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by Geetha Narayanan, LMFT

Geetha Narayanan is a first generation immigrant and parent working with teens, adults, and families to renegotiate and rediscover meaningful connections. Geetha has experience treating anxiety, depression, and life transition issues. Apart from English, Geetha is fluent in Hindi and Tamil. She has a private practice in San Jose, and can be reached at https://therapistsinsanjose.com/geetha-narayanan-mft/

Raise your words
Not your voice
It is rain that grows flowers,
Not thunder - Rumi

In his book Brainstorm: The Power and Purpose of the Teenage Brain, neuropsychiatrist and UCLA clinical professor Daniel Siegel describes the changes in the structure and functioning of the brain during adolescence. In one of his interviews for a teen magazine, Dr. Siegel talks about an architectural restructuring of the teenage brain and an emergence of the adolescent mind that is wonderfully creative, adaptive, and vibrant.  According to Siegel, "the adolescent brain is a construction zone: creativity, innovation, the capacity for abstract thinking, and the need to experiment are traits that drive this period. Unfortunately, as adults, we sometimes see the adolescent drive towards experimentation only as a negative, a sign that the teen is being ‘crazy’ or ‘immature’”.

Raising kids is tough and parents are not born with a manual for raising their children. Teens go through social, emotional, and psychological changes between 12 and 18. No two teens are alike, and the values, culture, beliefs, and the environment they grow up in all play a vital role in their wellness and health. The reality is a teen's brain is in the process of remodeling.

Indeed, adolescence can be a challenging time, to say the least, while seeking a secure emotional base or a container where they feel loved and accepted as each teen is going through changes so rapidly. Family can assist in building and supporting a teen's confidence, help shape their identity and be available during their trying times.

In India, summer meant playing outside for hours with occasional breaks for food or snacks. We never had many toys, including digital games or social media. Today's generation of teens, on the other hand, do not have any time for free play. Their days are packed with structured activities, even in summer, to build up a portfolio for the so-called top schools. When my daughters were in high school, they would share how their peers were planning to take many AP courses, online classes, internships over the summer, and more: schedules were packed. Many parents want their teens to go to their chosen top schools only. They have an unrelenting focus on academics at the expense of everything else, including mental health. These expectations and wishes put so much stress on teens, resulting in a growing epidemic of anxiety disorders, migraines, panic attacks, to name a few, and even auto-immune conditions, in some cases.

How can parents help
Create a stress-free zone: Parents and teens can develop a zone out time together. It could be watching their favorite buzz feed videos/TV, cooking/baking: a time of leisure without judgment or life lessons.

Efforts versus grades: We can counsel them without an obsessive focus on scores. It can be a life lesson that will help them focus on what they need to do and not stress about outcomes beyond their control. Constantly setting stretch expectations, leading to a relentless pressure to meet them, is toxic for teens’ health.

Sharing your past: Share your college experiences more as an understanding and awareness for your teen, not necessarily to communicate only how your (parent) generation's methods are correct. Such communication would make any teen feel that they never measure up and can damage their long-term self-esteem.

One-on-one: Celebrating your teen's accomplishments, sharing their disappointments, and supporting their hobbies helps your teen know you are  interested in them. You do not have to make a big deal of this. Sometimes it is just a matter of showing up to watch your child play a sport or music, reading together, or cooking or baking, and arts and crafts activity or giving them a ride to extracurricular activities.

Treats: Treats worked in elementary school, and they still do, such as a Starbucks drink or a Jamba Juice. Some parents feel that appreciating their teen's effort or journey would defocus them and stop putting in their efforts. However, research has shown that positive encouragement is vital for teens to succeed in any environment. It is not a bribe but an acknowledgment of their effort. In addition, an encouraging comment along with the reward will help make the message clear to your child how much you appreciated their efforts.

Be empathetic: Using active listening when you are conversing with your teen without interrupting with your own opinions or judgments, being curious and open-minded about their point of view, and having patience as they solve their problems can be the best thing you offer your teen. You need to increase your capacity to listen actively, be open, and provide a non-judgmental stance. For example, when a teen comes home heartbroken as they did not get their desired result in their quiz, a parent could respond, "I saw how much you worked on that; I am so sorry to hear that." This kind of empathy is powerful to hear someone say and soothes them.

Only STEM mindset: There are some misconceptions that only a few majors guarantee a job. Other than STEM majors, there are other majors in public health, global health, economics, nursing, etc., leading to great jobs and careers. Parents should encourage their children to create a career path that brings them joy as well as a paycheck.

Chores/jobs: As parents, we would like to rescue and complete our kids' activities and chores. However, it is an excellent time for teens to develop and mature with independent living skills. Managing simple tasks like laundry, cooking, or running errands for the house once they start driving, teaches them accountability/responsibility and time management.

Limit setting/boundaries: By setting up rules, boundaries and standards of behavior, you give a teen a sense of stability and predictability. Regular family meetings and explaining the benefits and consequences of following rules/boundaries would help. It also helps them internalize the concept of delayed gratification. Of course, there will be pushbacks, yet this practice is integral in a time of chaos.

Conclusion
Trust and respect are earned not by doing only heroic, victorious deeds, making significant changes, saving lives around you, but also by paying close attention to your teen's emotions and feelings. Dr. Siegel reemphasizes the importance of how young adults need to be seen and soothed by their parents. Relationships with our teens provide a template for relating with people when they step outside our homes. Developmental relationships are connections that help young people become their best selves.

For Parents:

Goleman, D. (2010). Emotional intelligence: Why it can matter more than IQ. New York, NY: Random House Publishing.

Siegel, D., & Payne Bryson, T. (2011). The whole-brain child: 12 revolutionary strategies to nurture your child’s developing mind. New York, NY: Random House Publishing.

Siegel, D. (2013). Brainstorm: The power and purpose of the teenage brain. New York, NY: Penguin.  

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Dmitry Vulfovich, LMFT

The use of medicines to treat the psyche is not an original advent of Western civilization. In fact, for thousands of years, prehistoric societies have used psychedelic medicines to treat mental and spiritual illnesses throughout the world. Indeed, the effects of psychedelics are much more profound than those of modern psychopharmacology due to their ability to uncover the core materiel of a person’s psychology.  Modern psychiatry is at a turning point as psychedelics gain recognition and legitimacy through clinical trials and public awareness. We are seeing a tremendous shift away from symptom reduction, and a move in the direction of healing trauma and transforming mental health on an experiential level.

The word shaman originally comes from Siberia and Central Asia, and actually derives from the Russian Tungus Saman, which could be translated into whole man or holy man. According to Terence McKenna (1992), shamanism is the “practice of the Upper Paleolithic tradition of the healing, divination, and theatrical performance based on natural magic, developed ten to fifty thousand years ago" (p. 4). Almost every indigenous culture has its own psychoactive medicine. Some of the major medicines include: psilocybin mushrooms and Salvia Divinorum in Southern Mexico, Iboga in Western Africa, the Peyote and San Pedro cactus in North America and Peru, and Ayahuasca in the Amazon Basin. Clinical research with psychedelics in the United States is now being allowed by the FDA in institutions across the country, as well as around the world, with such substances like MDMA, psilocybin mushrooms, Ibogaine, DMT and LSD to treat disorders ranging from alcohol addiction, depression, to post traumatic stress disorder (PTSD), to cluster headaches and obsessive-compulsive disorder (OCD).

How Psychedelics Work

While it is still being researched regarding the neurochemistry, psychological pioneers of psychedelic exploration like Stan Grof, MD and Ralph Metzner, PhD, often depict the experience as one of “consciousness expansion”.  A simple way of understanding this term is by looking at the inverse definition, which is “restricted consciousness.” People are often restricted and limited by their self-perceptions or self-concepts.  A person may be identified with a certain identity, sometimes due to traumatic events or systemic conditions, and the psychedelic experience has the potential to broaden the self-concept beyond the ordinary parameters. In other words, people have the opportunity to see themselves as something much greater and feel interconnected with all of nature and the cosmos itself. The most principal commonality in the psychedelic experience is ecstasy, which is described as an “experience that transcends duality; it is simultaneous terrifying, hilarious, awe-inspiring, familiar and bizarre” (McKenna, 1992).

A good metaphor for the process of transcending the ego is the hermit crab: as the crab grows it eventually finds its shell increasingly uncomfortable and restrictive because it has outgrown it.  At that point, it has to move out and be vulnerable enough to find a new house. In some ways, the same processes occurs in human personal transformation. As a person is confronted with a limiting belief or identity, they have the opportunity to let go of certain identity structures in order to out-grow their ego. A person may find it no longer useful or meaningful to identify as a victim or may choose to no longer be involved with resentment towards their parental figures, for example. So, psychedelics are a powerful tool to aid and assist the process of personal and spiritual growth, as well as healing emotional pain and trauma along the way.

The psychedelic experience is not a walk in the park though: often times it can be scary, uncomfortable, and provocative. A common phenomenon, although with exceptions, is called an initiatory sickness.  This happens when the physical body undergoes a type of shock and vulnerability experienced as nausea, disorientation, or dizziness (McKenna, 1992). This, in turn, is speculated to have an effect on the mind and its susceptibility to new information that it receives in the trance state. This is how the ego is broken down and real emotional and psychological changes can be made. Healing trauma requires an attentive and holding environment for the client to access core material and repair missed moments and incomplete processes deep within them. For this reason it is important to have a guide, therapist or indigenous leader to support this journey. The therapist or sitter can be very valuable in steering and creating a space for the client to explore the inner dimensions. If the client is feeling trapped in some emotional realm and cannot seem to get out, the therapist can be a friendly voice that interrupts the client’s mental rotation and bring them back to the present moment (Danforth, 2010).

