Articles

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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

by Rowena Dodson, LMFT

Becoming licensed as an MFT in California, and especially in the Bay Area, was already burdensome under pre-COVID circumstances. There are not many options for paid internships in the Bay Area, which means years of working either multiple jobs (i.e. one’s unpaid internship as well as a paid job), or being lucky to have someone else earning the living. Some associates go into debt to complete the process. Other frustrations have been the sheer number of 3000 hours; the byzantine rules for the correct number and type of hours required to meet the 3000 hour hurdle; and especially brutal has been the waiting time after submission of hours to the BBS (most recently it has been about 5.5 months, and as long as 9 months several years ago). This adds 6-8 months onto an already years long process before MFTs start to make a living wage. We must also recognize how many people this process keeps out of our field, reducing much needed diversity in our therapist pool. 

Now with COVID and shelter-in-place (SIP) restrictions in the state, an already strained system for licensing MFTs in California is buckling. This is impacting associates and their ability to do this vital work with often the most vulnerable and challenged clients. For this article, I talked to seven associates and one newly-licensed MFT in the Bay Area about their experiences (see gallery of therapists who participated): how are they coping, what are their challenges, where are they finding support? I spoke with these clinicians during the first two weeks of April.  Some things they reported then may have changed by the time you are reading this article. Three of the participants ultimately chose not to be named for the article as they were concerned about having their stories out in the public sphere.

In order to understand fully their challenges now, it is important to keep in mind the backdrop to this current moment: 1) the unpaid or reduced fee work for years, 2) the most fragile and needy clients, 3) the painfully slow process of navigating the BBS process to licensure, and 4) the lack of official acknowledgement for the vital role associates play in providing mental health care to Californians.

There were many overlapping themes from the therapists’ accounts of what was happening before and during SIP. These themes included financial impacts, issues with doing remote therapy, and frustrations with the BBS. They also discussed how these frightening times are affecting them even while they support their clients, and where they are finding support.  

FINANCIAL IMPACTS:
As discussed above, becoming a licensed MFT entails significant financial sacrifices.  Several therapists mentioned the financial strain on their families throughout their education and internships. Compounding this now are SIP restrictions, causing postponed exams and difficulty getting the administrative work done to submit hours for approval. Delay in licensure finalization means delay in starting to earn a viable living. Additional financial impacts are rental for an office that cannot be used immediately and the inability to start a private practice because of SIP.

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Because her licensing exam was postponed, Jyoti continues to be paid at associate-level wages, which are barely half of what she will earn when licensed (for doing the same work that she is already doing now). She has a May 1 exam date scheduled that she hopes will still go forward. Similarly, Connie has been earning associate-level pay for her private clients and earns no fee for her agency clients currently. She was looking forward to converting her agency clients into fully paying clients in her new private practice, now postponed. 

Connie and Susan had already rented an office for their practice, having anticipated that Connie would be licensed imminently. They are now bearing that expense without the income they anticipated. Sharon, newly licensed, was ready to find space for her private practice and to take on new clients, but has been prevented from proceeding because of the shut down. Moreover, “starting new clients with telehealth is not what I had imagined.” So for now, she is still not earning money. Although considering pro bono work supporting health care workers, that is more work for which she will not be paid. Looking to the future, Natalie agreed that “building rapport is more challenging when one starts off with telehealth.” She is also concerned that financial difficulties may prevent clients from seeking help as this crisis goes on, which will make it harder to build a practice once licensed. “Everyone is sort of in survival mode.”

For Dariah and Monica, the current crisis with its financial implications for non-profit agencies is very concerning. They each mentioned their worries about the stability of their own jobs in this financial collapse, even while acknowledging that their agencies are doing everything they can to keep their therapists. Monica has also been delayed by SIP in getting her final signatures on her hours from supervisors who are now not at the office, as well as getting an official letter that she needs from her agency showing their change of agency name.

