and lawn mowing provides. With old volleyball kneepads pulled over my knees in homage to my favorite sport, I work at ground level, eye-to-eye with the garden nemeses that impede our barefoot backyard adventures. (If you’ve never stepped on a sprouted sour cherry tree root barefoot, it’s like traversing your living room and stepping on an errant Lego® block, randomly left behind, circle-side up! Ouch!)

While weeding, I enter the quiet space of a self-induced Eriksonian trance and process my day, thinking of clients’ stories, past and present, and their journeys to face the unimaginable to try to evolve beyond what they’ve experienced. I think of the importance of taking the time and putting forth the determination and commitment it takes to dig with my hand trowel to the bottom of those sometimes sprawling roots to carefully and tenderly lift them out of the ground so as not to leave a piece of them behind that can regrow and repopulate in their place. I meditate. If only the “errant” thought, belief, or behavior (their own or someone else’s) that caused or continues to cause them harm could be uprooted, whole and in its entirety, and cast away onto a compost pile to be transformed and recycled, seeped of its energy and sustenance and used to nurture a new thought, behavior, or self-affirming belief in its place. Perhaps the grass truly could be greener on the other side.

I continue my gardening from behind the lawnmower, upright and removed from the closeness of the weedy encounter, gear up to “rabbit” mode, and pull the cord until it sputters to a start. Although it sometimes takes a few tries to get our old mower going, once it is, we’re off and running steadily for about an hour together. I typically break a sweat as I push our mower back and forth, systematically turning around trees and our kids’ swing set, breaking down the task by completing small sections of the yard one at a time. Despite the heat of the day, I take comfort in the steady pace I can keep, guided by the mower’s propulsion system, and the constant hum of the engine in motion. I can more easily see the progress we make using the larger and more powerful tools of the trade. The tall and uneven blades of grass are trimmed for a fresher and more orderly appearance.

As I push the mower, it’s easy to set the direction. The machine, unthinking and unfeeling, willingly moves forward and turns under my guidance. Its ease of use allows me to enter the same unthinking and unfeeling space by the grace of our interaction, a welcome break after a hard day at work, providing therapy, then weeding. We only need to pause once or twice so I can empty the grass catcher and refill the gas tank, operations that are simple to complete and require no real brain power on my part. The wonderful part about mowing is how progress is steady and visible, and how it’s easy to estimate how far we’ve come and how much is left to go before it’s done.

As a therapist, I find it important to be able to do things in my personal life where the beginning and end are easily marked and where progress along the way is obvious and quantifiable. Systemic training has taught me to look for the smallest incremental measures of success, counting each little step as a victory, and celebrating each in turn. To have physical reminders of this progress and the success it implies is rare in the therapy room.

We need to concentrate and rely on our clients’ reports, drawing out the stories of their successes with our encouragement, questions, and genuine interest, because gardens invaded by weeds do not tend themselves. Neither do gardens of the mind invaded by psychological trauma. Left to fester, the deleterious effects that characterize what Judith Herman referred to as “the central dialectic of trauma”—simultaneously wishing to deny the existence of the events that underpin the trauma, and needing to uproot them from their nestled hiding places and expose them to the harsh light of day—require an experienced hand to contain and prune them until they can be thoroughly weeded. Gentle guidance, using the powerful tools of the trade and the established therapeutic relationship, can help our clients activate their own self-propelled encouragement engines, even if only for an hour a week, during a season that may be more—or less—long in their lives. I fervently guard the hope that with practice and over time, they will learn to operate at a higher gear, developing their own containment, pruning, and weeding skills, will recognize their own successes, and will notice the greener grass growing in their own backyards.

Reference

Herman, J. (2015). Trauma and recovery: The aftermath of violence – from domestic abuse to political terror. New York, NY: Perseus. (Original published in 1992)

Male Survivors of Sexual Abuse: The Prelude to Healing

Posted on by Psychotherapy.net Team

Researcher and clinician Bessel van der Kolk reminds us that when it comes to the immediate and long-lasting impact of trauma, “the body keeps the score.” Psychic and somatic pain are stored, ever-present, ready to break through into consciousness—keeping the survivor in a state of high alert for danger—all the time, everywhere. Helping clients make connections between these painful states and the trauma memories allows them to begin the process of healing and grants the clinician access to this hidden painful domain. In this way, client and therapist can begin to loosen the hold of the trauma, free the victim of its insidious and regressive pull, and help them live less painfully in the present and move less encumbered toward the future.

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Sexual abuse is one form of such trauma that is surprisingly common in my practice with men, and that is associated with painfully held secrets and a seemingly desperate attempt to minimize both psychic and physical pain. In my work with these men, I have found that when the trauma narrative is produced and the pain can be present simultaneously, the healing is (in part) automatic. Surprisingly, in men who have had little if any vocabulary for emotions, words to describe painful and long-buried emotions materialize.

I had the opportunity to work with Mike, a large, burly tattooed man in his early 40’s. Tortured by his excessive masturbation, a pattern of frequency that exceeded his already high-baseline, he self-referred, with trepidation. Shortly into the therapy, as the topic shifted from his repetitive sexualized behavior to a challenging relationship with his son, the product of a recent divorce, things shifted. As he recited both his internal and external struggle, things calmed down. Not coincidentally, with a heavy heart, he revealed that his son was the same age as he was when he was abused for a short period by his then 12-year-old brother, a memory that held not only pain but intense shame, guilt, anger and remorse.

Then there was Gabe, a middle aged man with two young-adult children from his first, somewhat unhappy, marriage. As he reluctantly approached therapy, he talked about a recent episode of sexual acting out during his current, second, much happier marriage. With his ultra-conservative Italian Catholic background, he was perplexed with his actions and the lies he employed to shield them. His behaviors had not yet taken full form, as he had only “flirted” with the notion of being with others. Gabe shared that as a young boy, he was repetitively used as a tool for his much older, post-pubescent sister’s masturbation. There was no penetration and he was not asked to do anything specific to satisfy her. Telling the secret was painful for Gabe, who, as his repressed rage was given voice, allowed the pain as well as the tears to flow.