Preparations for Psychedelic Therapy

Regardless of the increase in popularity of psychedelics, both precaution and sacredness need to be incorporated in the process.  A proper therapeutic setting and intentional purposefulness, or set, must be in place before participating. The set is important, which is the primary component of this type of therapy refers to the traits, mind state, and expectations of the client regarding the experience (Danforth, 2010).  An overall structure of the session should also be thoroughly discussed and agreed upon, starting with the rules and agreements between the therapist and the client such as: staying on the premises until all have agreed that the session is over; agreement that the client is not destructive to themselves, anyone else, or any property; agreement that no sexual activity between the client and therapist is allowed, as well as, agreement to follow all instructions from the therapist (Greer, 1998).  One of the most basic preconditions in this type of therapy is having the client meet with the sitter, typically a psychotherapist, numerous times before the psychedelic therapy takes place in order to develop and maintain rapport and trust, which has been found to minimize the danger of adverse reactions to the medicine (Goldsmith, 2011).

Similar to dream work, the psychedelic experience can sometimes be scary and contextually difficult to understand. Especially for beginners, the experience can be disorienting and confusing.  Supplemental psychotherapy, also known as pre-integration, is essential to begin psychedelic therapy. There are also various somatic grounding and body-oriented techniques taught to the client to optimize the therapeutic benefits of the medicines. One highly effective method of pre-integration therapy is called Focus-Oriented Psychotherapy (Focusing), founded by Eugene Gendlin, which emphasizes awareness, concentration, and acute receptivity in regards to the body’s innate wisdom. The pre-integration therapy helps the client to cultivate the faculties to localize their problem through meaningful somatic sensations and the ability to shift and signal particular changes in an assisted self study. This can be exceptionally effective with clients who are stuck and able to recognize their problem, but could not work through it completely during the ceremony.

This style of therapy is highly conducive for the psychedelic experience because it allows for the immediate felt sense of the experience to guide the therapy, and the preparation entails practicing how to orient inwardly and experience problems from a holistic bodily sense. A therapist involved in Focus-Oriented Therapy typically follows three main guidelines in relation to treatment planning. First, the therapist has to track and name the client’s felt sense of the issue. Second, they aid and assist the client to attune to their bodily sensations to allow the emergence of felt senses (Danforth, 2010). The third function of the therapist is to redirect the client from self-criticism or any attitudes that could hinder the momentum of their process (Danforth, 2010). Gendlin (1996) proposed a concept called absolute listening, which provides authentic gestures from the therapist that reflect understanding of clients’ inner process. Focus-Oriented Therapy essentially provides considerations and preparations for psychedelic therapy, and offers essential components of an overall meta-theme called the inner guide, which promotes self-trust in the client through the immediate felt sense of the body.  This, in turn, allows clients to rely more deeply on their inherent intelligence for guidance during a psychedelic session, as well as identify the primary goals for the session (Danforth, 2010). Focusing was originally its own type of therapy and is effective as a somatic-experiential type therapy, but has been adopted in the literature for preparation for psychedelic use.

Mindfulness in general is an absolute prerequisite for psychedelic use, because the altered state can feel like a stormy ocean.  Therefore, it is important to be able to ground and self-regulate during uncomfortable moments.  Vipassanna, an ancient body scanning technique stemming from Buddhism, is an excellent complement to psychedelic healing. The technique teaches the meditator to develop the faculties of awareness by systematically sensing and tracking body sensations from head to toe. An equally important element to Vipassanna is the practice of equanimity, which is the ability to observe the entire field of matter in the body while neither suppressing nor expressing the feeling and sensations. Basically, the person is taught to “be with it.” This kind of preparation is extremely grounding and an excellent way to initiate and conduct the ceremony.

Post Integration: Applied Knowledge

Taking the time to process and integrate a psychedelics experience can determine how much actual psychological benefit a person can accrue from it. A trained therapist can experientially explore and revisit themes touched upon in the psychedelic experience in order to help the client make sense of the journey and its meaning. Visual content from a journey can be processed as modalities of the imagination, similar to parts work (IFS), Jung’s Active Imagination or Gestalt. The client can have the opportunity to organize components of the experience as metaphors that reflect inner dynamics and character patterns, instead of scary hallucinations.

Probably the most crucial aspect of the integration process is taking the meaning and insight and applying it into lived and practical changes in one’s life. People can of course have deep insights about themselves and the world, but the application is key. Often times, clients are encouraged to use symbols and key figures from the experiences as impetus into transformation. For example, if a person has overcome a difficult moment in their psychedelic experience as personified by a dragon or serpent, they may choose to start wearing clothes or jewelry with those totem animals, or incorporate those attributes into their dancing or other behaviors like speaking up for themselves. Clients can also continue to process the fruits of their journey and find meaningful applications for various life events, relationships, and mental challenges. If clients discover through a psychedelic experience that radical acceptance of their anxiety and depression allows them to feel peace experientially, they may experiment with ways to apply this allowing acceptance when they get stuck in resistance in other areas of everyday life.

Conclusion: The Inquiry is the Medicine

Psychedelics offer a psychosomatic inquiry into mental health disease, and with that inquiry, there is an opportunity for integrated healing and transformation out of suffering. Traditional psychiatry, although useful and necessary, pursues the utopian ideal of, eventually, getting rid of all mental diseases through the use of biomedical research, but this narrow view fails to address the subtle psychological and spiritual aspects of illness and natural living processes, which are completely incompatible with that pursuit (Capra, 1982). If we eliminate the symptoms without inquiring into the roots and mechanics of the way the disease manifests itself in the first place, on a process level, we run the risk of regenerating the disease in a new or repeated symptom. Indeed, there is an underlying unmet need or inner conflict behind the disease: to get rid of the surface manifestation of the conflict only will never lead to fulfillment and completion. Psychiatrists are also doing their best to alleviate pain and suffering in order to make the patient more comfortable through illness, which may seem like a good thing, but it may lead to a distorted view of health and a lack of meaning in regards to a person’s conglomerate philosophical orientation towards their body and how their lifestyle may impact their health (Capra, 1982).

In an attempt to integrate this difficulty, psychedelic-assisted therapy and modern holistic health disciplines consider disease as anything that limits the freedom or potential of the organism, and expands the cure for disease to include substance, activity, event, or a combination that helps to restore the biological functioning and harmony of an organism (Grossinger, 1990). It is essential to start looking at how stress causes disease in the body, as well as understanding the trauma-informed perspective and the imbalance of needs instead of an imbalance of chemicals in the brain.

Dmitry Vulfovich is a Licensed Psychotherapist and Clinical Director at the Process Therapy Institute. His specialty is treating trauma and other mental health issues using a holistic body-oriented approach. Dmitry is a long time advocate and practitioner of ethno-botanical medicines and Zen healing arts. Dmitry is also a master teacher trainer at PTI, which involves experiential one-way mirror training and classes in the Process Model. Dmitry is a community leader, DJ, lecturer and workshop facilitator.

References

Capra, F. (1982). The turning point: Science, society, and the rising culture. New York, NY: Bantam Books.
Danforth, A. (2010). Focusing-oriented psychotherapy as a supplement to preparation for psychedelic therapy. Journal of Transpersonal Psychology, 41(2), 51-160.
Gendlin, E. T. (1996). Focusing-oriented psychotherapy: A manual of the experiential
    method. New York: The Guilford Press.

Goldsmith, N. M. (2011). Psychedelic healing: The promise of entheogens for
    psychotherapy and spiritual development. Rochester, Vermont: Healing Arts Press.
Greer, R. G. & Tolber, R. (1998) A method of conducting therapeutic sessions with
    MDMA. Journal of psychoactive drugs, 30(4), 371-379.
Grossinger, R. (1990). Planet medicine: From stone age shamanism to post-industrial healing. Berkeley, CA: North Atlantic Books.
McKenna, T. (1992). Food of the gods: The search for the original tree of knowledge – A radical history of plants, drugs, and human evolution. New York: Bantam.

Back to Fall 2021 Newsletter

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by Kylea Taylor, LMFT

Clients who are having transformative psychedelic experiences are already coming into our practices! I have a very small, very full practice these days, but several people each month now approach me expressing the same need. These people often share wistfully, “I tried to talk to my long-time therapist, but [she, he, they] didn’t understand, and just didn’t seem to feel comfortable with my psychedelic experience.” These people reluctantly started to look elsewhere for a therapist with whom they could talk about some of the most profound experiences they have ever had. They wanted to find someone who would understand what they mean when words fail them in trying to describe their numinous visions and psychospiritual breakthroughs. They are looking for a therapist who will be able to help them integrate these transcendent experiences into everyday life.

In this article I want to suggest how we as therapists can show up for this paradigm shift in culture and our profession. It is my wish that we all become aware that there are ethical differences in working with clients who are experiencing psychedelics and be willing to learn the territory of extra-ordinary states of consciousness (E-OSC).

Why are these potential clients taking psychedelic medicine? Some of the callers with whom I talked have become interested in taking psychedelics because they read Michael Pollan’s book, How to change your mind: What the new science of psychedelics teaches us about consciousness, dying, addiction, depression and transcendence. Pollan, a best-selling author and journalist, tracked down therapists in the psychedelic sub-culture, and for the first time in his life, took various psychedelic medicines himself under their care. He wrote so well about his journeys and what they meant to him that his book has intrigued and inspired readers to try psychedelics for self-evolution.