TELEHEALTH—CHALLENGES/POSITIVES:
Therapists I interviewed explored the practical issues and challenges of not being able to meet in person with clients. Of course, licensed therapists are also experiencing these issues. The transition from office to home in normal circumstances gives therapists some space to switch roles, process and then let go of the work from the day. Not only is that commute transition gone for now, but telehealth necessitates switching roles quickly within the household. Additionally, with remote therapy, we lose information that we normally perceive in person from body language, facial expressions and a certain energy that we feel in a room together; we may feel less connected to each other, and building rapport is harder. There is also the difficulty for clients and therapists to carve out privacy at home for a therapy session. Therapists may encounter technical difficulties with the online platforms and the loss of clients who are not willing to do remote therapy. Also of note is the increased therapist disclosure of having the client see into one’s private home when on a teletherapy session.

Natalie has found that some of her middleschoolers prefer the phone over video. She thinks video may make them feel too exposed. Similarly, Susan reports that some depressed teens with whom she is working struggle with motivation and connection in video therapy. And some of her older clients prefer phone over video. Monica, on the other hand, finds video telehealth surprisingly positive in her work with teens who are depressed and anxious. She thinks for teenagers, video telehealth might be an even better way to do therapy. “They are comfortable in their screens.” 

Connie, Jyoti and Natalie, who each mentioned having kids at home, are finding it challenging to have privacy and quiet to do their sessions. Connie finds that the only remedy is to hold her sessions from her car. Jyoti has two typical teenagers at home and really misses the structure and quiet of going to work at her office. Natalie said initially her two young kids were knocking at her door during sessions, “but they have adjusted and now ask me when mommy will be done today.”  

Connie also finds it difficult working from home with “the constant switching of roles without any transition between them, mother/launderer/teacher/therapist, so few boundaries or transition points between these roles.” In the same vein, several therapists mentioned the difficulty of being there for their clients from home—while they are also experiencing their own stresses from this whole Coronavirus reality. “It is difficult to be totally present for the client and then just go back to my regular life,” says Connie. 

Dariah is really missing being able to see clients’ body language and believes that clients feel less connection with the clinician over the phone or on video.  Her clients’ lives are chaotic and they are more likely to miss their virtual appointments than they would be for a scheduled in-session appointment. Despite these misgivings, she does take comfort that even just checking in with them by phone briefly is a source of support for them.

Natalie mentioned having technical issues at times with the two online platforms she is using for teletherapy. Regarding her at-home therapy space, she has tried to make her work space “very neutral, I’ve taken down personal pictures in the space,” in order to maintain some boundaries with clients. 

FRUSTRATION WITH THE BBS (and some kudos):
There is appreciation for the BBS having made a few rules changes that have positively impacted associates (i.e. loosening some telehealth rules). Other desired changes have not been made—for example, associates cannot work pro bono with first responders and health care workers because of supervision requirements that have not been waived. Rules about the necessity of in-person supervision for associates have now been changed to allow video-conferenced supervision for most practice settings (but initially excluded associates in private practice). On May 6 this was also extended to associates in private practice. Additionally, closed testing centers during SIP has been a hardship on associates who had already had exam dates scheduled or were about to schedule their exam.  As of May 1, some testing centers have reopened. 

 Jyoti and Connie are both disappointed that they are not able to do pro bono work—Jyoti with first responders and Connie more generally with people struggling with grief and loss in this time. “It feels like there is such a huge need,” says Connie. No changes have yet made way for those associates who are almost licensed to start working with those in need before they are fully licensed.

Lissa has been fairly pleased with the information updates the BBS is providing on its website and on its Facebook page. She said the BBS has requested that it not be contacted during this period, but it has been good about regularly publishing where they are in processing hours that associates have submitted. The Department of Consumer Affairs (DCA) has been a good source of information about BBS updates.

In terms of frustration with the BBS, Connie’s BBS story is particularly harrowing.  Having submitted her hours in June 2019, they were approved in late November.  Because of a health condition, she had applied for and been granted accommodations for the the Law and Ethics exam.  That approval was supposed to continue through for the licensure exam.  However, the exam vendor changed and BBS required applicants to reapply for accommodations, which were finally approved in February.  She was able to schedule her exam for March 18 and “was super prepared.”  On March 17, the exam was cancelled and testing centers closed.  Without the earlier delays, she would have already taken the exam prior to shut down.

Susan is surprised that that the BBS has not made online exams available, noting that California is ahead of the technology curve in other ways to streamline the licensing process. For her own hours, submitted in early April, she is hopeful that the BBS is continuing to process hours submissions during this time of shutdown.