Raymond held his secret for 50 years in a secluded psychic compartment, a private underground space in his life disguised largely by his out-of-control sexual behavior, never changing despite his 15-year marriage, 2 children, house, successful career and twin dogs. Held under wraps inside this man born of two German parents, this classified information was made known one moment after 5 years in therapy that had included couples therapy for his wife to work through the complex partner trauma, and intermittent individual sessions. With an outpouring of pain he cited a now-conscious awareness of a few sexual incidents during childhood with his older brother, a prodigy who was favored by the parents. This new awareness opened a space to create an honest account and narrative of his pain.

The stories seem never ending as is the pain locked within them, until it is finally released. I am not inferring that with the telling or retelling of the event, all will be cured. Yet, the changes I’ve witnessed that accompany the release of the traumatic stories have been profound and have provided an opening for deeper work. Insight was seemingly insufficient. Access inside the mental network housing the injury and its memory was critical.

One of the greatest, if not primary, clinical challenges I’ve experienced is the inability or difficulty for these men to use words to define their experience. Finding a voice for their wounds began a movement towards healing. Still, not all trauma survivors remember their incident that clearly, cannot report it as such, and many become traumatized by the retelling. In these cases, clients need a safe holding space in order to proceed and a skilled process consultant (a.k.a. therapist) to help work through the emotions as they emerge so they may re-weave a self-affirming and empowering life narrative that is neither permeated nor defined by the pain of trauma.

Resources:

APA Guidelines for Psychological Practice with Boys and Men

Male Survivors of Sexual Abuse

Betrayed as Boys, by Richard Gartner
 

The F**k-it Button in Clinical Practice

Posted on by Psychotherapy.net Team

A patient who worked as an airline cabin-crew described how she used to look after passengers in a placatory and compliant manner. As long as people were nice to her she felt effective and benevolent. However, when conflicts arose and she felt attacked or harassed, she was unable to produce any assertive response. Instead, she would remain overtly compliant whilst covertly humiliated, furious and vengeful. As soon as a cabin-incident would end, she would press the f**k-it button in her mind, secretly aware that she was now “doomed” to go through a familiar escalation that was unavoidable and inevitable. This led to an immediate relief; the reality of conflict, humiliation, rage and aggression was deleted and replaced with toxic excitement. Later, at her first opportunity, she would take her phone out of her pocket, go on a sex-dating app, and swipe many profiles looking for someone to fit her need to “hook up with the sleaziest man in the bar.” She would arrange to meet, get intoxicated and have unprotected sex. This was later understood as her need to feel both harmed and harmful—an aggressive aim camouflaged and equilibrated by self-harm.

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As a side note, before going back to the main argument, I would like to make a general observation here: Mobile phones are hives of f**k-it buttons for those who need them. As such, people hold the gate to a highly addictive world of potential toxic enactments in their pockets. Clearly, most people might not feel compelled to press these buttons but I suspect that many would do so anyway, just because the buttons are there, whilst those who rely on a f**k-it buttons for psychic survival would find not pressing them very difficult to avoid.

Most of my patients press the f**k-it button when they need to transition from a passive state into action. Once the button is pressed, the reflective and pained part of the personality takes a backseat from which it can only watch the unfolding enactment, usually rehearsed, ritualized and harmful. Significantly, the passive backseat observer is not an innocent victim. Instead, it is often the part of the personality that secretly presses the button in order to summon the enactment demon. It might then proceed to passively watch in horror (or voyeuristic excitement), later to report what happened with shame and guilt, projecting helplessness and asking for sympathy and protection.

People with whom I have worked who have been groomed and abused, or those who had to endure other chronic and oppressive relational trauma, rely on internal structures that helped them survive their experiences moment by moment. I often imagine these structures as protective systems that have been hacked into, their codes and algorithms changed from within, allowing access to intrusion, neglect and abuse by disabling or perverting benign protective aggression.

Like many of my patients who rely on f**k-it buttons and enactments, the airline crew worker I described was unable to use aggression in a protective, self-preservative way in the moment. It is hard to be anything but compliant and kind when all eyes and ears are on you in a closed cabin at 35,000 feet. Instead, she pressed the button, re-evoked the old hacked-into structure of her traumatic past, and transformed her aggression into a toxic, harmful and sexualized mix that she psychologically depended on in order to survive moments of intrusion and humiliation.

Most of my patients are initially surprised to find that they press the button a long time before they actually act destructively. Tracing it back to that point rather than focusing on the action at the end is very helpful. It usually shows that the button is pressed with great relief and even excitement, very different to the patient who later describes his actions with shame, guilt and regret. Rewinding a bit more usually leads to the emotional level of unbearable rage, humiliation or at times depression. Further rewinding often leads to an original relational trauma that needs to be explored in order to understand the creation of the initial structure.

Tracking the route back allows for a truthful path into the core, one that does not neglect collusion, sadomasochistic excitement or other addictive and gratifying states of mind. Clinically, I try to make sure that all parts of the patient’s personality act as my guides on this journey back, not just the shamed victim or the callous perpetrator. Exploring the f**k-it button, which part of the personality presses it internally, when and why, makes this therapeutic journey very accessible.

Lately, when I talk about this dynamic to other professionals, they often associate it to the political and social parallels of the current era: fake news, hacking, collusion and pressing the f**k-it button as a political choice–watching with glee at the destruction that follows. F**k-it buttons are in the mind. However, their concrete representations are abundantly available and easy to use in order to distract from any sense of oppression and convert aggression into excitement, envious attacks or sadism. Harmful aims are easy to hide behind screens, swiping and clicking away.

I believe that avoiding the buttons has become much harder these days. Spotting them in the consulting room and using them as a metaphor to enhance thinking and reflection is very helpful. One of my patients summed it up very effectively when he said, “So really, what you are actually saying is that I should stop pressing the f**k-it button and take the difficult way in rather than the easy way out.”  

What Blocks Creativity

Posted on by Psychotherapy.net Team

Was our original creative project the wish to love and be loved by our mothers?

What happens if that creative project failed and your mother wasn’t able to acknowledge, respond to, and reciprocate your love?

I like Harold Searles’ writing. One of his papers, ‘The Patient as Therapist to His Analyst’ from Countertransference and Related Subjects (1979), deals specifically with Searles’ idea that the patient is unwell in relation to how their original therapeutic strivings (In Searles’ view, the wish to love our mothers) failed.

Searles’ paper came to mind recently in my work with trauma survivors.