Other people who contact me are seeking help for their intractable PTSD and anxiety. They have read with new hope the stories carried recently and frequently in the New York Times and other big newspapers and magazines. This news touts the amazing success of the research done with MDMA-assisted psychotherapy for PTSD by MAPS (Multidisciplinary Association for Psychedelic Studies, that has its home office in Santa Cruz).

Phase II trials provided MDMA-assisted psychotherapy to a research group, as well as therapy without MDMA to a control group. Research subjects showed a “significantly greater reduction in the severity of symptoms” (MAPS) two months after treatment. Amazingly, study outcomes showed: “28 of 42 (67%) of the participants in the MDMA group no longer met the diagnostic criteria for PTSD, compared with 12 of 37 (32%) of those in the placebo group after three sessions” (MAPS). Phase III trials for MDMA-assisted psychotherapy were fast-tracked in 2017, because preliminary clinical evidence indicated [the treatment] may demonstrate substantial improvement over existing therapies for PTSD (MAPS).

The legal picture is changing for psychedelics because of MAPS’ successful research. MDMA is on track to be federally approved for psychedelic-assisted therapy. The State of California (and other states as well) meanwhile has decriminalized the use of certain hallucinogenic substances (MAPS). Many more seekers are finding their way to people who organize ceremonial experiences with psilocybin, ayahuasca or other plant medicines. Ketamine, a legal drug, is also being prescribed in off-label use by some doctors and psychiatrists for depression and other diagnoses.

What are the professional opportunities for therapists with psychedelic medicine? A cultural paradigm shift is underway and our customers—our clients—will at the very least want us, as their service professionals, to be able to discuss the treatment options for therapeutic psychedelic experiences and to listen with understanding when they describe their psychedelic sessions.

There will be professional openings in this field. There are therapists already working in research studies and in ketamine clinics. When the medicines are federally approved, there will be jobs in clinics for treatment sessions in which clients are administered psychedelic medicine, and there also will be opportunities to provide post-session integration therapy through alliances with doctors and clinics and via web referrals.

What are extra-ordinary states of consciousness (E-OSC)? Certain therapeutic methods invoke these normal, but expanded states of consciousness. Holotropic Breathwork®, psychedelics, drumming or other ceremony, EMDR or Brainspotting, or hypnosis are examples of these methods, each using different catalysts like the breath, plant or other psychedelic medicine, rhythmic entrainment, eye focus or eye movement, or hypnotic induction, respectively. Other profound life experiences bring E-OSC too, for example deep grief, reliving trauma, or a surprising, spontaneous mystical experience, perhaps in nature, in prayer, while listening to music, or during meditation.

These E-OSCs are sometimes mild and trance-like. But often, as in most therapeutic psychedelic sessions, they are very profound healing journeys, in which the client has less access to reference points in ordinary reality, may experience time distortion, may find it difficult to function or speak, and may express intense emotion spontaneously with sound or movement.

Ethical right relationship requires more and different attention by the therapist who is working with psychedelic-assisted therapy or integration therapy. It has been almost three decades now that I have been thinking and writing about ethics. From the beginning I have considered especially the ethics of working with clients who are having experiences in extra-ordinary states of consciousness.

In the 1980s and 1990s, I was studying with, then working with Stanislav Grof, M.D., a founder of transpersonal psychology, and Tav Sparks as a trainer in the Grof Transpersonal Training. We were training people to be practitioners of Holotropic Breathwork®, a method using the breath to enter an E-OSC. In that same time period, I was also studying at San Jose State for my M.S. in Marriage and Family Therapy and taking a traditional ethics education class there. This dual perspective enabled me to identify two main differences in ethics for professionals working with therapeutic E-OSCs: 1) the need to pay more attention to traditional ethical guidelines, and 2) the need to know and address different ethical issues involved in working with E-OSC.

The reasons for more attention to traditional ethics guidelines (like the well-articulated ones in the CAMFT Code of Ethics) are that in E-OSC there is often greater vulnerability, greater suggestibility, and greater transference and countertransference. The client may experience faster change in healing from transcendent states. Faster change means that there will be more issues of safety, navigating relationships, and dealing with cognitive dissonance. “Psychedelic therapy heightens the importance of trust, trustworthiness, and safety.” (Carlin, & Scheld, 2020).

E-OSC also require attention to different issues that normally do not arise in talk therapy. A thorough description of E-OSC differences is part of InnerEthics™, an inner approach to ethics that complements, with self-reflection and awareness tools, the outer guidance of laws and codes. The foundation of InnerEthics™, described in my book, The ethics of caring: Finding right relationship with clients (2017) is self-compassion. Self-compassion supports our willingness to learn about our own motivations and to develop a heightened attunement that can discern the client’s best interests, even when we are navigating the dimensions of right relationship in extra-ordinary states of consciousness.

What are some of the different ethical issues involved in working with E-OSC? Adequate training above and beyond what is provided to most psychotherapy students is essential for doing psychedelic psychotherapy. The training that is needed is both didactic and experiential. E-OSC journeys include categories of experience that are outside the usual scope of talk therapy. Such training includes cognitive learning about the expanded cartography of the psyche mapped by Stanislav Grof (1985) , in which he describes the categories of biographical, perinatal, and transpersonal experiences often occurring in E-OSC.

Experiential training (actually taking the medicines or doing Holotropic Breathwork® in a supervised session) is essential for a therapist to learn this cartography of the psyche through inner experience. It is so important to know firsthand the compelling power of the inner healing intelligence, to be surprised in the release of our own traumas and biases, and ultimately to learn implicit trust in the unfolding process in E-OSC. Grof (1985) wrote: “If [professionals ] have not experienced deep letting go….their own fear, lack of personal knowledge, and insufficient faith in the process may communicate itself, preventing [the client] from going fully into the experience to complete it. This can happen even if the [professional] does nothing overtly to interfere with the [client’s] process” (Grof, 1985).  

Rene Harvey (2021) writes about the importance of training in “trigger management” for therapists doing psychedelic psychotherapy. Her chapter in the wonderful book Psychedelics & Psychotherapy goes into detail about self-management, debriefing, formal supervision, follow up attention to any material arising, and the importance of attention to relational aspects like transference, countertransference and projective identification.   

It is crucial to be able to self-compassionately identify our own cultural programming and do self-management to control our impulses, so as not to let them inadvertently interfere with a client’s trajectory in a psychedelic session (Taylor, 2017).  Female clients, for example, need to be trusted to find their way in psychedelic sessions to expand beyond the limitations women learn culturally: “The psychedelic is the transformational ticket out of a limiting pattern for the female client…. She may feel free to experience her authentic self, understand how roles have been defined for her. She may be ready to confront self-doubt. She may be able to see beyond externally and internally imposed restrictions and find confidence in her unique gifts.” (Taylor, 2019).  

Monnica T. Williams, Sara Reed, and Jamilah George (2020), three black women therapists, describe their own experiences taking MDMA as research subjects, and then offer a list of competencies needed by psychedelic therapists to work ethically and skillfully with people of color: “(1) to be able to identify normal cultural variations in the expression of psychopathology and personality, (2) to recognize trauma related to racism and other forms of oppression, (3) develop good rapport with people of color by appropriately expressing caring, empathy, and respect, (4) comfortably engage in discussions of racial topics, and (5) identify and examine personal biases as they relate to ethnic and racial differences” (p. 133)

In summary, in order to work ethically with clients directly in psychedelic sessions or to do post-session integration therapy, it is important for therapists to follow the admonition of Socrates to “know thyself” by continuing to do deep self-reflection and to learn, from their personal experiences in E-OSC, the inner territory of the psyche and the character of the particular medicine or method being used. In 1980 Grof wrote, after supervising hundreds of LSD sessions: “Because of the unique nature of the psychedelic state it is impossible to reach a real understanding of its quality and dimensions unless one directly experiences it” (Grof, 1985). 

Kylea Taylor, M.S., LMFT is a California licensed Marriage and Family Therapist (MFC #34901). Kylea has been thinking, writing, and teaching about ethics for almost three decades. She has developed and teaches InnerEthics™, an inner, self-compassionate approach to ethical self-reflection and right relationship with clients. She served for two years on the Board of the Santa Cruz chapter of CAMFT. In her part-time therapy practice she specializes in the integration into everyday life of profound experiences, spiritual emergence, and transpersonal phenomena. She also provides ethics consultations to professionals using the InnerEthics™ relational approach. Kylea started studying with Stanislav Grof, M.D. in 1984, is a certified Holotropic Breathwork™ practitioner, and was a senior trainer in the Grof Transpersonal Training from 1993-2000. She is the author of The ethics of caring: Finding right relationship with clients, The Breathwork Experience, Considering Holotropic Breathwork™, and is editor of Exploring Holotropic Breathwork™. In the 1990s she assisted Stanislav Grof and Jack Kornfield in “Insight & Opening”, weeklong programs that combined Holotropic Breathwork® with Vipassana meditation. Kylea has presented her own programs in the USA, Europe, and online. Kylea is also President of SoulCollage Inc.   https://kyleataylor.com/  https://innerethics.com/

References

Carlin, S., & Scheld, S. (2020). Developing ethical guidelines in psychedelic-assisted psychotherapy. MAPS Bulletin Annual Report, 30(3), pp. 27-34.
Grof, S. (1980). LSD psychotherapy. Nashville, TN: Hunter House.
Grof, S. (1985). Beyond the brain: Birth, death, and transcendence in psychedelic psychotherapy. Albany, NY: SUNY.
Pollan, M. (2018). How to change your mind: What the new science of psychedelics teaches us about consciousness, dying, addiction, depression and transcendence. New York, NY: Penguin Press.
Mitchell, J. M., Bogenschutz, M., Lilienstein, A., & al. (2021). MDMA-assisted therapy for severe PTSD: A randomized, double-blind, placebo-controlled phase 3 study. Nature Medicine, 27, 1025-1033. doi:10.1038/s41591-021-01336-3
Nuwer, R. (2021). A psychedelic drug passes a big test for PTSD treatment. The New York Times. Retrieved from https://www.nytimes.com/2021/05/03/health/mdma-approval.html
Taylor, K. (2017). The ethics of caring: Finding right relationship with clients. Santa Cruz, CA: Hanford Mead.
Taylor, K. (2019). Ethical considerations for psychedelic work with women. MAPS Bulletin Annual Report, 29(2), pp. 28-31.
Williams, M. T., Reed, S., & George, J. (2020). Culture and psychedelic psychotherapy: Ethnic and racial themes from three Black women therapists. Journal of Psychedelic Studies, 4(3), 125-138. 

