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Mental Health

Therapy 101 Series: Lesson One is Knowing Your ABCs

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If you’re a therapist, ideally, you have access to intervention training and a good clinical supervisor. What if you don’t? Many new therapists, social workers, and other psychosocial professionals enter the field without concrete psychotherapy intervention training, and most without sufficient experience to know  how to immediately implement it in every unique presenting situation. One may be an intern and are hopefully closely supervised and guided. Another may have earned an entire, relevant graduate degree without specifics on evidence-based psychotherapy practice included. There is hope, however, since this is where most of us started either way. Being a therapist may wrack your nerves at baseline.

Articles in the Therapy 101 series will focus on tips, tricks, and tools that can help get you started if you can’t get intervention training immediately and/or you can’t use clinical supervision to get you over the anxiety. What follows is only the beginning, and does not necessarily make you more qualified, magically clinically licensed, and does not offer specific intervention training.

Please note: This series is not intended to endorse practicing therapy without intervention training, licensure, or good clinical supervision, but rather empower social workers without the tools and resources to get needed training keep their therapy job, and get to the next, best practice step.

So where to start?

If you’re not new to providing therapy, imagine the last time a client said something that really threw you for a loop. You didn’t know what to say. You didn’t know what to do. Maybe you sputtered a bit. Maybe you were just silent. Maybe you communicated volumes with shocked nonverbal cues. Either way, you felt like there was a void or crisis you couldn’t adequately fill or resolve. If you are new to providing therapy, this may very well describe your day job! Congrats! It’s pretty exciting even with that semi-regular feeling of helplessness.

What is therapy anyway?

Therapy generally defined in the dictionary is “medical treatment of disease”, but since you are probably a social worker or social work student, we will assume you are more likely to be curious about psychotherapy, which we will refer to simply as “therapy” for the rest of this article, and which the National Alliance on Mental Illness defines:

Psychotherapy, also known as “talk therapy,” is when a person speaks with a trained therapist in a safe and confidential environment to explore and understand feelings and behaviors and gain coping skills.

That could very easily be you with or without specific intervention training. If you have a Master of Social Work degree, you are trained in Human Behavior in the Social Environment and Social Work Practice, at the very least. That me be little consolation to you as a new or inexperienced practitioner of therapy, so what do you do first when you don’t know what to do next?

Know Your ABCs

  • A for Affect – How do you feel? What emotions are you experiencing?
  • B for Behavior – What do you do? What actions do you take or have you taken?
  • C for Cognition – What are your thoughts? What are you thinking?

These are the most core questions you will ask any client/consumer and once you connect them to a trigger/context, you’re one hop, skip and jump away from many forms of therapy. They can come in any order. In fact, many psychotherapy styles specifically focus on thoughts, feelings, actions, and behavior so being comfortable asking these questions, or falling back to them when you’re not sure what else to say and the “strategic silence” you improvised or rationalized is going on a little too long.

Imagine a client describes something you have never heard about before, have never heard described to you by someone who experienced it, or is quite clearly traumatic. You may picture yourself as the perfect therapist knowing just the right question to ask to pop the clearly present keg of catharsis. Chances are, you will not have the perfect question in a situation like this. But you can always ask the following:

“What are your thoughts on that?”

“How do you feel about that?”

“What did you do beforehand? Afterwards? As it was happening?”

These three questions can (almost) literally be repeated into infinity:

What did you think and feel after you did that thing?

What thoughts and feelings led up to doing that thing?

What did you do/think/feel next?

How often do you think/feel/do that? When was the first time?

If you’re not careful, you can actually end up asking questions into infinity, because clients and everyone else tends to really enjoy when someone sincerely asks them questions about themselves. Stay tuned for a post on setting boundaries on your allotted time and everything else in a future post.

Also, don’t forget the other “A”

The above does not include the trigger or as Albert Ellis stated it “activating event.” The questions above will become less random and purely reactive to the client’s responses as you organize them around triggering events, people, situations, activities, and places.