In my private practice, I have worked with a number of people who have suffered early and sustained trauma. The psychotherapy often succeeds in helping these clients build up more of an understanding of what happened to them in their early life. It enables reflection and the construction of ideas and thinking that goes some way to explain what happened to them. It frequently throws light upon why they have been attached to self-destructive behaviours throughout their life.

In the psychotherapy, periods of self-limiting and self-destructive behaviour are explored and the client often becomes more relaxed and confident. They become better able to think and reflect on themselves and to collaborate constructively in the work. But when the session ends, they retreat, withdraw and often fail to build on what they have been doing in the therapy.

When we meet for the next session, they explain that they have not wanted to think between sessions about the work we were doing in case the work did not have its intended or hoped-for positive effects. Instead, they retreat or shut down.

One client, a particularly creative woman I will call Mo, had wide-ranging ideas and a number of projects that interested her that she would have liked to develop and work on. But, the pattern Mo was attached to was that she would go no further than to think briefly about her projects and then shelve them. Mo’s attitude toward her creativity contained a powerful repressive dynamic.

I came to think about this repressive dynamic, this limiting attitude to herself and her ideas as reflective of the failure of her first creative project—Mo’s wish to love and be loved by her mother. Mo’s relationship with her mother never developed into a loving reciprocal one. Her sense was that her mother may have been in a state of undiagnosed post-natal depression. It seems there were particular problems in Mo’s early home life. Partly as a result of this she was often left neglected and abandoned for long periods. Mo’s wish to love was met with anger, rejection, and resistance.

I came to understand this as part of the transference to the therapy and then began to see that it might be understood as describing the relationship Mo had with her own creativity. Though Mo could have very interesting ideas that captured her imagination in her sessions, she would later abandon them and leave them ignored, only to hesitantly pick them up again in the next session.

This led me to think about the way our creativity, not just our capacity to have an idea, but more particularly the possibility of following our ideas through, might be bound up with our original maternal relationships.

In psychotherapy, a client starts to develop a greater understanding of themselves and what they went through early in life. They become better able to reflect and to develop more benevolent and caring attitudes to themselves and others in the sessions. But outside of the therapy, they do not manage to sustain these attitudes. They return to a position in which they put themselves down at the expense of others and remain fixed to limited expression of creativity. The attitude they express to their own creative ideas contains thwarted, complicated and destructive impulses.

Have they transferred to their own creative selves, expressions of the sense of failure and disappointment they experienced in their original maternal relationship? Do they treat their creativity as an inferior object to abandon at will? My work with Mo has led me to think that a consequence of early trauma and abandonment may be reflected in the way people struggle to pursue their creative projects in later life.

Could this apply to your patients? Has their creativity become caught up in the pattern of their original creative failure(s)? Instead of writing their novels or memoirs or even other less lofty creative projects, do they continue to struggle with failed beginnings? Is the repressive early relational world that they experienced what they become destined to locate and repeat in their attitudes to you and their therapy?

Is it possible that through the shared creative therapeutic venture that you can both come to see the problems they experienced in their relationship with creativity as reflective of problems in their earliest relationships? Could you use that information or insight to help them change and improve their relationship with their creativity? 

Janelle Johnson on College Counseling

Posted on by Psychotherapy.net Team

The Clinical Landscape

Lawrence Rubin: You’ve dedicated your career to college counseling, working with students who appear to experience many of the same problems clinicians encounter in outpatient clinics, crisis centers, and substance abuse facilities. Are college counseling centers microcosms for the clinical world outside of the campus?
Janelle Johnson: I would definitely say what we’re seeing at community colleges and at universities around the United States is reflective of what’s going on in the nation
LR: Can you give me some examples?
JJ: There has been a trend where colleges have been able to provide more support services so students can attend. In the past, these students were not able to attend because of a diagnosis or not having the right medication. They couldn’t perform in college. But now we see a lot of students coming that have schizophrenia or bipolar disorder and we have disability accessibility services to help them. Here at our college,
one third of the students we see are diagnosed with a mental health disability rather than a physical or learning disability
one third of the students we see are diagnosed with a mental health disability rather than a physical or learning disability.
LR: So, they come in with previously diagnosed mental health conditions which may run the gamut from adjustment and anxiety disorders all the way out to schizophrenia?
JJ: Absolutely. We see students every day that may have a lifelong diagnosis, who are able to come to college now, but they need resources around their diagnosis. Student counseling services often try to work with their outside providers because we see ourselves as providing supportive counseling. At larger universities, there is access to medical providers to help with monitoring medications. It depends on what your setting is at your school. If a college center does not have a medical provider, then we obtain a release, so we can actually work with a psychiatrist or a therapist that’s not on the campus, especially when it comes to monitoring medications for more serious diagnoses.

Emerging Adults

LR: So, these students that you’re seeing who have come with diagnoses are accustomed to being in treatment, are they open to being referred back into the community, even after they’re in a college counseling setting, or do they hope the counseling center will give them all they need?
  
JJ: That’s a very interesting question. It depends on their maturity level and how they’ve worked with medications in the past. Even with a seemingly simple diagnosis like ADHD students will often say, “I had these accommodations in high school. They sent me to a counselor.” Perhaps they had more of a medical professional do an assessment. But they come to college with the idea “well I’m in college now, I don’t need any of this.” I think most colleges experience students who come to college and try to maintain, but whatever their diagnosis is we also know that this is an age where certain mental illnesses start to show up.

Sometimes there’s an incident that brings a student like this to the counseling center where, depending upon its size, they may be able to receive an assessment. Large schools like the University of North Carolina has around 30 people on staff with psychiatrists, licensed psychologists and licensed counselors. But in a smaller private school or community college, we send them out into the community for some type of assessment or we refer them back to professionals they may have seen in the past

LR: So, a third of the students who visit the counseling center come with a previous diagnosis and may be accustomed to treatment, and they may be receptive to referrals back out into the community. What about the other two thirds? The ones who come to you and may not realize that they’re struggling or may have an emergent psychiatric disorder. How do you hook them?
JJ: What we see, especially with younger students, is emerging adulthood—that transition where they’re starting to be responsible for themselves. We try to talk to them about how they want to live their lives and how they want to express themselves as adults. In the past, when there have been mental health issues, a lot of that push either came from the parents or the school. Whereas in college, I think one of the mental health hooks that we offer them is saying, “you know, these are decisions you can make yourself. How do you want to be?” We give them some options as compared to the past where they were told what to do.