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by Kaye Bishop, LMFT

Kaye Bishop is an LMFT in private practice for 34 years. She attended two month-long Process Communities in Colorado with Virginia Satir, studied with Satir for six years until Satir’s death in 1988. Kaye is a member of the Virginia Satir Global Network. Kaye was an Adjunct Professor at Santa Clara and JFK universities and worked for nine years as Counseling Supervisor at Silicon Valley Independent Living Center. For the last 15 years, she has been supervising associates and trainees at Almaden Valley Counseling Services. Kaye has had extensive experience as a group leader and workshop presenter working from a Satir model perspective. She can be reached at 408-837-5973.

At the turn of the 20th century, society was patriarchal. Women did not yet have the right to vote. Men were the authority figures. In the family, the husband/father made the decisions that his wife and children were expected to follow and obey. The therapeutic interaction at that time was also based on this hierarchical model, expert and patient. The early treatment model for psychology introduced by Freud and his followers was a traditional doctor-patient relationship, expert and patient. In this model, the client trusts the expert: the therapist. The aim of treatment was to focus on the symptoms and the treatment modality was individual therapy.

In the 1950s-1960s, with the development of humanistic psychology, a new model for treatment was developed based on an understanding that people affect one another. New treatments unfolded based on the interaction between therapist and client to promote change and growth. This led to the realization that it might be a good idea to treat members of a couple and families together. The realization that people affect one another and need to express what they think and feel about their situation was a significant move away from Freud and his followers whose model was individual treatment. During this time, couple and family therapy models were developed. In these new humanistic models, the therapist’s use of self became the main vehicle for growth and change.

Virginia Satir, a skilled psychotherapist, group leader and teacher, was a pioneer in the development of humanistic psychology. She became the first president of the Association of Humanistic Psychotherapy. With her development of a family systems approach to therapy and the publication of her book People Making in 1967, Satir cemented her place as a leader in humanistic approaches to treatment. People Making was translated into 13 languages and with the revised and augmented publication of The New People Making in 1988, her work became the model for family systems approaches to therapy. Family and group approaches joined individual therapy as valid treatment modalities.

I first met Virginia Satir in the summer of 1983. I heard that she was leading a month long Process Community in Mt. Crested Butte, Colorado. The focus of the Process Community was on teaching the Satir model and on personal growth. I signed up and it proved to be a life changing experience for me. I attended the advanced training in 1984, again in Mt. Crested Butte, a much loved place for Virginia, and continued to study with Satir until her death in September 1988.

In Satir’s model and other humanistic models, the therapist’s use of self is the main vehicle of change. Basic elements of all psychotherapy models are:
−  A therapist,
−  A client,
−  A context,
−  The interaction between therapist and client,
−  A model for treatment.

My training and 34 years of experience have taught me that there is no such thing as objectivity in the therapeutic relationship. Each client, each context is unique. It seems evident that therapist and client cannot help impacting one another as human beings. The influence of the therapist’s self or personhood occurs regardless of, and in addition to, the treatment philosophy or approach used. Therapeutic techniques, per se, seem to have little to do with results. The person of the therapist is the catalyst for change. It is who the therapist is as a person, not what she or he does, that makes the difference.

In this view, the therapist is the agent of change. The realness of the therapist and how she or he uses the self in the therapy, through modeling congruence and other interventions, will shape the world the client is headed toward, the new possibilities for change and growth the client is learning.  For this reason I believe that we, therapists, need to be in our own therapy if we are doing therapeutic work with others. It is true that we cannot take our clients any further than we, ourselves, have gone.

I have had a long interest in Buddhism and how Buddhist philosophy speaks to what I have learned through my teachers’ teachings and years of practice. In the early 2000s, I joined a Rigpa meditation and study group led by a student of Sogyal Rinpoche, Buddhist teacher and founder of Rigpa, a Buddhist sect. His work teaches meditation,  contact with the self, and presence. His work also teaches that in order to teach or practice psychotherapy, it is necessary to have gone through the process yourself. Otherwise, it is like teaching without the knowledge.

The Power of the Emotional (Limbic) Brain

How, then, does the therapist affect change and growth in the client? It appears to have a lot to do with our emotional brain, the limbic system. Neuroscientist Paul MacLean, in his research at the National Institutes of Health in the 1960s, discovered that our brains are made up of three parts, different in structure and function. There is the neocortex, the limbic system, and the R-system, the old survival brain. McLean described the limbic system as a vibrational energy system, unlike the neocortex which is an axon/dendrite system. He and other researchers in the last twenty-five years suggest that it is the limbic (emotional) transmission between therapist and client that is the key to healing. Limbic transmission refers to the therapist’s attunement and empathy toward the client as well as the regard the client develops for the therapist.

At the beginning of the 21st century, three psychiatrists/researchers at the University of California San Francisco Medical School, Thomas Lewis, Fari Amini, and Richard Lannon, wrote and published a terrific book based on their limbic brain research titled A General Theory of Love. They discovered that our minds seek one another through what they call limbic resonance, the process by which two people become attuned to each other’s inner states through mutual exchange and internal adaptation. An example of limbic resonance is courtship where lovers can become so attuned to each other that they can seemingly read each other’s minds or complete the other’s sentences.

The way in which an attuned mother regulates her child’s emotions is another example. If the mother is upset or frightened when her child falls, the child also reacts with upset or fear and cries. If the mother remains calm, the child tends to be calm also. When any two people form an attachment, they become emotional regulators for one another. This is certainly true in the therapeutic relationship as well.

We know also that emotions affect physiologic rhythms of the body. For example: a tailgater pushing from behind causes a body response in us. An anxious, rushing person elicits a different response in the body than a calm person. Research has shown that people who have contact with others do better emotionally and physically and live longer than those who do not.

Lewis, Amini, and Lannon (2000) show that we actually change one another’s brain through a process called limbic revision. According to the researchers (2000), “In a relationship one mind revises another; one heart changes its partner” (p144). It seems that attuned human beings have the power to remodel the emotional parts of those they love. Because of this, what we do in a relationship matters more than any other aspect of human life. Who we are and who we become depends, in part, on whom we love. This, of course has important implications for psychotherapy and therapist use of self.

Applications of Brain Research to Psychotherapy

We as therapists, then, have the power to revise the minds of our clients. In fact, that is what therapists do and seek to do. This is accomplished through attachment (joining and establishing a relationship), limbic resonance (empathy), and through limbic revision. Interestingly, the therapeutic relationship, then, the emotional interaction between therapist and client, and psychotropic medications both act on the limbic brain system in similar ways to affect changes in mood.

Power

Virginia Satir taught that the use of power is a function of the therapist’s use of self.  The therapist is in a position of power due to his or her training, role, status, and person. By contrast, the client is in a position of vulnerability. Satir stressed that due to this difference in power between therapist and client, it is important for the therapist to remember that power can be used either for controlling the other or for empowering the other. Therefore, the therapist must guard against:
−  The relationship becoming a negative use of power,
−  Developing a dependency in the client.

Therapists wish to serve and not to harm our clients. We can unknowingly do harm, however, if our own unresolved issues get in the way of therapy. The danger here is unrecognized counter-transference and its resulting projections. Signs of counter-transference include:
−  Feeling stuck,
−  Protecting the client,
−  Rescuing,
−  Taking sides,
−  Rejection of a client.

Therapist as Model

A major way in which a therapist uses the self is as a model for their clients. Through their humanness, behavior, and way of being, therapists model:
−  Acceptance,
−  Congruence and realness,
−  The joy of learning and growing,
−  Humanness,
−  Self-care,
−  Self-valuing,
−  Attending to and responding to the self.
If we are not careful we can also model:
−  Lack of acceptance of self and other,
−  Incongruence,
−  Unwillingness to admit mistakes,
−  Lack of self-care and self-valuing,
−  Self-abandonment.

Satir believed that emotional honesty between therapist and client is the key to healing. If the therapist’s words and affect do not match, this creates an unsafe environment for clients that often replicates the client’s childhood experience and can cause further wounding.

There is a close relationship between what the therapist believes and how she or he acts. How the therapist uses the instrument of self depends upon:
−  How complete one is as a person,
−  How well one cares for oneself,
−  How well one is tuned into or present to the self,
−  How competent one is at one’s craft.

Virginia Satir, (2000), stated that “the person of the therapist is the center point around which successful therapy revolves” and, “it’s who you are, not what you do that counts” (p. 25). Remember that the greatest instrument you have for healing is yourself. It is how you use the instrument of self that leads to successful therapeutic outcomes.