EMOTIONAL IMPACT:
Emotional impacts range from frustration and worry at cancelled exams, how slowly the BBS moves, and concerns about when exam centers will reopen; to feelings of sadness at not being able to support first responders and health care workers. There is also resentment at a system which exploits associates. Of course all of these therapists have been impacted by the pandemic, just as we all have, and have fears for their own families and jobs. And they are supporting their clients who are going through this same experience. Trying to study for upcoming exams during this time is also difficult because of anxiety. 

Susan is “frustrated that we are free labor until we get licensed.” She said the public mental health system in California is built on associates working for free or minimal wages. The BBS essentially has little incentive to quickly process applications for licensure, given that associates are staffing mental health agencies and keeping the system afloat while they wait. She is also very concerned how this financial piece affects diversity in our field.  

Several therapists mentioned feeling that the BBS does not acknowledge or recognize the sacrifices that associates are making and the challenges of working with the most vulnerable clients for little or no pay. Connie noted she “would like it if the BBS could acknowledge what all associates are doing for free in very challenging circumstances. This would really help.” On the other hand, Dariah said with awe in her voice that “only in this moment has she seen therapists and social workers being recognized as ‘essential health care workers.’ That feels really powerful.”

Monica said that her concentration has been impaired because of anxiety. She had been studying for her exam, “but now this whole situation has disrupted my concentration and ability to absorb information.” She may need to delay the exam because of that. 

Dariah is grateful that she has a job, that she is an “essential employee”  and can work. But she is worried about how this is impacting her family members and that her mom might lose her job. 

Natalie discussed how this is a mutual experience, that we as therapists are going through the very same stressors that many of our clients are bringing into sessions. “In most cases it is easier to have boundaries.  And this experience makes it much harder….  We are being called upon to support them with all this uncertainty. It is very strange.”  

FINDING SUPPORT:
All the associates who are still under supervision mentioned their supervisor as a major source of support in this time. Others are participating in group supervision still, or have their own loose group of fellow practitioners with whom they consult. They are finding fellow work colleagues and other therapists incredibly validating and helpful in weathering this. People also cited personal therapy as a source of support in getting through, as well as exercise and friends.  

Connie emphasized that “supervision has been super helpful and . . . a really good place to process some of what’s happening.” Monica is using the pre-licensed group from SCV-CAMFT as a good source of support, in addition to work colleagues and her supervisors.

Natalie said “CHAC has been really awesome about this.” In individual and group supervision: “A lot of the discussion has shifted from clients to supporting the clinicians in this process. They did that transition pretty early so that has been very validating, to hear others’ experience in groups.” Natalie observed that the mental health field seems to be handling issues around work/life balance and stress during SIP better than, for example, the technology sector where her husband is employed.  She appreciates this.

Lissa still attends CHAC trainings online, and finds her colleagues and supervisor at CHAC very helpful. 

CONCLUSION:
The current pandemic has exposed in dramatic relief the many cracks in our system of licensing MFTs in California as well as providing mental health care to people in need. It has exacerbated inherent problems in this system, as in many other systems (i.e. health care generally, education). Nevertheless, our interviews demonstrate the incredible resourcefulness, resilience and generosity of people in this field, seeking to provide mental health treatment to Californians. Associates deserve much more support and expeditious processing to licensure, that is clear. They also deserve acknowledgment of their tremendous contributions to the mental wellbeing of California citizens. Perhaps this pandemic will be an alarm signal that the system to license MFTs needs an overhaul. Associates should be paid fairly for the crucial mental health care they provide to our state. This would enable a much broader diversity of people into this field and ultimately provide better care for us all.  

Many thanks to the individuals who took time and shared openly with me. Just a brief update on some of our participants at the time of finalizing this article in mid-May. Jyoti successfully passed her exam on May 1 and wants to express that the Pearson testing center handled everything beautifully and safely (she was one of the first candidates on the first date that testing centers reopened). Natalie has since completed her hours and has submitted them to the BBS and finished her work at CHAC. She continues in private practice. Sharon has moved forward with starting her private practice from home using telehealth. Connie now has a rescheduled exam date of July 1. She notes that the BBS has become more responsive and interactive with associates on its Facebook page in the last few weeks, including conducting a live session. Lissa has not yet heard from the BBS concerning approval of her hours.  