I’ve met a lot of students who were actually on medications for ADHD or who were taking antidepressants. Their parents said to them, “oh, you don’t need this anymore” and took them off. They were in that gray area of not functioning that well but having that parental oversight to get things done. And

then they come to college, and without their medications or follow up, the parents just expect them to do well, but they don’t
then they come to college, and without their medications or follow up, the parents just expect them to do well, but they don’t.
LR: So, these are emerging adults with whom you try to work developmentally around taking responsibility and seeking resources, which sometimes helps them to reach out for and effectively use treatment.
JJ: Yes, and at the community college level, we try to partner with community agencies so oftentimes, we can make those referrals right in our office with the student sitting here. We can put the student on the phone and facilitate appointments.

Getting Them Hooked

LR: So, you may actually be the frontline for these kids. Do you find that some of these students are resistant to the services that you provide? Or resistant to being referred out for more serious problems that they may not even think they have?
JJ: Yes, I think that we do see some resistance. The BITs (behavior intervention teams) or campus care teams sometimes need to intervene when students become disruptive in the classroom learning setting. We talk to them and try to engage them in counseling. Faculty and other students try to be patient, but I think when a student becomes disruptive, we try to figure out what’s going because we tell them that they are jeopardizing their ability to be on campus.
LR: It sounds like you have to be a little more heavy-handed or hope that the campus support teams can build enough of a relationship with the student and walk them over to the counseling center.
JJ: That’s absolutely true. You know, some people are very compliant. Other people are interested in finding out what’s going on with them because they may have that feeling like, “I don’t want to keep living like this. I don’t feel good.” But, then other students have a hard time recognizing that their behavior is disruptive or that there’s any issue. It really depends on how they’re supported when they’re at home and then how they’re treated. Sometimes I find students with very high intellectual functioning have their own unique mental health issues. It’s really difficult with some of those students because you can talk to them very intellectually and they can process what you’re saying, but
they feel like treatment is going to somehow interfere with their creativity or their ability to perform in school
they feel like treatment is going to somehow interfere with their creativity or their ability to perform in school.
LR: Is there a specific student that comes to mind?
JJ: A young male student I recently spoke with had a bipolar-one diagnosis and had recently received an ADHD diagnosis. He was watching his peers advancing on to their master’s degrees while he was struggling to complete school—but having this very fatalistic attitude about himself and about his ability to complete. But when you speak to him, when you look at his courses and grades, he’s got As. Schoolwork is not an issue but he lives in this sort of fatalistic place. “Why am I doing this? I’ll never amount to anything. I always fail at everything. Look what all my peers have already done.”

I think oftentimes a student feels overwhelmed on the campus and sort of wanders into our area hoping that someone will speak with them. What we usually do in that case is to obtain a release. We try to follow up to let the outside providers know that perhaps the student is in a downward spiral and perhaps he needs his medications checked.

That’s also where Cognitive Behavioral Therapy (CBT) comes in. It helps the students to look at thoughts that really aren’t helpful—the misconceptions that they have about themselves which sometimes can be very challenging. 

LR: Do you get a sense, at least on your campus, that there’s a stigma associated with going to the counseling center or being seen coming out of the counseling center? And if so, how do you address that on campus?
JJ: I have a sense of that most campuses are working really hard with different kinds of programs to remove that stigma around coming to the counseling center. We see different initiatives like the JED and Active Minds programs and peer support groups. I could give an example like suicide prevention. Some campuses do things where they lay out backpacks in the quad for how many students have been lost. And then they have a place where you can come out to honor somebody you’ve lost or write something about yourself—some kind of thing where you can participate. I feel like there is increasing recognition of mental health on campuses and getting help if you need it.

On our campus, in particular, and I think on a lot of campuses, we do classroom outreach. We appeal to students to refer other students to us. Sometimes we find that’s even better than faculty referring students. Staff bring students over. But we find sometimes if your peer, another student says to you, “Oh my gosh, you’re just going through a horrible time. You know there are counseling services here on campus? You know, let me walk you over there or let me show where that’s at.” We find that’s really beneficial. 

Challenges of Dual Enrollment

LR: Yours is a two-year college. But there are also high school students on campus. Do you find that these young people have unique clinical problems and challenges?
JJ: We’re seeing a lot of early admission, college dual-credit high schools on campuses. And at Santa Fe Community College we do have a high school right on our campus. It’s even happening at some four-year schools where there’s a high school house. They have some high school teachers and some high school curriculum, but almost immediately students are being placed into college-level classes. What you see happening is
they’re graduating from high schools one day and then receiving either a certificate or an associate’s degree the next
they’re graduating from high schools one day and then receiving either a certificate or an associate’s degree the next.

Regarding the mental health of these particular students, some are very high functioning, very motivated, but some of these students are in this fast-track program because they’ve not done well in the traditional public high school. They’ve had conduct problems or social interaction problems. The parents think, “we’ll take you over here to our college so you’ll be able to take college classes and you’ll be in this high school but it’ll be a lot more flexible for you.” But these students who haven’t performed well in the past may have an inability to follow through and can’t really manage themselves in college. One of our counselors in particular had a student with a very high level of ADHD who didn’t come to the counseling appointments on time. This sort of high school/college program can actually create more anxiety and more unmanageability and adjustment disorders for students.

LR: So, these kids may not be in an appropriate fit for college life just yet?
JJ: Perhaps, but it’s hard to say. What schools are doing with this early college high school programs are really a positive move for a lot of students because I think high school has let a lot of them down. I think high school is a really difficult time for a lot of students because of pressures around social media and bullying. So, being on a college campus really helps them be with other college students who are motivated to get a degree. But there is always the question of whether they are developmentally ready or mentally ready. And while there is a high school counselor here for those particular students, they are spending a lot of time on other things like scheduling and achievement testing.

Addressing Suicide on Campus

LR: Suicide rates are very high in the college-age demographic. How are college counseling centers set up to address that? 
JJ: I think a lot of college counseling centers are trying to address that with different kinds of programming. The JED foundation, for example, offers programming for college campuses. Active Minds is another one that offer all kinds of wellness programming for campuses that also addresses suicide prevention. Also the American Foundation on Suicide Prevention in New York.

Suicide is the second-highest cause of death for our demographic.
Suicide is the second-highest cause of death for our demographic. Even if you go up in age a little bit, which is the demographic for a lot of community colleges, then suicide is the third-highest cause of death. So, I think on most campuses we are all actively working with programming and bringing support.