References

De Beauport, E. (1996). The three faces of mind: Think, feel, and act to your highest potential.         Wheaton, IL: The Theosophical Publishing House.
Lewis, T., Amini, F., & Lannon, R., (2000). A general theory of love. New York, NY: Random House.
Satir, V. (1972). People making. Palo Alto, CA: Science and Behavior Books.
Satir, V. (1988). The new people making. Palo Alto, CA: Science and Behavior Books.
Satir, V. (2000). The therapist story. In Baldwin, M. (Ed.), The use of self in therapy

(pp.17-27). New York, NY: The Haworth Press.

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Questions submitted by Rowena Dodson, LMFT, Director-at-Large

Diane Byster, LMFT, NCC, RYT is a Licensed Marriage and Family Therapist, National Certified Counselor and Registered Yoga Teacher. Diane currently co-facilitates an ISTDP 3-year Core Training Program in Alberta, Canada and provides case consultation to licensed marriage and family therapists, social workers, psychologists and psychiatrists in the U.S. and in Canada.

We are focusing this issue, in part, on modern psychodynamic therapies. We are very interested in your work in intensive short-term dynamic psychotherapy (ISTDP). Can you tell us more about this modality? What does “short-term” mean?

ISTDP is an experiential therapy that helps the patient face the feelings they avoid by regulating their anxiety moment-to-moment, and helping them see and turn against defenses that are maladaptive. Through this process the therapist helps patients observe and develop compassion for their inner life and relinquish habits of self-rejection. Although based on psychodynamic theory, ISTDP integrates techniques from multiple approaches, including cognitive, behavioral, somatic, Gestalt, and mindfulness therapies.

Short-term means that this approach generates more impactful results in a shorter span of time than most other therapies. ISTDP is an evidence- based approach that demonstrates greater efficacy in treatment outcomes than even more popular therapies, such as CBT.

What specific aspects of this way of working make this a psychodynamic therapy?

Psychodynamic means working with conflicting forces from the unconscious. Clients enter therapy for a variety of reasons, such as relationship difficulties, anxiety, depression, procrastination, lack of self confidence, problems with self-assertion, low motivation etc. However, patients are often unaware of the specific forces that may be causing their difficulties. For example, because they have been hurt through neglect, abuse, dismissal or being pressed into service of taking care of an impaired parent, patients developed coping strategies both adaptive and maladaptive to protect those early insecure relationships and manage themselves.

We often meet with patients when the strategies that they put into operation, automatically and unconsciously, no longer work for them. Our hardwiring evolved to unconsciously detect safety and danger in our relationships. That’s how we learned to survive! When patients perceive threat, mostly unconsciously, they deploy all of the strategies that they learned to protect themselves growing up. Of course, they don’t see those strategies. As we invite the patient to form a close relationship with us, in order to help them with their presenting difficulties, the invitation to closeness registers as an unconscious threat, and the patient puts into operation all of the ways they learned how to survive. They show us, in the present, the precise history and nature of their suffering. Through moment-to-moment tracking of anxiety pathways and defensive habits that interfere with closeness and reaching their treatment goals, the patient gradually learns how to see themselves more accurately, regulate their anxiety and turn on their defensive structure that has created their suffering. When this happens, feelings spontaneously arise, which, when unfettered by anxiety and defense, facilitate deep healing. This process often brings unconscious memories to surface that can be addressed in the present and resolved.

Could you give us a short fictional case example, with a problem someone might bring in and what the work would look like with that client?

A middle-age married man with two teenage children came to see me for therapy when he lost his job, became depressed, and his wife threatened to leave the marriage. The man thought that having been in a job that he didn’t like was causing his difficulties, and that if he had a new job, it would solve his problems. While getting a new job might improve his circumstances and possibly his mood, what the man did not see was how his passivity and detachment were causing the problems in his marriage, getting him depressed and were critical variables that contributed to him being fired. Of course, unaware, the client presented his passive, detached stance with me in therapy. He also did not see how operating from a detached, passive position covered his inner feelings and vitality, which would help free him from a deadly cycle of turning on himself.

The critical tasks of therapy were helping the man reframe the problem as not the job outside of him, but rather observing the defenses operating inside him as causing his difficulties, experiencing his will for his own well-being and turning on these defenses. Once the patient turned on his own defenses, this led to a spontaneous rise in grief/sadness that he had been hurting himself for years by putting these defenses into operation in all of his important relationships and blocking closeness with himself and his wife. The client’s ability to bear his sadness about his own self-harm was a crucial variable in the healing that took place.

What kinds of clients is this therapy most suitable for?

Clients who suffer from mood disorders such as anxiety and depression, difficulties with motivation, self-assertion, procrastination, addiction, trauma histories, underemployment, conflicts at work or with family members, and character disorders, such as chronic passivity.

Are there clients or populations with whom you decide not to use ISTDP and if so why?

Clients who do not want to work in therapy and see therapy as only a place to chat and vent would not benefit from ISTDP. ISTDP therapy is not a therapy that happens to the patient; rather, it is a co-created enterprise between the therapist and client, both putting their full effort towards the client’s stated goals.

ISTDP would also not be suitable for patients who are actively suicidal, homicidal, or engaging in domestic violence. We also modify approaches within ISTDP to account for particular client characteristics such as severe fragility.

How does this modality work with African American clients, Asian American clients and other clients of non-European descent?

This therapy was originally conceived and developed by an M.D. of non-European decent, Habib Davanloo. It is currently practiced worldwide, including North America, Europe, Asia, and the Middle East.  

Are there issues that come up or adjustments that you make in order to meet your clients where they are?

Yes, for instance, for clients who suffer with severe anxiety there is a graded approach to ISTDP where we help clients using specific interventions that help build their self-observing capacity and increase their anxiety tolerance.

My understanding is that this a very directive approach, where the therapist is more highly directive of sessions. I find that interesting since my impression of more traditional psychodynamic therapy is very much allowing the client to freely associate and bring up what comes into their head in the moment. Can you talk about this? And what does “directive” look like in ISTDP?

A common misperception about ISTDP is that this therapy is a directive or confrontational approach. In reality, ISTDP tries to help patients become aware of what they want and desire, so that their desire directs the therapy, and their defenses do not misdirect it away from the patient’s goals. In this active approach, both the therapist and client are fully engaged in helping the client solve their presenting difficulties and reach their goals. Both the therapist and the client have respective tasks to help the client attain their goals. The engine of this therapy is the patient’s will and innate healing force for their own health and well-being. This therapy facilitates an environment where the native force for health within the patient can naturally emerge. An active therapist and a passive client will not generate results. Only when both parties are fully active, are positive results possible.

I tend to be less comfortable being more directive in sessions. Does that mean that ISTDP would not be as appropriate for me as a therapist?

Unfortunately, defenses are usually directing the patient’s life and creating the symptoms and presenting problems. So, as an act of compassion, we help the patient to see and turn against their own defenses, so that the patient’s desires can direct the therapy. The patient’s will must direct the therapy, not the therapist. So the therapist is following the specific unconscious signals of the patient, so that the patient can direct him/herself.

Or, is that something that one learns to become better at as you learn ISTDP?

There are many different skills and competencies in ISTDP that therapists learn over time. ISTDP offers a variety of workshops, supervision, immersions and longer training programs that help therapists build new skills to be more effective with their clients.

What do you love most about working in this way with clients?

I love being active with clients, learning about how our brains function, and acquiring a set of concrete skills that make me more effective as a clinician. I especially love not only helping patients reduce their symptoms; this is the only therapy that I am aware of that creates genuine character change.

Who influenced you to learn ISTDP?

I was first introduced to ISTDP by attending a seminar in 2006 on Attachment Theory with Mary Main and Eric Hess. One of the co-presenters was Robert Neborsky, M.D., president of the California Society for ISTDP. He delivered a fascinating lecture and presented a video of a patient he had seen over time, which showed true character change. What I saw unfolding on the videotape simply took my breath away. I knew I wanted to find out more about this approach. After attending a few other workshops on ISTDP, in 2008, I enrolled in a 3-year core-training program with Robert Neborsky, M.D. and Josette Ten Have De Labije, PsyD.

In 2010, during my 3rd year of core training, I attended a workshop with Jon Frederickson, MSW, founder of the ISTDP institute. The concepts that Frederickson presented were so clear and compelling, I knew immediately that I wanted to learn more from him. So, I reached out to Frederickson for individual case consultation, which has now spanned over 10 years! I have continued to take many advanced trainings with Jon Frederickson and with other well-known ISTDP teachers including Allan Abbass, M.D., Patricia Coughlin, PhD and John Rathauser, PhD.

You actually teach and mentor other therapists in learning ISTDP, is that right?

Yes, and I absolutely love that part of my work! I attended a 3-year teacher/supervisor training in ISTDP from 2011 – 2014 with Patricia Coughlin, PhD. I am currently pursuing an additional 3-year training program as an ISTDP trainer and supervisor with Jon Frederickson. Frederickson and I are currently co-facilitating a 3-year core-training program for trainees in Alberta, Canada. The group has now entered its 3rd year. I am very fortunate to mentor and supervise licensed marriage and family therapists, social workers, psychologists and psychiatrists learning ISTDP from all over the U.S. and in Canada.

Can you talk more about your work teaching and mentoring others?