PARTICIPANTS

Lissa Dutton, AMFT, most recently worked at Community Health Awareness Council (CHAC) doing school-based work and working with in-house clients. She submitted her 3000 hours to the BBS in December and hopes to hear soon that she can take the exam.  

Sharon Greenstein, LMFT, had submitted her hours in July 2019 and was approved to take the exam in early December. She took the exam in February and was licensed in late March. She had taken time off from her last position at CHAC to study and take care of her family. She would like to open her own private practice now.

Jyoti Nadhani, AMFT (and a SCV-CAMFT board member) is scheduled to take her exam May 1. She is concerned the date may be delayed given shelter-in-place restrictions. Jyoti works in private practice. 

Monica (not her real name), AMFT, works for an area agency in an Intensive Outpatient Program for youth. She completed her 3000 hours in March (she is still collecting hours for her LPCC). She has not yet submitted her MFT hours to the BBS and has found it more difficult to get final signatures and other administrative details done during this time when her supervisors are sheltering at home.  

Connie (not her real name), AMFT, has been working at an agency and also in private practice since she submitted her hours in June 2019. It took 5.5 months to get them approved by the BBS. She needed accommodations to take the exam given a health issue, so her approval process took longer than normal. She was finally scheduled to take the exam March 18 and then the day before the testing center closed. She is now in limbo not knowing when she can expect to take the exam.

Susan (not her real name), AMFT, finished her hours at the end of February but found it difficult during March to get her hours signed off from her supervisors, again because the supervisors were then sheltering in place  She did submit her hours to the BBS on April 1. She most recently worked at CHAC.

Dariah Brown, AMFT, is still earning hours at her job at Gardner Family Health Network. She has about 800 hours to go before reaching her 3000 hours.  

Natalie Shahar, AMFT, works for CHAC doing school-based counseling at a middle school. She also works in private practice. She has about 30 hours to go to have her 3000 hours.

Resources:

https://www.facebook.com/BehavioralSciencesBoardCA/ - there was a live session which was recorded recently on BBS facebook. There is a lot of information in this session.

https://www.bbs.ca.gov/pdf/updated_coronavirus_statement.pdf 

https://www.camft.org/Resources/Legal-Articles/Legal-Department-Staff-Articles/Telehealth-FAQS-for-Therapists-During-COVID-19 - 

https://www.bbs.ca.gov/pdf/bbs_wavier_faqs.pdf - associates whose registrations expire between March 31, 2020 and June 30, 2020 do not need to attempt the California Law and Ethics Examination in order to renew their registration.

by Kent Campbell, LMFT

“ALL INDIVIDUALS LIVING IN THE COUNTY [ARE] TO SHELTER AT THEIR PLACE OF RESIDENCE EXCEPT THAT THEY MAY LEAVE TO PROVIDE OR RECEIVE CERTAIN ESSENTIAL SERVICES."  Order of the Health Officer of Santa Clara County, March 16, 2020

In February a creeping tidal wave of news announced that a novel coronavirus was sickening thousands and killing dozens globally. News stories from Asia about limiting travel and increasing fears bubbled up around us. In what seemed an adequate response at the time, my suitemates and I bought hand sanitizer and bleach wipes, and we talked about practicing good cleanliness in the office. By the middle of March, the stock market crashed, citizens were told to shelter in place, and none of my suitemates and I were using our offices at all; everyone had switched to meeting clients through telehealth.  Just like that the global economy, global public health, and our businesses radically changed.  As a result, healthcare in our country may never return to the way we used to work.  

I have been practicing psychotherapy in my suite since 2004. I remember being the first clinician to advocate for internet service to the office, not that many years after discussions about what kind of an ad to run in the Yellow Pages. While the world has changed in many ways, much of our business operates in a tried and true fashion—two minds, two hearts sitting in a room together, talking, thinking and feeling our way through life, and practicing healthy relationship patterns. Theories and approaches shift with changes in the field, but the act of two humans (or more) making time to meet face to face defines how most of us have always done our work. I sit in my chair and my patient sits across on my couch—that’s how this has always worked. For many of us, social distancing and public health requirements drastically changed all that.