At Santa Fe Community College we actually have a certified faculty member do Mental Health First Aid Training. Mental Health First Aid is a program that originally came out of Australia that has been embraced in the United States. It’s a day-long program for people in the community who are not mental health professionals. Here at Santa Fe, it would be our campus community—our faculty, staff, other students who take the training. 

LR: So, when it comes to the more serious disorders, and suicide in particular, it’s critical that college counseling centers work in conjunction with community agencies and have programs on campus so that students are never alone. And neither are college counselors alone because they’re always linked to other resources?
JJ: Right. College counselors work with these different available resources, create their own programming or belong to these organizations that provide free programming.
The idea is to eliminate the stigma, raise awareness and have people participate.
The idea is to eliminate the stigma, raise awareness and have people participate. The campus is a community and we encourage students to participate in these suicide prevention programs and to be part of a campus community that supports helping students reach out. People need to recognize the signs and to be comfortable approaching people.

Disconnected from Families

LR: On a related note, we know that LGBT youth are at particularly high risk for suicide. How do you address the needs of these students?
JJ: A lot of campuses are looking to find ways to support students who are in the process of self-identifying or have someone on their staff assigned to programming in that area who works on removing stigma. In New Mexico, which is a very Catholic state with a lot of immigrants, some of these families persist in saying to their children, “your religion doesn’t accept this. You can’t do this. If you do this, you can’t live with us.” So, we try to work on that by asking these students, “How can you speak with your family? How do you want to live your life?” These students still recognize their religious teachings but don’t want that being used against their identity.
LR: So, you try to work within their families and with the cultural issues that impact their emerging LGBT identities?
JJ: Campuses will either look for programming or design their own programming around supporting these students, and then work with them on these issues in counseling.
A lot of these students actually feel safer on campus than they do at home.
A lot of these students actually feel safer on campus than they do at home.
LR: Speaking of unique challenges, what about first-generation college students.
JJ: I do believe they have unique clinical challenges because many of them do not have a history of going to college. Additionally, many of these young people also have to help out financially in their homes. So they live at home, come to college but also work to help pay the rent, the utilities and the car payments. And then there are issues around their transition to adulthood. We help them speak to their parents about what they need to be a successful college student.

Some of them will say “my parents are making me feel like I’m crazy because I need more time to study and I can’t take care of my little brother or pick him up from school every day.” It’s an interesting dynamic that plays into their mental health because when they don’t feel supported or understood at home, they experience anxiety, depression and acting out behaviors. It’s not that families don’t support going to college—they absolutely do. But they don’t know what that means or what it looks like.

Raising Awareness

LR: There’s a lot of research into the short and long-term effects of adverse early childhood experiences and the need for trauma-informed education. The idea is that some of these kids are coming to school with such a heavy trauma burden that they can’t concentrate, can’t relate and are at high risk for drinking or self-harm. Have you seen this on your campus and how do you deal with that?
JJ: There are different kinds of trauma. Here
in New Mexico, we have a lot of Native Americans, so we talk about historical trauma
in New Mexico, we have a lot of Native Americans, so we talk about historical trauma. In addition to these historical events, some of our students come from a background of trauma in their home or in their childhoods. In the college counseling setting, we work with these students around issues of safety, peer support and collaboration—empowering the student to have a voice while they are exploring their issues. We are not dismissing what has happened to them but we’re looking at how the therapy works for them, helping them to move forward with that trauma and not to feel re-traumatized by being in our college setting.
LR: Are drinking and substance abuse significant problems on college campuses?
JJ: We’re not seeing it as much on commuter campuses like ours that do not have housing, although I do think it is a presenting problem in our counseling centers. It’s different on residential campuses, and particularly in the dorms. But we do see students coming to campus who are inebriated, or who have problems that other students are reporting. They may be coming to class and they sound like they’re drunk or other students can smell it on them.

I do think it is an issue that is hard issue to address. College counseling centers try to work with students on maintaining their sobriety. I think if they’re actively using or they can’t even function then it is critical to refer them to treatment center. Another student may binge drink only on weekends and otherwise be high functioning, but it also starts to catch up with them. They may not be getting proper nutrition, or may be having problems with sleep, hygiene or relationships. These effects of drinking begin to interfere with their functioning in the college setting. With these students, we try to talk more about responsible drinking and help them to understand how their drinking interferes with their learning and progress and help them explore how they can be more responsible. 

Serving our Veterans

LR: You had mentioned that you have a veteran’s program on campus? Are there unique clinical needs for these students?
JJ: Often college campuses have veteran support centers which provide resources for veterans and their families. These resources include counseling services. Although we are not housed with the veteran’s service center on our campus, veterans know about our counseling services. We also have a veteran’s hospital in Albuquerque, New Mexico, which is about 60 miles away and a veteran's counseling center in Santa Fe.

Our veteran’s center also brings counselors onto our campus about once a week to meet with the veterans. This is not to say that some of the veterans don’t come to our regular college counseling center. Having served first and then coming to college can be a challenge and clinical needs depend on whether or not they are a combat veteran. The

combat veterans may feel that there is a stigma around coming to the regular college counselor
combat veterans may feel that there is a stigma around coming to the regular college counselor who hasn’t experienced what they have or have a military background. Larger campuses actually hire counselors who have served in the military. This can be helpful because veterans have trauma about reintegrating. They’re used to following authority and a more established and structured day. Sometimes they have difficulty with younger students who aren’t respectful. 
LR: Or knowledgeable!
JJ: Sometimes, these younger, less sensitive or aware students don’t conduct themselves very well in class which is very troubling for veterans. And then of course, we do have veterans that have PTSD or depression; situations that require more treatment. But a lot of times, I think it is more about adjustment, depending on how long they served and the college program they’re in.

CBT and Beyond

LR: We’ve been talking about various treatment needs of college students and I know that CBT and other empirically supported treatments are the rage these days. I’m wondering if it also dominates the college counseling landscape.
JJ: I think there is a lot of support on college campuses to use research-supported therapy modalities. CBT has a lot of related therapies including DBT, solution focused and even positive psychology. The reason it works in our setting is because we’re tasked to triage students that come in. There can be a high need for services and students oftentimes wait to get in to see a counselor or a mental health provider. So, I think we want to use therapies that we know can assist with more immediate behavior change.