What is central in teaching and supervising is to meet each therapist exactly where they are in their personal and professional development, and to amplify their innate wish to learn and become their best self. It’s important to cultivate the strengths of each therapist as well as help them understand and compassionately learn from mistakes. A key principle in ISTDP therapy is that we are always guided by response to intervention. And doing therapy, of course, is not like balancing a ledger. The entire person of the therapist is involved; and the person of the therapist meets the humanity of the client. So it is the crucial combination of integrating specific skills and developing the best qualities of our character that make therapy work successfully. ISTDP teaching and supervision builds on both.

What are the biggest struggles you see your students having with this way of working?

A couple of things come to mind. One common difficulty is not trusting the native healing force within each client. When we don’t trust our client’s innate capacity for health, we end up doing more under the erroneous assumption that we can heal the client. A typical way this plays out in therapy, is that a passive client can make an active therapist work harder. When this occurs, the natural healing force, which we call in ISTDP the unconscious therapeutic alliance (UTA), will not arise in the client. So, doing less is often more and yields better results.

Some therapists early in training may hesitate showing their work because the supervisor will see their mistakes. ISTDP is, in part, learned through working from the student’s videotape of their work with patients. The videotape is valuable because it points to the specific areas where the therapist may need additional support from the supervisor. Mistakes are viewed as a normal and even essential part of the learning process, and the therapist/trainee slowly begins to grow their own self-compassion muscle by learning and benefiting from their mistakes.

Anything else you’d like to share that I didn’t specifically ask?

Even learning some of the basic skills in ISTDP will help improve therapists’ treatment outcomes.

Diane maintains a private practice in Northern CA and has taught yoga at yoga studios in the Bay Area and at corporations. Diane has also taught workshops on ISTDP at Stanford University Vaden Counseling Center, at Stanford University Law School, and for the Northern California Professional Association of ISTDP.  Her website is www.byster.com.

Rowena Dodson is on the SCV-CAMFT News committee, and has been a licensed therapist since 2016. She has a private practice in Mountain View, and works as a per diem therapist at El Camino Hospital adult outpatient behavioral programs. Her emphasis has been on helping adult clients find their voice and their power to shape the lives they want. She can be reached at director-at-large@scv-camft.org.

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Written Interview with Shirani M. Pathak, LCSW

Shirani M. Pathak, LCSW, has been a licensed therapist since 2012. She identifies as a psychotherapist and spiritual healer. Shirani founded the Center for Soulful Relationships where she offers psychotherapy and coaching services, and specializes in couples. 

Questions submitted by Rowena Dodson, LMFT, Director-at-Large

Rowena: Tell us about your Center for Soulful Relationships. How did you come up with this name, especially the soulful part? How does this soulful express itself in your work with couples?

Shirani: My specialty is relationship therapy, and at the Center for Soulful Relationships, I work with individuals and couples offering counseling intensives and retreats. Of course, right now due to COVID, all of my services are held virtually, and it’s amazing to me how powerful this work is—even in the virtual format. 

As for how I came up with the name, a large part of what I experienced growing up and also being an adult, was to disown the parts of myself that were connected with intuitive wisdom. I come from a lineage of women intuitives and healers, but, due to colonization and the effects of colonization, I had been taught to fear these intuitive parts of myself. Part of my own personal liberation and reclamation work has been to take ownership of my intuitive abilities (which I believe we all have access to). 

Prior to doing my reclamation work, my practice was called the Relationship Center of Silicon Valley. There came a point in my own healing when I knew my work was meant to have a broader reach than just Silicon Valley, and one day my practice’s new name, The Center for Soulful Relationships, literally dropped into my awareness and it felt so right. 

As a matter of fact, only recently did I learn one of the origins of the word soulful is expressing deep feelings and emotions. And, the work I facilitate in my counseling intensives is definitely deep and feeling-ful! Not only that, by helping clients access their deep feelings in relationship with one another, and by both witnessing and being witnessed in this profoundly intimate personal work, they are actually able to create lasting change within themselves and their relationship. It truly is magical to watch. 

R: When working with couples, what treatment approach do you use and what does that look like in your work? 

S: Though I am trained in many different modalities, my favorite modality for working with couples is Relational Life Therapy (RLT), developed by Terry Real. My style is quite active and directive so when I learned about Terry and his work, it felt like the perfect match! I am an advanced RLT practitioner and my favorite parts of the work are doing family of origin work. 

A large part of my 2-day couples intensives is focused on family of origin and the relational wounds clients have been carrying (and repeating) for most of their lives. Holding space and facilitating the healing of years of relational pain, in the presence of their partner, is one of the most amazing experiences. Light bulbs start to turn on, partners start to realize the pain their partner has been carrying, and when they do their own part of the work, they realize how they have been contributing to perpetuating the pain. 

When we love one another, we don’t want to hurt one another, and when couples realize WHY they engage in the behaviors they do and how it hurts their partner and repeats the pain they’ve carried their whole lives, they want to change. People want to do better. We can’t actually do better until we understand why it is that we do what we do. 

R: What kinds of issues are you seeing couples struggling with right now in this time of COVID and the wave of protests for racial justice in the US?

S: Most of my couples have the privilege of being able to work from home and have done the work of understanding themselves and their partners, which actually makes them much better equipped for handling the current COVID situation. While most other couples are nit-picking and nagging at each other, my couples have developed the tools and understanding they need to see this time through. 

As for the protests for racial justice and how it has been impacting my couples, that’s been a mixed bag. For some, this is nothing new. They’ve been living with it their whole lives, they just want to learn how to live in Black or Brown joy while letting the people who created this mess clean it up. For other couples, they’re waking up to the realities of what raising Black and Brown bi-racial kids in America means on a whole new level. 

R: You very specifically reach out to couples of color—to Black, Indigenous, and People of Color (BIPOC) and those partnered with them on your Center for Soulful Relationships website. Can you talk more about this work? Are there issues that might be unique to couples of color and interracial couples that White couples do not face?  

S: "Cultural competence", which we are taught in grad school, is one of the most flawed phrases out there, and very much comes from the lens of supremacy culture. We need to learn about cultural humility. I will never be competent in a culture that is not mine. I need to learn what are the challenges people of different cultures and ethnicities face. What challenges are unique to them because of the color of their skin, or the texture of their hair, or even their name? I need to educate myself on these things and also be open to hearing directly from each client and their experience. I cannot presume that I know another’s experience just because I’ve done some learning on the challenges and issues they face as whatever group of people they belong to. I need to take what I learn and use it to inform my work with each person, not assume that I know their experience. A great book for me was So You Want to Talk About Race, written by Ijeoma Oluo. I highly recommend everyone in the mental health field read it. 

R: Are there differences in how you work with White couples vs. BIPOC couples?

S: The only difference in my work with White couples vs. BIPOC couples is recognizing the lens each of them sees the world though. White people, due to the systems that have been created, live their lives through the lens of supremacy. Black and Brown people, through the lens of colonization and enslavement. I have to keep each of these in mind and consider the lens I’m speaking to and through. Where it gets real fun is working with interracial couples or even multicultural couples, because I need to keep in mind the lens each partner is operating from. 

R: What has been your own personal journey in becoming competent in working with clients who are racially, ethnically, or culturally different from you?

S: Growing up as a Brown immigrant woman, I thought I knew all there was to know about race, racism, and the racial injustices we see every day. I had myself been discriminated against, ridiculed and bullied ever since the time I was in elementary school—even though I went to a school that was filled with predominantly Black and Brown kids. I often wondered why teachers, librarians, and even the playground monitor never stopped the kids who were being mean.  I went through life either trying to hide, or simply fit in. Telling my story today is a privilege and an honor, so thank you Rowena, for inviting me to this interview.

In grad school when I learned about “cultural competence” I again bought into the belief that I now knew what I needed to know about working with people of different cultures. It wasn’t until I read So You Want to Talk About Race that I realized how wrong I was. After reading that book I actually apologized to clients and even friends and colleagues about the micro-aggressions I had inadvertently perpetuated because I thought I was “culturally competent” rather than culturally humble. That was truly humbling and a game changer in my work. I think my work has only gotten richer since then. 

R: Have you had any mentors in this work? What have you found to be most important to you? Do you have a consult group or someone you consult with?

S: For the therapy side of my work, Terry Real’s mentorship program is where I hone in my couples therapy skills. I also pull heavily from mentorship work I’ve personally done with Keri Nola, a retired therapist and mentor for other therapists and healers. For the racial healing and anti-oppression side of my work, I’ve been learning from Milagros Phillips, Robyn Mourning, and Andrea Ranae. 

R: If I might ask, how have your own experiences as a woman of color shaped who you are as a therapist and the work that you do?

S: Connecting with my intuition, doing my own personal liberation work and reclaiming parts of myself, along with actively participating in dismantling the effects of colonization within me and in the way that I work, have taken me to whole new depths (and heights) in my work as a therapist and also as a healer in this world. I get to bring all of me to my client work, and my couples love that I get to be human with them, as opposed to some expert in a hierarchical (and incredibly damaging) relationship with them. 

R: Anything else you’d like to share that I didn’t specifically ask?

S: As mental health professionals you are entrusted with the well-being of those who work with you. Get out of supremacy culture by thinking that you are “culturally competent” and get into cultural humility. Read the book So You Want to Talk About Race. Take advantage of the many trainings that are being offered as a result of the uprising we are in. And actively do your own personal work of dismantling supremacy culture, or the effects of colonization or enslavement within yourself. I have a podcast, called Fierce Authenticity, where I am sharing what I’m learning and I invite you to have a listen, too. 