As therapists, we hear about the way this disease and its consequences have impacted our clients as well as our individual families and friends. For example, I work with several parents who are balancing varying degrees of home-schooling their children while being asked to work their same full-time tech jobs from home. Some clients are surprisingly thriving amidst the challenges. One man has seen his depressive symptoms fade as increased responsibilities to care for his children gave him reason to be proud of himself for the first time in years. An anxious woman who feared so many things now feels at ease as she cares for her family and enjoys the slower pace of life. Crisis can indeed be a mix of danger and opportunity. Surely many of you reading this article have your own stories of the tribulations and successes everyday life brings our neighbors and clients these days.

While the risk of exposure to COVID 19 is universal, the effects of sheltering in place and getting sick are not. Many in our community are fairly seamlessly able to work from home, maintaining their salaried income. Others were laid off or asked to take a reduction in pay, or see anticipated income slip away as business decreased.  Some of our neighbors lost their ability to work entirely: not everyone can work remotely. Discussions grow about how this illness impacts some communities of color more than Caucasian ones.

CONTINUE READING FROM THE NEWSLETTER...   

This experience also affects clients’ ability to attend sessions and pay for therapy.  Several of my patients reduced the frequency or ceased meeting this last month. One of my clients lost all his income as his small business shuttered; another woman had to apply for unemployment insurance benefits for the first time in her life. Many of our neighbors are without adequate income to pay for rent, let alone pay for counseling services. Reports are that domestic violence reports have increased and anecdotes from other countries suggest increases in divorce might follow pressures of sheltering in place.  

For my practice, this past month I have offered to meet a few patients in person, but nearly everyone has asked to meet over the phone or computer. I currently work with about half of my clients by voice over the phone and about half on video conferencing using my online practice management software.  For long-time clients, I sometimes enjoy using phone calls to do our work.  We do not need eye-contact, we know the cadence of each other’s voices. There is space to think and feel—and even stand or move while talking. Video screens share even more detailed glimpses into family homes, sometimes the living room and sometimes the garage. We can learn more about our patients from observing the parts of their world displayed on the screen as well as how they handle these changes and challenges.  

Being in my office puts my heart and mind into a mindset, a frame of mind ready to be the therapist.  There are times when being at home supports that mindset, and at other times there are distractions that detract from my being present. I have taken to driving to my office to make some voice and video sessions. I spoke with several therapists this week who likewise will go to the office for their work, even though there will not be any clients in the room with them.

The anxiety most of the world is feeling touches our conversations with our patients in several ways.  Our clients have some degree of uncertainty and fear that they  or someone they care about may fall ill. Our therapeutic frame has shifted from four walls to a video call. Surely there is some concern that either the client or the therapist might be ill and not displaying symptoms, potentially threatening the wellbeing of the other if we are in a room together. Therapists have anxiety about future clients beginning treatment online instead of the office, and many clients have reason to be anxious about their income and our local economy, let alone large global trends. Anxiety abounds. Yet, humans find comfort in sharing this experience with one another.  

I started my group practice, Family Matters Counseling Services, two years ago, some 17 years after beginning my work in this same therapy suite on Bascom Avenue. My seven staff members and I strive to provide counseling across the lifespan to children, teens, and adults, as couples, families, and individuals, with an appreciation for psychodynamic thinking. The rapid requirements that citizens avoid social contact led us to decide to meet solely over the phone or computer instead of meeting in person. Some of our clients opted not to meet via telehealth, for various reasons. Referrals began to slow and nearly stop as the news hit and real social distancing began. As the business manager, it is frustrating to not be able to connect patients with my staff of therapists. We are here to help people who are suffering, of which there are many, and yet some of those people are not in a position to reach out to a new therapist at this time.  Several of my colleagues saw their caseloads decreasing. That means less income for all, but for marriage and family therapist associates that also means fewer hours earned for their licensure and at a slower rate than they had planned.  

I reached out to my colleague Stacy Dever Levy, an associate MFT, who works with adults as well as children and teens. I asked her how she handles providing therapy to children during the age of social distancing. Perhaps like most of us, Stacy finds challenges and opportunities utilizing telehealth. She explained, “the transition to working over video and phone has gone smoother than I would have expected. With adult clients, some prefer video and some prefer a phone call. While I strongly prefer meeting in person, I think that after the initial adjustment period, for most of my adult clients, our work has proceeded along as before.”  