Albert Ellis, who established Rational Emotive Behavior Therapy, had his own ABC’s which can be similarly helpful if you’re first trying to wrap your head around how to provide therapy: A for Adversity or Activating event, B for Belief about the Adversity, and C for Consequences.

I know and am comfortable with my ABCs: What next?

A previous mentor once suggested picking a “home” theory and/or technique to fall back on when you’re not sure where to start. Different theories and techniques are certainly more effective with different client populations, so there’s nothing wrong with being a bit eclectic, but as a therapist you will be working with people who are their most overwhelmed, anxious confused, angry or sad. It’s likely you won’t always know where to start or what to say. This makes sense, because it’s likely for many new to therapy that they don’t know what the “right” thing to say is either, and they’re the premier expert on themselves.

There are many options with which to start:

Once you have decided what theory and intervention you want or need to start with, seek certified training. Some of the links above will take you official training for each style, which will ensure you are actually getting the training that has been studied to be effective for that style.

It is great and best practice to do the full training and receive certification in whatever theory’s intervention you select, and if that’s an option you should certainly do it. Many therapy programs do not reimburse your extensive training in a therapy discipline. If that’s the case, and you can afford a three day, single day, or couple hour training in an intervention style, you may be able to use techniques, if not the entire intervention. You could use open-ended questions, affirmations, reflective listening and summaries, but not be implementing the actual Motivational Interviewing intervention.

Therapy 101

Posts in the Therapy 101 series focus on tips, tricks, and tools that can help get you started as a social worker practicing as a therapist. They do not necessarily make one more qualified, a licensed, clinical therapist, and does not provide specific intervention training or information.

This series is not intended as an endorsement of practicing therapy without intervention training, licensure, or good clinical supervision, but rather empower social workers without the tools and resources to get needed training keep their therapy job, and get to the next, best practice step.

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Anthony Heard, MSW, LCSW is a pediatric social worker at the University of Illinois Hospital in Chicago with experience in trauma-informed care, child protection, and healthcare. His interests range from these areas to health psychology and chronic disease to evaluation capacity building and implementation in social service programs.

          
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LGBTQ

The Power of Language & Labels

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A while ago I posted a meme which said, “Better to have lost in love than to live with a psycho for the rest of your life.”

I liked it, of course, otherwise, I wouldn’t have posted it. Eleven others did too, some commenting on Facebook, “Amen to that,” and “Definitely!!”

Then this: “Hate it. It’s beat up on people with mental illness time again. Ever had the amazing person you love tell you that they just can’t deal with your mental illness anymore? Our society is totally phobic about people with mental illness having intimate relationships.”

Woah, that came a bit out of the blue. I hadn’t made the link between “person with a mental illness” and “psycho”, otherwise I wouldn’t have posted it. It didn’t say, “Better to have lost in love than to live with a person with a mental illness for the rest of your life.” I had linked “psycho” with the often weird, unspoken assumptions people make when in relationships, which have kept me out of long-term relationships all my life.

It made me think, though. Suppose it had read, “Better to have lost in love than to live with an idiot for the rest of your life.” Would that have been a slight against people experiencing unique learning function?

Probably a more accurate meme would have been, “Better to have lost in love than to live with an arsehole for the rest of your life.” But that’s not what the image said.

For the record, I have had someone I loved tell me he couldn’t cope with my unique physical function anymore. It was hard to hear, but ultimately he was the one who lost out. And I know intuitively many would-be lovers haven’t even gone there — again, their loss and my gain, because why would I want to be with anyone so closed-minded?

The power we let labels have over us can be overwhelming. If I had a dollar for every time a person called someone a “spaz” in my presence, I’d be wealthy. If I got offended because “spaz” is a shortened version of “spastic”, which is one of my diagnoses, and I got another dollar for that, well — I’d be angrily living in the Bahamas.