To learn more about the Center for Soulful Relationships visit www.CenterforSoulfulRelationships.com.  Shirani is also the author of Fierce Authenticity: Show Up. Be Seen. Get Love, self-published, and has a podcast also called Fierce Authenticity.

Rowena Dodson is on the SCV-CAMFT News committee, and has been a licensed therapist since 2016. She has a private practice in Mountain View, and works as a per diem therapist at El Camino Hospital adult outpatient behavioral programs. Her emphasis has been on helping adult clients find their voice and their power to shape the lives they want. She can be reached at director-at-large@scv-camft.org.

References

Oluo, I. (2019). So you want to talk about race. New York, NY: Hachette Book Group.

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by Dariah Brown, AMFT

Dariah Brown, AMFT, graduated from Palo Alto University with her MA in Counseling Psychology in 2017.  She currently works at Gardner Family Health Network in their adult program for mental health. She has about 500 hours left before she can take the BBS exam to become a licensed therapist.  

It was summertime in August and I was a day behind orientation for the upcoming academic school year. After enduring 12 months of heavy didactic coursework in grad school, I had recently returned from a family vacation. I felt prepared to begin my career as a therapist providing mental health support services at a local middle school. Through textbook and self-reflective essays, I had been taught how to be a therapist. Now it was time to apply my newfound knowledge. I powered through the weeklong intensive training, getting to know my colleagues and building on my support system for what was going to be one of the most challenging and rewarding experiences of my life so far. At 21 years of age, I believed I was gifted with the ability to connect with adolescents in secondary education.

My first week at the school, I focused on gathering referrals, getting acclimated to my new office (closet), and preparing a brief introduction of myself and the services I would be providing during back-to-school night for the students’ parents. The speech was to be delivered in an auditorium in front of hundreds of parents and their children. Public speaking had always been a weakness of mine, but I was not going to allow that to impede my ability to stand confidently in front of strangers as an advocate for mental health. My heart was racing but I grabbed the microphone, stood up from my chair and said, “Hi, everyone! My name is Dariah Brown. I am currently in school training to become a mental health therapist. I have received an undergraduate degree from the University of Hawaii at Manoa, and I am looking forward to working with you in this new school year!” Once I sat back down in my chair I realized that my career was just beginning.

The first few months were composed of series of situations related to adjustments, mistakes, compromising, and advocating for myself. Being a 21-year-old therapist, I recognized immediately how young I was in every staff meeting. I had to stand up straighter, smile more often, and stand my ground. Every week, I had a staff meeting with the principal and vice principal. I arrived at each meeting riddled with anxiety. I came prepared, having written out my concerns for each of my clients and their overall well-being. I also entered each meeting ready to stand tall and be a voice for the voiceless. However, I felt that my credibility, knowledge, and overall confidence were tested frequently. I was (again) the youngest in the room by at least 20 years. At every meeting my body was shaking and I was near tears. Much of what I stated felt as if it was not being taken seriously, and I could not help but attribute my experience to my age. I felt as if I were losing my confidence in this career that I had barely begun. 

From then on, every week became a challenge for me. Not just in engaging the practical skills I learned, but from receiving feedback and constructive criticism from professors, supervisors, classmates, and colleagues. Every week was focused on what I had done wrong rather than what I had triumphed over. Feeling insecure, unconfident, and incompetent was prevalent and became a daily battle. Not to mention the phase of life that I was navigating: I was in my early 20s and not even sure who I was as an individual. 

My first year as a mental health practitioner was over, and before I knew it, I had graduated with my Master’s. My life had changed drastically throughout the course of three years—both professionally and personally. My personal life had taken a turn after having made the difficult decision to end a six-month engagement to my partner shortly after graduating. Still conducting sessions and providing services, I found myself mourning, recovering, and heavily processing with my personal therapist where I saw my life to be heading. I could not focus, and in many occasions, I felt numb during sessions with clients. How could I tell them that it is okay to cry and that it is healthy to take a step away to process and check in with ourselves, while I was numb and suppressing every emotion I was feeling? It felt terrifying to find myself having begun grad school with a five to ten year plan and feeling like that had been lost. It felt as though once I graduated grad school, I allowed myself to stop and breathe. Before I knew it, I finally saw myself and realized that I was 24 years old. If I was not, “Dariah, the therapist” who was I? Was that what I wanted to do for the rest of my life? Was I mature enough or responsible enough to hold someone’s pain? To become accountable for their safety?

I was scared. I was plagued with low self-esteem. I thought that there was no way anyone would trust a 24-year-old therapist who could pass for a 13-year-old in high school. Would I? Could I? No, I could not. So, I quit. I got myself a studio apartment, cut and dyed my hair, updated my wardrobe, and was hired to be an admissions counselor. For one year, I reconnected with old friends, traveled for work, networked, and made lasting memories. My job was all about contact work and presenting in front of an audience. And in that role as an admissions counselor, my supervisor became my mentor. She was a therapist who had decided to course correct and work in academia. She taught me confidence, her words forever guiding me wherever I felt challenged. I found my voice. I found my strength. I realized that I genuinely love and care about the well-being of others. And as a result, I found myself applying for therapist positions to continue gaining hours towards licensure. Being a therapist and an advocate for interpersonal wellness is the path that makes me happy. I chose this role because I have always been taught to provide help, give love, and never expect anything in return. And despite my age and how young I look, I will forever make the conscious decision to help others in need. To walk with them through their suffering and hold their pain. This is my passion and always has been. I just needed to look within myself to find it. 

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by LaDonna Silva, LMFT

LaDonna Silva, LMFT, is a licensed psychotherapist in the South Bay area working in private practice with individuals, couples, and families. Her specialties include working with trauma, grief, relationships, and the LGBTQ community.

The Process Therapy Institute (PTI) has experienced a tremendous loss in our community and I have felt inspired to share with the greater therapist network how this has unfolded and what is now happening with the PTI community.

Change...

The Process Therapy Institute, a non-profit founded by Don and Carol Hadlock, has been around since 1982. They have trained over a thousand therapists, initially learning with a rotary telephone call interrupting a therapy session with guidance and suggestions. The training eventually transitioned to an earbud and a one-way mirror. The primary focus of the training was lovingly coached into the ear of the interning therapist on how to stay present and settled in self while experientially working with live clients. I have always believed the Process Model is two-fold: The Art of Being and The Art of Doing. Don and Carol developed this model over the years; both were active in the community and SCV-CAMFT board members many years ago.

I joined the community in 2003 when I met Don at JFK University.  He ran group process for JFK for many years. I returned to the community to become a PTI board member and watched Don and Carol Hadlock slowly transition away from the primary caretakers of the institute and active leaders of the model. When Carol stopped managing the books, it became more difficult to oversee the stability of PTI. The Board eventually convinced them to hire a bookkeeper, so we could get a clearer picture of the inner workings and financial status. Don resisted this idea for quite some time and then realized how helpful it would be to let go of these responsibilities. The Board of Directors also decided to put Don Arnoldy into the Executive Director role. Don Arnoldy had been a board member since 1990 and his wife Nancy Ryan was one of Don’s first students in 1982. We were preparing for the inevitable.  

Change...

We debated very difficult decisions, including whether or not we would let PTI close when the lease was ending in Campbell. We discussed Don’s level of commitment: in his heart he was 100% committed, but he had a full time job now taking care of Carol who was progressively showing signs of Alzheimer's. It was certainly weighing on his heart as to how to manage it all.  Don Arnoldy stepping in was truly a gift to PTI and I know it made Don’s heart very happy that someone was willing to help run the institute.  

Change...

So, I am writing this article six months after his death. My life and the PTI community have  changed dramatically. Where is my friend, mentor and dear colleague?  I miss our lively conversations over breakfast or lunch about a variety of topics: the process theory and model, transpersonal inquiries, and the inner workings of our own lives. Since his death, my heart and the heart of so many in the community are tender and grieving this tremendous loss. Every time I question where he is, the universe seems to offer ways to feel him, hear him, and connect with him. Every now and then I giggle because I still hear him in my ear offering guidance. That guidance has been instrumental teaching therapists how to be present, connected to self, and trusting in a client’s innate ability to heal. As I explore another model of therapy, I truly miss having the ability to dive deeply into conversations with Don, dissecting the teachings and being curious together. Ironically, the deeper I dive into the Internal Family System (IFS) model, the more often I find language similar to Don’s teachings of the essence of being with self. I love that many in our PTI community are out in the world integrating the process model into their practices. This is the beauty of PTI continuing out in the community, and that Don and Carol’s legacy continues.

Change...

I recently hosted a Zoom memorial that was well attended with over 75 therapists in the greater community. Several therapists chose to share the impact he had on their lives and on their therapy practices. Many shared how he had been a healthy father figure in their lives and many had this universal belief that they were special to Don. This, I truly believe was true. He loved and appreciated many therapists within the PTI community and that community has continued to grow. Service is part of the heart of PTI and not only do therapists in training need our invitation to learn more deeply about themselves, but the greater community also is in need of a tremendous amount of support and love right now. 

My hope is that you will continue sending clients that you are not able to see in your own practices to PTI, and that you will consider investing some of your own time for self-care… especially right now in these times. May your own hearts be touched by mentors, teachers, and leaders in the community. I believe Don knew how much he was loved by the extended PTI world, and his death is a beautiful reminder to continue telling those we love how much they mean to us.  

Change is inevitable...

With love and light...

LaDonna runs consultation groups, has taught at several local universities, and loves teaching and presenting. She studied at the Process Therapy Institute (PTI) for many years and is currently training in the Internal Family Systems (IFS) model. She is passionate about the healing process and supporting others in finding their internal freedom.  She can be reached at www.ladonnasilva.com.