We don’t have the luxury for long-term care with students.
We don’t have the luxury—and I don’t know if it is a luxury—for long-term care with students. So, those kinds of therapies can really be useful. You can give the student homework and worksheets—something they can hold onto so that they can feel like they’re moving forward and like they’ve accomplished something. I’ve even had students with whom I’ve suggested a reward system to help when they were struggling with something and want to see improvement. Larger campuses can even incorporate these kinds of therapies into a group setting and can direct students to be part of therapy groups.
LR: Would you say that college counselors are pressured to use these proven methods and not encouraged to use creative-expressive modalities that incorporate art, play and music? 
JJ: We’re not forced to do that—it would depend on the counseling center and how many staff members they have. I do see the creative going on as well. In New Mexico, Southwestern College offers a master’s degree in art therapy and I’ve had interns from there on my campus who have done art therapy with our students and they’ve really liked that.

There is some room for creativity, but you have to be working to move the student forward especially because you’re working in a limited timeframe; a college semester or a college quarter and then there’s a break and they go home. I am at a community college where we are looking toward a goal-oriented type of therapy. If they bring in extreme trauma or are in an abusive relationship or are fighting an addiction, treatment is better is referred to a community partner. We use whatever modality is supportive of their counseling and helps them to meet their goals.

And for most of them, their goal is to complete college, find a career and move forward. So, we try to facilitate that. If there is a major mental illness diagnosis, we make sure that they have a community provider who may be doing something like DBT groups. I don’t feel like college counseling can replace that.

College Counseling Competencies

LR: With regard to the provision of treatment, what are some the unique competencies that a college counselor should possess?
JJ: At the university level, a lot of schools hire licensed doctoral-level clinical directors. The counseling staff is sometimes made up of licensed counselors. In New Mexico, I’m a licensed clinical mental health counselor. Some college centers hire licensed clinical social workers who are in clinical practice. That’s is the more traditional set up. Our organization, the American College Counseling Association expects that any counselors working in a college setting be licensed.

What we see in California is an interesting example where most of the universities are using doctoral level licensed psychologists in their counseling centers. In their community colleges, they are using master’s level clinicians. But they don’t have licensure at that level. It’s hard for me to talk across the board, however the American Counseling Association has been working on licensure portability along with licensure accountability.

I would say that if you’re going to work in a college setting, you should be licensed in the same manner that you would to work in a private practice or at any other clinical facility—you need the degree and the experience that comes from practicum and internship to do this work. Unless, that is, you’re in a college where they’re calling you a counselor and you’re doing academic advising or something like that. If you’re in a college mental health counseling center, you’re doing the same kind of work anybody would be doing as a mental health professional anywhere else. The scope of your practice may be limited in that you have to do more community resource referrals. But, your knowledge and ability including understanding the DSM, various diagnoses and treatment modalities fully impacts your work every day. You need to be able to do it.

LR: Do college counselors need to like teenagers and emerging adults? Wouldn’t that be a prerequisite?
JJ: I think that you want to be able to work with that population. Three years ago, I started an internship program here at Santa Fe Communi

Reflections of a Psychology Resident in Trauma and Acute Care

Posted on by Psychotherapy.net Team

“I can’t believe this is happening right now! I need to pinch myself” is a thought that has passed through my mind multiple times during my residency in trauma psychology at a level 1 trauma center. I knew it would be different from typical outpatient psychotherapy and assessment, but I still hadn’t anticipated the intensity and intricacies involved, or the adjustment required to my clinical approach. In traditional settings, we tend to encounter people months or years after major medical crises and life-changing injuries are sustained. “The cases I now faced in the trauma center were acute, often causing visceral reactions that weighed on my heart in ways I hadn’t experienced before”, and they stretched and sometimes fell beyond the schemas provided by my graduate training.

The Intensity: Extreme Presenting Problems

Most of the patients I saw were admitted for treatment of injuries following vehicle collisions, falls, gunshot or stab wounds, pedestrian or bicycle vs. auto accidents, self-inflicted incidents, and periodically complex and life-threatening medical problems. The range of stories and circumstances I encountered on a regular basis were like the far-removed scenarios portrayed in entertainment or reported on the evening news, including brutal suicide attempts, physical and sexual assaults, attempted murder, hostage situations, home invasions, drownings, and almost stunt-like accidents. Some of the most disturbing, though, were the most seemingly innocuous accidents that resulted in unfathomable and devastating consequences.

“It’s no surprise that returning daily to a workplace like this one would have a personal, cumulative effect.” I noticed that I drove a bit more carefully. I evaluated my own financial situation while envisioning my own hypothetical future in which I or my spouse was in the hospital under circumstances similar to those of my patients. I imagined how I might feel, pacing the hallways, gazing at a loved one in a hospital bed, or being delivered painful news. The flip-side of being empathetic, a trait so many clinicians possess, is that we can see ourselves in the suffering of others. So, seeing the look in the eyes of those who are told they will never be independent again (e.g., due to complete SCIs-spinal cord injuries), or who are grappling with the reality that a loved one’s injuries are not or were not survivable, or when they learn they were the cause of another’s death, was profoundly painful on a human level. The mirror neurons facilitating our shared humanity fire, and someone else’s current predicament and threat of mortality became my existential discomfort and personal grief as well.

The Intricacies: Working in Medicine

In anticipation of encounters with our clients, we therapists typically wonder, “Will Sarah show up for her appointment today?” or “I wonder if Frank remembered his homework?” Questions I often found myself wondering in the trauma center went something like, “Is Jennifer in surgery again?”, “Has David been extubated yet, so we can converse?” or “What is Joe’s GCS (Glasgow Coma Scale) and/or Rancho score, and is it high enough to permit engagement in meaningful conversation?” Moreover, privacy was minimal, and I had to grow accustomed to visits with patients being interrupted by other essential (trauma surgeons) and often also comparatively non-essential (custodians) staff. I learned to discern when and how to defend our time and request, “Could you come back in 15-20 minutes?” while taking patient priorities into consideration.

Discernment was also required for determining the level of engagement with a patient and/or family based on their location in the stages of acuity. Was the patient just admitted? Is the family in the midst of the most acute stage of shock or grief? Is the patient really needing mental health triage? For some, answering questions posed by a relaxed professional is reassuring and distracting; for others, it may feel insensitive. “My initial visits typically involved collecting a brief psychosocial history, but doing so is simply not appropriate with, for example, families grieving the anticipated passing of a loved one.” In those cases, I simply helped the family to become aware of available support.