I think the evolution of language — and the generalization of words like, “gay,” “spaz,” “idiot” and “psycho” — creates the opportunity for them to lose their charge and liberate us from their stigma. By allowing them to continue having power over us, though, we re-traumatize ourselves every time we hear them. Words are symbols and they change meaning over time and in different contexts.

I celebrate that “gay” means “not for me” rather than “fag”; that “spaz” means “over-reacting”, not “crippled”; that “idiot” means “unthinking”, not “retarded”; and that “psycho” means “someone with weird, unspoken assumptions”, not “a crazy person”.

By letting words change meaning for us, we are redefining diversity and creating social change. It’s not a case of, “Sticks and stones will break my bones but words will never hurt me.” It’s recognizing that, unless someone is looking directly at us menacingly, calling us gay, spaz, idiot or psycho, we’re not in their minds — they’ve moved on.

Maybe it’s useful for us to move on with them?

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Culture

Under Pressure

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As it turns out, the behaviour of people around us is contagious. This is truer the closer these relationships are – we are much more influenced by the attitudes of friends and family than we are by those of strangers.   We often think of peer pressure as a bad thing we should resist, but it can also be a powerful influencer in terms of shifting social attitudes for the better as well.

I recently read an interesting article in Scientific American about the power of social pressure and how it can influence our behaviour.  For example, one 2003 study found:

  • If a person gains weight, the likelihood their friend would also gain weight is 171%
  • When smokers quit, their friends are 36% more likely to also quit
  • Having happy friends increased the likelihood of an individual being happy by 8%

It’s also true that fitting in feels good.  We all want to feel a sense of connection and belonging and these things are hugely important to our personal wellbeing.  The difficulty is, of course, when fitting in means feeling pressured to change parts of ourselves in ways we are not comfortable with.  And feeling under pressure to force yourself to be something you’re not can cause a huge amount of psychological distress.

It’s a no-win situation – we either change (or pretend to change) for the sake of fitting into the group – and feel awful and uncomfortable about not being able to be who we really are – or we stay courageous about our convictions, but experience ostracisation and pay another kind of emotional price for that, too.

So what’s the answer?  I’m really not sure, to be honest.  I know that personally when I was younger I felt huge amounts of pressure to hide my nerdy and academic interests because they didn’t seem to be shared by the people around me.  I didn’t talk about my love for sci-fi, comic books, or video games with anyone.  Or show that I loved attending classes and soaking up knowledge anywhere I could.  I simply never seemed to have any friends who had the same interests.

But through my 20s I became a lot more comfortable in my own skin and more confident that being different in some way was okay.  Just the other day a colleague pointed out a nice, but expensive, piece of jewellery online.  She asked, “Wouldn’t you like to own that?”  I replied, “Actually, I’d rather have a new Xbox!”  We laughed about it.  I didn’t feel like an outcast.  I felt like I was being genuine and appreciated for that.

And maybe this is the key.  Sometimes a lot of the pressure to conform is external, but I wonder how much of it is internal as well.  I wonder if my friends in my younger years would have accepted me for who I was if I had given them the chance to.

Or maybe my hard-won comfort with who I am helps other people to feel more comfortable being themselves around me, too.  We’ve removed that pressure, together.

But I’m curious – how affected (or unaffected) do you feel by social pressure?

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Diversity

Is It More Than Just A Shooting?

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Several articles in response to the shootings in Minnesota, New Orleans, and Dallas point fingers at racists, PTSD, and mental illness. Although these issues are valid, there is a multitude of factors making this issue far more complex than a singular culprit like mental illness.

Underneath all these shootings and acts of violence is fear, an emotion we don’t often factor in when discussing shootings. Fear causes fight or flight reactions in humans, a strong, protective instinct which can, at times, cause reactions that aren’t typical of our normal behaviors. When we experience fear, whether real or perceived, our adrenaline increases and as an act of self-preservation. Our reactions to fear may cause us to act in ways our “normal” brain might not have. Unfortunately, it can also cause us to react in a way which can take the life of someone in the name of self-protection or justice.