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 by Alex Basche, LMFT

The human spirit must prevail over technology. --Albert Einstein

Welcome to the Machine
Technology has become, for better and for worse, an integral part of our lives that often is taken for granted. Consider the smartphone, for example. This pocket-sized device contains a million times more computing power than the Apollo 11 supercomputer. Indeed, it is seemingly impossible to imagine a world without smartphones, let alone the internet, computers or social media. With 79% of Americans actively using at least one social media platform, we are more connected with one another than in the history of humanity.

There are now multiple generations who have been born into this futuristic era. These digital natives have a seemingly innate ability to navigate a dizzying array of apps, gadgets, programs and other tech that many of us find perplexing (to say the least). 

In his Spiderman comics, Stan Lee (1962) once wrote ''With great power comes great responsibility." The modern adolescent is expected to balance after-school activities with homework, socialization, family time, and self-care; in addition to managing the overwhelming responsibility of their personal technology use. It is truly no wonder that:

• 1 in 3 adolescents will meet criteria for an anxiety disorder by age 18, 
  
• 1 in 4 adolescents will have vaped nicotine within the past month by 12th grade,
  
• The rate of adolescents meeting criteria for Major Depressive Disorder increased by 52% between 2005 and 2017 (Coyne et al., 2020).  

COVID-19’s resulting shelter in place ordinances have essentially created a perfect storm for technology abuse and addiction. With teens forced to stay home and spend their school day online, a diligent student may spend 5 to 8 hours per day in front of a screen for their studies alone. Including their fun screen time from gaming, social media, YouTube and TV streaming shows (Antos, 2020), they might spend a staggering 7 to 15 hours per day. This sedentary lifestyle, combined with a lack of in-person socialization, is indeed a disturbing pattern.

A process or behavioral addiction to technology often is considered within the context of digital gaming (as opposed to board or card games). As treatment providers, we can extrapolate many aspects of assessment and treatment to other related technology addictions, such as social media. For the purpose of simplicity, however, the remainder of this article will focus on gaming.

The longest study ever completed on adolescents and gaming addiction, published in May of this year, had foreboding results. Tracking 385 teens over 6 years, researchers found that 10% would develop technology addiction by the time they entered adulthood (Coyne et al., 2020).  
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The single largest predictor of addiction? Levels of prosocial behavior, or behavior that benefits another person or people. Community service, helping a friend study, following household rules and supporting a peer going through a difficult time are all examples of such behavior. Greater amounts of prosocial behavior are protective against a gaming addiction.

Thus, it has never been more important for therapists to have sufficient knowledge and awareness of how such technology use impacts our clients and what might mitigate the high use of technology. Truly, we must prepare ourselves for the developmental and socio-emotional impacts that will result from the new normal tech diet consumed during shelter in place.

Diagnosis and Assessment
When considering the concept of technology addiction, it is important to remember that the DSM 5 has yet to establish a definition. Indeed, all we have at this point is Internet Gaming Disorder (IGD) and its delineation as an area of further study. Frustratingly, the name alone demonstrates a gross misunderstanding of different mechanisms of use (e.g. social media, single player gaming and general internet use).  As Cerniglia et al. (2019) explain, IGD is defined by:

1. Preoccupation with gaming, 
2. Withdrawal symptoms when gaming is taken away or not possible (sadness, anxiety, irritability), 
3. Tolerance, the need to spend more time gaming to satisfy the urge.  Inability to reduce playing, unsuccessful attempts to quit gaming, 
4. Giving up other activities, loss of interest in previously enjoyed activities due to gaming, 
5. Continuing to game despite problems, 
6. Deceiving family members or others about the amount of time spent on gaming,
7. The use of gaming to relieve negative moods, such as guilt or hopelessness,
8. Risk, having jeopardized or lost a job or relationship due to gaming.

The International Classification of Diseases (ICD-11) recognizes Gaming Disorder as a pattern of gaming behavior (digital-gaming or video-gaming) characterized by: 

1. Impaired control over gaming, 
2. Increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities,
3. Continuation or escalation of gaming despite the occurrence of negative consequences, 
4. The behavior pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months.

Addiction itself is much like an iceberg protruding from the ocean. We can see only a small portion of it outside the water, yet underneath is a gargantuan, jagged, frozen mass. From low prosocial behavior and frustration tolerance to tantrum behaviors, these tech-addicted teens may sadly have parts of their development frozen as well. In their review of 24 recent studies on teens with IGD, Choi et al. (2019) found that:

• 92% met criteria for some form of an anxiety disorder,
• 89% met criteria for some form of a depressive disorder,
• 85% met criteria for some form of an ADHD,
• 75% met criteria for some form of an OCD.

In assessing for pathological technology use, therapists have a number of free and thoroughly-validated tools at their disposal (Young, K.S., 2013; Young, K.S., 2007):

1.The Problematic Online Gaming Questionnaire (POGQ) is an excellent tool that measures the six factors of gaming addiction:

a. Preoccupation,
b. Overuse,
c. Immersion,
d. Social isolation,
e. Interpersonal conflicts,
f. Withdrawal.

2.The Internet Addiction Test-Revised is one of the oldest and most validated assessment tools for problematic internet use, including social media. Its revised version adds craving and updates the language to reflect current technological changes.

3.Similar to the classic CAGE assessment for alcoholism, the Bergen Social Media Addiction Scale (BSMAS) is not meant as a standalone diagnostic tool but rather a supplemental one:

a. You spend a lot of time thinking about social media or planning how to use it,
b. You feel an urge to use social media more and more,
c. You use social media in order to forget about personal problems,
d. You have tried to cut down on the use of social media without success,
e. You become restless or troubled if you are prohibited from using social media,
f. You use social media so much that it has had a negative impact on your job/studies.

It is not difficult to imagine why so many children and teens are developing pathological technology use.  The outside world has not exactly been a safe place. In 2018 it was literally engulfed in flames and is now being ravaged by a pandemic. As a teen, hours upon hours of gaming can serve to bolster a sense of autonomy (control through achievement), social connection/belonging, and an overall immersive escape. Understanding your client’s core motivation(s) for their use can give you a clearer idea of replacement behaviors, a key aspect of treatment. 

As therapists, it is our duty to not only diagnose and treat technology addictions, but to empower parents, caregivers and natural supports through psychoeducation as well. Below are a number of wonderful resources to aid you in taking these small steps as individual providers. In doing so, perhaps the current generation of teenagers will one day be able to take a giant leap for us all. 

Alex uses a strength-based approach to foster genuine self-acceptance and meaning-making. His philosophy centers around strengthening and harnessing connections between the body, emotions, thoughts, and behaviors to create healing and growth. Alex believes in treating the whole person, from improving self-care to school/career counseling to resourcing. While working for Two Chairs as a clinician, he leads a variety of workshops and training related to Technology Addiction, Anxiety, Behavior Modification and group curriculum development. Alex has helped create and lead programs treating technology addiction in teens across the Bay Area. He can be reached at www.ResetfromTech.com

Resources

Websites:

RESTART in Seattle: The Top Treatment Program in the U.S. - www.netaddictionrecovery.com

Self-Help & Support Groups for Teens and Adults -  www.gamequitters.com

Online & In-Person Anonymous-Style Groups - www.olganon.org

Family Media Plan- The Cornerstone of Effective Intervention in the Home - www.healthychildren.org/English/media/Pages/default.aspx

Children’s Screentime Action Network: A coalition of clinicians, educators and advocates offering myriad worksheets, handouts and news in relation to the balanced use of technology in minors. https://screentimenetwork.org/

Books:

Cash, H., & McDaniel, K. (2008). Video games & your kids: How parents stay in control (K. Lucas, Ed.). Grand Rapids, MI: Issues Press.

Young, K. S., & Nabuco de Nabreu, C. (Eds). (2010). Internet addiction: A handbook and guide to evaluation and treatment. Hoboken, NJ: John Wiley & Sons.

References:

Antos, M. (2020, April 15). New Data from Circle Shows Parents Depend on Screen Time Management Tools More Than Ever During Shelter-in-Place. Globenewswire. Retrieved from: https://www.globenewswire.com/

Cerniglia, L., Griffiths, M. D., Cimino, S., De Palo, V., Monacis, L., Sinatra, M., & Tambelli, R. (2019). A latent profile approach for the study of internet gaming disorder, social media addiction, and psychopathology in a normative sample of adolescents. Psychology Research and Behavior Management, 12, 651–659. doi:10.2147/PRBM.S211873

Choi, B. Y., Huh, S., Kim, D. J., Suh, S. W., Lee, S. K., & Potenza, M. N. (2019). Transitions in problematic internet use: A one-year longitudinal study of boys. Psychiatry Investigation, 16(6), 433–442. doi:10.30773/pi.2019.04.02.1

Coyne, S.M., Stockdale, L.A., Warburton, W., Gentile, D.A., Yang, C., & Merrill, B. (2020). Pathological video game symptoms from adolescence to emerging adulthood: A 6-year longitudinal study of trajectories, predictors, and outcomes. Developmental Psychology, doi: 10.1037/dev0000939

Young, K.S. (2007). Cognitive behavior therapy with internet addicts: Treatment outcomes and implications. CyberPsychology & Behavior. 10(5), 671–679. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/

Young, K.S. (2013). Treatment outcomes using CBT-IA with internet-addicted patients. Journal of Behavioral Addictions. 2(4), 209–215. doi:10.1556/JBA.2.2013.4.3