Often in trauma cases, physical recovery must make headway first, but sometimes emotional needs are salient from the get-go. Once, I visited a woman the morning after a terrible car accident. She asked her family to leave the room, allowing us to visit for the next hour or so. She had questions about pre-existing anxiety, acute stress, psychotropic medication, psychotherapy, faith, and how to overcome grief associated with another’s death from the same accident. It was perhaps one of my most memorable visits with a patient, and one of those therapeutic encounters in which what we have to offer and what the patient needs align perfectly.

I have often joked, “Which has more acronyms, the field of psychology or the military?” I think the military takes the cake on that one, but medical jargon is nearly as unfamiliar to a professional outsider without formal medical training. Terms used regularly during our morning multidisciplinary “dispo” meetings were often totally foreign: NG tubes, pigtails, cannulation, fasciotomies, TPN, rhabdomyolysis, dysphagia, Miami j collars, to name a few. What I found particularly entertaining and surprising was the assumption on the part of the medical staff that I understood what they were talking about when providing me with updates about a patient or explaining medical procedures and their complicating factors with technical language. Other concepts were easier to understand, such as “we sucked peas out of his lungs.” The first task entailed learning what many of these terms meant.

The second task was to determine if and how medical concepts might have significance for my work with the patients. Sure enough, many did. Ventilator weaning and “high flow” trials have particular significance in spinal-cord-injured patients, as these processes often elicit substantial anxiety due to uncomfortable physical sensations and often subsequent, though inaccurate, fears of suffocation. This anxiety can stall or slow progress towards independence from life support and therefore potentially shift discharge plans such as whether to consider short-term rehabilitation or long-term care. Other medical conditions also have clinical implications. Proximity of amputations (e.g., foot vs. leg) has bearing on functional outcomes and emotional adjustment. Fistulas, such as gastrointestinal fistulas, are abnormal openings between or within internal organs and other structures, often resulting as collateral damage from surgery. They are difficult to repair and complicate or substantially delay discharge plans, demoralizing many patients afflicted by them. Ostomy bags, which may be necessary for patients with fistulas, are another cause of maladaptive adjustment, especially for younger patients. Perhaps one of the most severe situations is the need for a patient’s placement on the ECMO (extracorporeal membrane oxygenation machine), a “hail Mary” medical effort to save a patient’s life. The ECMO machine functions as total life support, providing cardiac and respiratory functions, and is intended to be a bridge to other treatment. Psychological support is provided every time a patient is expected to be an ECMO candidate.

Communication with medical staff in the trauma center is not entirely dissimilar to the communication with medical staff in primary care settings which many mental health professionals are more familiar with. However, determining what is useful for them to know in the trauma surgery department strikes me as much more difficult. Conversations are not about outpatient weight loss, smoking cessation, and medication compliance, but about behavioral, psychological, and emotional factors that happen to be deeply embedded in a unique and intense medical system. “Life and death issues are more often at the forefront.” Much of what we discussed with patients’ treatment teams was problem-solving patient-specific challenges that might require increasing patient morale or adapting the environment to fit a patient’s needs. It goes without saying that we were asked to evaluate patients when apparent psychological comorbidities were interfering with treatment progress or even when ambiguous patient behaviors left their treatment teams puzzled (e.g., reported the loss of sensation or movement in limbs with no apparent medical evidence to support such deficits).

The Adjustment: Clinical Work

The sights, smells, and sounds in the hospital are unparalleled elsewhere. Gnarly bruises and X-fixes, splashes of blood on the floor, bloodshot eyes, genitalia, unidentifiable bodily fluids collecting in clear containers hooked on the end of hospital beds, the occasional stench of excrements in hallways, beeping alarms of bedside machines, images of damaged body parts from post-explosive incidents, a deceased child’s body. Once I visited a man after an assault. His eyelids were sutured closed because of the nature of the injuries his face sustained. While we were talking, he coughed, and the pressure immediately caused blood to stream from his eyes. He commented, “I think my eyes are watering…” I paused before responding. I didn’t want him to panic, but I knew my subsequent departure to get help would probably sound the alarm anyway. “Actually, I’m afraid you’re bleeding a bit. I’m going to get your nurse,” I said. He started whimpering, the panic rising. “Don’t worry; we’ll take care of you right away! Take a couple deep breaths.”

As is the case in some other settings, our clients or patients were not always seeking mental health services. While some had requested it, patients in the trauma center typically are not looking for mental health care and occasionally are not very receptive to it. Normalizing talking to a psychologist right off the bat is important. So, after introducing myself and with a sincere but wry smile on my face, I tended to say something along the lines of, “Most people don’t plan on coming to the hospital, let alone the ICU. It’s pretty overwhelming. While everyone else’s job here is to take care of you physically, I’m here to check in to make sure you’re doing okay otherwise–to make sure that your time here is as smooth as possible.” The goal is to make interacting with a psychologist seem routine (as it often is) and easy, in part because there is not always much time to build rapport.

Understandably, many of the conversations center around the cause for hospitalization and related injuries and treatment. Follow-up questions will entail quality and amount of sleep, pain levels, appetite, and mood. The mode of interacting with patients, at times, differs substantially from what happens in traditional psychotherapeutic settings. Unless there is a glaring reason not to, I responded with a hug when prompted, asking no questions. “And I cried with grieving families when sincerely felt waves of emotion welled up, though I made sure to not cry more than they did!” While sitting in one family meeting in which the trauma surgeon described clearly how he had exhausted all options to save the teenage boy’s life after falling ill suddenly just several days earlier, the family broke down in tears. The patient’s nurse, my practicum student, and I could not help but also freely shed tears with them. Due to the intensity of patients’ medical circumstances and threats to life, withholding expressions of genuine emotion appears cold and overly clinical, practically inhuman.

Clinical Interventions

A state mandate requires psychological care for brain and spinal cord injured patients. In addition to those patients, we evaluated and treated patients experiencing psychological symptoms that are affecting treatment or having trouble with general coping while hospitalized. These included generalized or situational anxiety, depression, acute stress and adjustment difficulties, grief/loss (life, limb, or function), and suicidality/risk (specifically if there is a need to place a patient under suicide watch and pursue involuntary psychiatric hospitalization). Additionally, we screened patients for psychiatry services and evaluate for capacity in medical decision-making. Occasionally, particularly unique cases would come up, such as when a treatment team cannot determine a medical cause for a patient’s altered mental status. Lastly, we were consulted to provide family support when needed and to authorize child visits to loved ones in the ICU-when they were younger than 13 years old.