So, imagine the stress of living in a neighborhood where people are killed, gunshots are heard regularly, and those around you are involved in nefarious activities. Long-term stress can have severe consequences – such as physical health issues and problems with cognitive thinking. For children, toxic stress results in behavioral and development issues. Living in a state of constant fear never allows an individual to care for themselves, always on the alert for potentially dangerous situations. Living in fearful conditions where a community’s needs aren’t met and their safety is questionable, a physically and mentally harmful lifestyle is already enough to deal with. Now, factor in racial profiling, police bias and brutality, and classist targeting.

In low-income neighborhoods, police are not always responsive. The police don’t often know you or your family and tend to approach certain neighborhoods with harmful preconceived ideas. Whether it’s internalized hate, racial profiling and learned bias, classism or just plain ignorance, many police officers are not educated about communities different from their own and only have reference points from television and media, which reinforce harmful stereotypes. If this is the basis from which police are viewing the public, it’s highly likely police will target certain groups out of fear.

It is important as a society, we do not downplay the personal responsibility we have for our actions nor the sheer horror of violence. But we are not born disliking people of color, women, immigrants or cultures different from our own. Through our learned experiences with family, school, media, or religious institutions, we learn to be separate and fear groups who are not like us. We look around and see people who only look like us and learn to live in a comfortableness rather than question the status quo which oppresses certain groups more than others.

So, how do we get past this fear? Education, compassion, and empathy are key. As a community, we need to be more responsible to one another and have difficult conversations about race, gender, and class while challenging our own internalized biases. Speaking to our legislators, media representatives, friends, and family is a power to hold ourselves and others accountable for racial profiling, classism, abuse of power, and internalized fears. We need to put our foot down and refuse to settle for superficial conversations or answers to large, complex problems.

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Mental Health

The Surprising Downside to Mental Health Awareness

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It’s common knowledge our society isn’t great with mental health. We don’t talk about it enough and invalidate those who are struggling. We often simplify mental health issues as personal weakness while ignoring complex factors which comprise mental well being. By focusing mental health awareness on illness or “weakness,” we are not adhering to scientific research which shows a complicated web of factors comprises mental health.

It’s interesting, then, that many of our mental health “awareness raising” narratives relate to illnesses and chemical imbalances. Awareness raising campaigns often portray mental health as an individual medical problem. However, when we consider this on a societal level, it is hard to justify the idea that nearly everyone develops abnormal brain chemistry. We don’t have a collective wonky wiring making us all depressed or vulnerable to mental health issues.

Our personal challenges might be emotional bruises from our childhood circumstances, for example, poverty, trauma, bullying, instability, or learning difficulties. We may also face more recent challenges such as a lack of fulfilling friendships, stress, alcohol or drug dependency, debt, trauma, or tumultuous relationships. Indeed, some of our challenges might have followed us across the spectrum of life, factors including gender, race, sexuality, (dis)ability, emotional sensitivity levels, etc.

We know those of us who face greater life challenges are more likely to be at the sharp end of distress. To me, that’s not an individual, medical problem, neither on scientific or ethical grounds. Yet, these factors are often a sideline in awareness-raising campaigns.

The common “illness like any other” narrative simplifies a complex issue, suggesting some people are ill and others are simply not. This narrative would be necessary, perhaps, if psychiatric diagnoses were reliable and clearly differentiated people with and without mental “illness.” This narrative might also be necessary if conditions of distress were proven biological illnesses, but they’re not. Mental health diagnostic criteria are subjective and culture-bound, there is no clear line between mentally “ill” and mentally “well.”

Depending on which mental health professional one sees, the kinds of questions which are asked, even factors such as one’s age or gender, one could get a very different diagnosis. For example, Borderline Personality Disorder is characteristically feminine. Many people cycle through a range of professional labels before finding one which fits their personal experience – often, a person adopts several diagnoses before finding their best fit.

Also, note how the presence of a “chemical imbalance” or any other biological test for that matter, is not a criterion for a mental health diagnosis. We cannot detect depression, developmental disorders, eating disorders, or “personality disorders” in a blood test, brain scan, or any other biological test. Indeed, science has not proven there is a chemical imbalance for many mental health diagnoses.

According to the British Psychological society, “Our experiences and distress are likely to arise out of a range of factors. The things that have happened to us, including influences on our development before, during and after birth, childhood and educational experiences, our current circumstances and responses, our brains and bodies, and how we make sense of our lives are all important… there is no firm evidence that mental distress is primarily caused by biochemical imbalances, genes, or something going wrong in the brain (with a few exceptions, such as dementia).”

Of course, we know taking medication can help some people feel better. But by promoting an “illness like any other” way of understanding mental health, we are suggesting distress should largely be treated as a physical illness, i.e. with biological treatments. However, medications have the best results when given to people with severe distress and for the shortest time needed, considering long-term medication often has serious side effects.

Many people find the illness narrative useful and validating. For some, it offers answers or proof their distress is valid and should be taken seriously. But this is up to the individual, who should be able to have a choice as to whether to accept the medical “illness” metaphor of understanding or to seek alternative understandings about their distress.

This article, then, is an evidence-based suggestion that we, as a society, need to be more open to dialogues and alternatives when addressing mental health. We need to consider the full spectrum of understanding mental health and raise awareness of the multiplicity of factors supporting and hindering our well being. Only then can we be truly empowered to take control of our mental health – both as individuals and as a society.

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Health

Personality Disorders: How They Affect You

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Most people get along with others. There might be the odd bit of friction between a person or two, but for the most part, most people get along.

There is a sub-group of people, however, that doesn’t seem to get along with almost anyone. These persons tend to project blame onto others for their conflict and may also cause others to feel guilty for not meeting expectations in the relationship. Further, some of these people while feigning interest in others, are really only interested in meeting their own needs. These people can be manipulative, self-serving and distressing to others. If they themselves are distressed, it is only due to the reaction of others, or for others not attending to their demands. They tend not to be distressed about their own behaviour. In fact, when confronted on their own behaviour, they are quite unable to see a problem with themselves and treat the confrontation as a serious attack. They are incredibly adept at making excuses which continue to exonerate themselves while making it seem like everyone else is the problem.

If you explore their childhood, one often sees a history of abuse or abandonment. There may have been parental alcohol or drug abuse and violence in the home. These persons may have been subject to many moves in childhood and care by multiple alternate caregivers.

Such persons may have a personality disorder. A personality disorder is a psychiatric diagnosis given to adults whose behaviour brings them into conflict with many persons and society. Their behaviour presents as frequently troublesome, inflexible and persistent.  There are many behaviours common to persons with a personality disorder. When clusters of certain behaviours are seen in the same person over time, different types of personality disorders are identified. Hence 10 distinct types of personality disorders are distinguished and there are mixed types. Some persons are loud or dramatic while others cause rifts in relationships between other persons with themselves seeking to be in the middle. Some may flaunt the law, believing it is their right to do so and others make everything seems about themselves. These characteristics relate to the histrionic, borderline, antisocial and narcissistic personality disorders.

Treating Personality Disorders

Personality disorders cannot be treated with medication, although someone with a personality disorder may have another disorder such as depression or anxiety, which can be treated with medication. The personality disorder itself may be treated by psychotherapy; however, many persons with personality disorders are treatment resistant. In other words, the psychotherapy does not work and the personality disorder continues. The reason many are treatment resistant is due to the nature of the personality disorder. Another feature of the disorder is the inability of the person to view themselves realistically. They have tremendous difficulty or may be fully unable to realistically appraise or see their own behaviour as troublesome. Therefore, they are quite unable to accept it is they who have the problem and needs the help.