Due to the constraints of the setting (limited privacy, limited time per visit and number of visits, physical limitations and particular focus of stressors), many of the interventions were supportive and patient-centered. Donald Winnicott’s notion of providing a holding or “containing space” for whatever a patient needs comes to mind. Interventions frequently involved psychoeducation and coping skills development, such as relaxation strategies (deep breathing and visual guided imagery) that serve multiple purposes, from facilitation of sleep to anxiety and pain management. The monitors showing a patient’s heart rate provided accessible biofeedback to assess impact. Naturally, and unfortunately, deep breathing is not possible for intubated/ventilated patients. I encouraged patients to identify other coping skills. For example, one patient described how much she loved music, so we discussed how incorporating periods of time to listen to her favorite music each day would help to improve her mood. Also, I occasionally suggested patients utilize affective labeling1, either privately or in conversation with others, to reduce emotional distress.

It was particularly rewarding to find ways of adapting traditional psychotherapy techniques and concepts into concisely-packaged interventions in this setting. Basic cognitive-behavioral concepts could be explained to patients in ways that are easily understandable and immediately applicable. Unpleasant circumstances could be positively reframed. The relationship between automatic thoughts and emotional and behavioral consequences could be briefly outlined, and even cognitive distortions could be gently pointed out with the purpose of promoting more adaptive adjustment while under inpatient care. I might say to a patient, “You are absolutely faced with objectively legitimate physical challenges right now. That said, sometimes the particular ways in which we react to our circumstances can actually create additional obstacles that we just don’t need to deal with as well. Let me describe a bit more about what I mean, and you can tell me what you think.”

Since this was a trauma environment, and nearly all the patients we saw had undergone major traumatic events, “I got particularly excited to find ways of packaging evidence-based trauma treatment interventions or concepts for accessible use” – Cognitive Processing Therapy (CPT), being a particular favorite. After providing basic psychoeducation about acute stress and normalization of such responses, I liked to use a variety of analogies to further illustrate what acute stress responses are and how one might consider responding to them with the goal of healing in mind.

To illustrate why re-experiencing symptoms occur:

  • Our lives are generally like flat lines, stable and constant, with occasional blips (reflecting moderate stressors such as interpersonal conflicts and illnesses), and traumatic events are a major blip on that line. (This is consistent with the phenomenon of flash-bulb memories.)
  • A file folder (traumatic event) remains outside of the filing cabinet (narrative of one’s life, full of other experiences) until it can be adequately sorted and placed (This is an analogy borrowed from the CPT manual materials.)

To illustrate why avoiding avoidance and emotional processing are important:
  • Physical wounds require tending (cleaning, stitching, ointment) because, without this, they can become infected or heal improperly. Emotional wounds are similar, needing attention and care, in the form of emotional processing, for the sake of closure.
  • As children, when we learn to ride bikes, we often fall off, maybe skin a knee or bruise a thigh. If not coaxed into getting back on, fear of riding a bike will maintain or even increase. But if the fear is managed and overcome, the new skill is mastered, and the fear dissipates. (This is especially so for patients after car accidents, for instance.)

On several occasions, I noticed that maladaptive automatic thoughts-or cognitive distortions had already developed in the wake of a major trauma. From a CPT framework, these are called “stuck points” and are either “assimilated” (past-focused, typically on traumatic incident) or “over-accommodated” (present/future-oriented statements). These are problematic because they will likely interfere with healthy post-trauma adjustment. The major themes of trauma are often apparent and include control, responsibility, intimacy, trust, and safety. I recall a few instances of talking to husbands of female patients who blamed themselves for vehicular accidents that were entirely due to extenuating, external factors. Their self-concepts, characterized by competence and accomplishment, paired with immense love for their spouses, meant they pinned the blame squarely on their own shoulders, despite intellectually understanding otherwise. Emotional reasoning at its finest. I hoped that outlining some of these cognitive and emotional responses and challenging these stuck points empathically planted seeds for greater self-awareness and supported progress on a more adaptive, long-term trajectory.

Of important note, conversations about trauma in the acute phase such as this are not the same as structured crisis incident stress debriefings that are largely unsupported or even contraindicated in the literature. Patients and family members are left to determine whether or not they want to discuss the traumatizing incident, and emotional reactions are rarely therapeutically explored in significant depth. While conducting a mental status assessment, I would ask patients if they recall the incident, while informing them I am not asking them to tell me about it, though they can do so should they choose. This provides them with more control and a greater sense of security when discussing their mental health status.

Other psychotherapy skills we learn as clinicians were relevant in this setting, including:

  • recognizing the time and place for silence
  • identifying and therapeutically pointing out avoidance (or when the molehill is the cover for the mountain)
  • utilizing empathy without becoming consumed by it
  • consulting when faced with ambiguity and ethical quandaries
  • getting creative in efforts to connect with others from different walks of life
  • permitting oneself to not have all the answers
  • being resourceful in clinical problem-solving, particularly in a multidisciplinary setting

In Closing, For Now

The trauma, acute care setting left me with a resounding sense of gratitude (which I also find is a terrific inoculator against anxiety and apprehension). In observing the enormity of human suffering, I was humbled when counting my blessings and reflecting on the dedication and compassion displayed by so many members of the medical teams. Friedrich Nietzsche famously stated, “He who has a why to live for can bear almost any how.” The existential significance of this work was not lost on me. What amazed me is not just that people find a way to face another day under truly dire circumstances, but that so many do. I have come to accept that, in this context, I may not always have been able to treat the diagnosis and cure all the symptoms. The environment and physical conditions provided ever-present limitations. But I developed a tremendously deep appreciation for the resilience of the human spirit and appreciated the significance, and perhaps inherently healing effect, of sitting with others during their darkest moments.

Related References
Kircanski, K., Lieberman, M. D., & Craske, M. G. (2012). Feelings into words. Psychological Science, 23(10), 1086-1091. 
Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist and patient materials manual. Washington, D.C.: Department of Veteran Affairs