People who live with someone with a personality disorder may come to believe they have the problem, rather than the person with the disorder. The one with the personality disorder is so good at projecting blame and their version of reality and are so inflexible, that others are drawn into accepting blame and feeling guilty. Hence treatment for the family and friends of the person with the disorder becomes paramount. Treatment or counselling is aimed at educating the family and friends as to the nature of the disorder and at helping these persons form strong boundaries to protect from the intrusions of the one with the disorder. Some family members or friends may also have to distance themselves to be self-protective and others may need coping strategies to manage situations as when they need to be near the person with the disorder.

If you are having difficulty with someone as described above and even if they do get help, get help for yourself. Describe the situation to the therapist and seek education, guidance, and support to manage the relationship and make choices as to how you will cope and decide what is acceptable for you. You are allowed to be independent of the person with the disorder, regardless of the relationship.

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Aging

4 Calming Techniques to Improve Your Mental Health

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If you are like me and the other nearly 325,000,000 trillion people in the U.S., you have experienced stress. From raising kids, dealing with your boss or handling a health issue, you can feel overwhelmed. But there’s good news! Learn how to create peace and take control of your life.

Determining the Type of Stress

Most people do not realize stress, a response to stimuli, comes in two varieties: good stress and bad stress. Bad stress or distress happens when your perception of an event is threatening. According to Stress Management Society, “Through the release of hormones, such as adrenaline, cortisol…the caveman gained a rush of energy…”. This onset of biological and emotional reactions resulted in the need to fight or flight.

Good stress or positive stress is the opposite response. It is marked by feelings of happiness and a sense of confidence. Your thoughts are focused and the energy is motivating.

4 Paths to Calm

Now that you know more about stress, you can start to manage it. Try these tips to make stress ignite your creativity and passion. Make stress work for you.

1. Keep It in Perspective

So, how do you transform your bad stress into good stress? Change your perception. If your job causes you to relocate, consider it a career opportunity. If the throbbing in one of your molars means you need a root canal, don’t panic. Discuss it with an emergency dentist Calgary. Consider it an investment in your health.

2. Calm the Monkey

Your mind races with thousands of thoughts all day. Anxiety builds as you obsess about future concerns. What if this happens, what if that happens? Stop!

Just breathe. As you mindfully count from 1 – 10, inhale and exhale slowly. Feel your heart rate decrease.

The Buddhists used this breathing method for quiet meditation to conquer the Monkey Mind or frenzied mental condition. In Mindfulness: Taming the Monkey Mind by Mitchell Wagner, the author states, “It is not possible for the mind to be open…when it is consumed by anxiety.”

3. Choose the Right Foods

What do yogurt, pistachios, and spinach have to do with relaxation? They contain key ingredients which affect your mood.

Pistachios

According to Organic Facts, pistachios have “6 grams of protein per ounce…”. Protein contains an amino acid which produces serotonin, a regulator of hunger.

Spinach & Avocado

The folate found in this green leafy vegetable produces dopamine, a chemical producing feelings of pleasure. Folic acid improves memory in adults experiencing stress. Avocados are also high in folate and vitamin E.

Yogurt

This comfort-inducing snack is filled with probiotics. It delivers healthful live bacteria in the gut linked to good mental health.

Strawberries, Raspberries, & Blueberries

These fruits are high in vitamin C which helps fight stress.

4. Become a Yogi

Yoga is a tradition dating back 300 years ago. Yoga is low impact and is a synergy of mind, body, and soul.

The International Journal of Yoga published “Exploring the therapeutic effects of Yoga and its ability to increase the quality of life” and found “Yogic practices enhance muscular strength…reduce stress, anxiety…”. Bikram, Hatha, and Kundalini are some of the best forms of yoga for beginners.

Invest in Stress Management

Consult with your doctor. Read books and attend local exercise classes. Stay up-to-date about trends.

Stress is a part of life. Learn stress management. Anticipate the unexpected and choose a strategy challenging you to do your best. Then, sit back and relax.

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