Teens of course tend to feel most comfortable using their phones. Stacy says, “with teens, while I miss seeing them in person, it has been beneficial to see them in their own environment, and they seem to be able to make good use of the sessions; they seem comfortable with technology and often seem more relaxed.” She sometimes offers two half-sessions per week or shorter sessions for children and adolescents instead.

“With children, it is quite different working remotely. For the most part, I encourage kids to engage in the same kind of play or art activities we had been doing together in the room. With play, I invite them to use their own toys,” Stacy explains. “We have also been engaging in art activities and adaptations of games like I Spy, Scavenger Hunts, Simon Says, Red Light/Yellow Light/Green Light. There have been some benefits to seeing the kids in their home environment. For example, they can show me their room and items that are important to them. I have invited them to share feelings that they have had during the week and choose items in their home that represent those feelings. It has required us all to be more flexible.” 

If children can adjust to telepsychology, how could a couple in conflict work on their dynamics without falling into overwhelming conflicts? I called Holly Osment, MFT, a classmate from Santa Clara University, where Holly now teaches courses in the Counseling Psychology Department. 

From Holly’s perspective, working with couples transitions well to telehealth. She currently meets weekly with five couples, four of whom continue to focus on their issues and who are very much able to connect with Holly online. The fifth couple had a preexisting dynamic where one partner was very reluctant to engage in the process; that person was even less interested in working online. Otherwise, couples can sit next to each other to process their experiences and feelings from the comfort of their home. Her clients appear to be managing the transition well; her caseload has even increased as former patients returned to meet with her as the stresses of sheltering in place ratcheted up.

It might have helped that Holly is already comfortable with this video conferencing. She held sessions over video conferences enough before March 2020 that made the transition feel relatively easy. She knew the process and how to manage the experience. Holly told me, “It is not the same as meeting in person, of course, and I do not prefer it. But I am also not eager to resume sitting in a closed room with someone who could be asymptomatic, they blow their nose because of emotional crying, and inadvertently spread the virus around the room. With that in mind I may continue video conferences for a good long while to come.” 

Our society may be caught up for a while in this unusual community health situation. With talks of bending the curve, second waves, and a new normal, unknowns are guaranteed. At the same time, mental health work is now recognized as an essential service. Therapists are allowed by law to continue working with their clients and some of our community have been doing just that. Whether to work with children or teens or because of other considerations, some clinicians have met with clients in their office throughout this time. 

My colleague Geoff Nugent, Ph.D., LMFT, who manages his own group practice, Nugent Family Therapy, has had a limited number of clients seen in their offices since the beginning of the shelter in place requirements. They have clear guidelines that client and therapist follow. Doors are propped open to enter the suite and distances are kept. It seems that for those therapists interested in continuing their work and clients ready to meet face-to-face, this process works.  

Dr. Nugent and his colleagues, like many of us, assumed that the shelter in place order would be brief before a return to “normal.” As the length of time to avoid social contact continued, he and his staff found that office visits and new referrals decreased over time. They had to pivot to be able to offer online sessions and determine best practices for the new arrangements. Now here in May, referrals have increased, processes are in place, and the group moves forward better prepared to support their clients in this new era.

For one last perspective, I spoke with my mother, Carol Campbell, MFT. She served as the president of the Santa Clara Valley Chapter of CAMFT and of the CAMFT state board. She has been  practicing psychoanalysis and psychoanalytic psychotherapy in Palo Alto for the last 15 years. She can do a lot of things very well, but to be honest, using technology is not her strong suite.

To our surprise, Carol found that working over Zoom with her analytic and traditional patients turns out to be very effective. Some of her patients state they can focus more while seeing her on the screen, while others  even appreciate being able to write on their computer simultaneously to take notes. She and her patients together have adapted to using the computer to communicate. They can still make effective interpersonal connections, although it is clearly not exactly the same as being in the room together. That said, no one has to commute to the office either. For Carol, the benefits outweigh the challenges and the distance. In fact, she is so pleased with the experience that she has moved her entire practice permanently to operate mostly online: she now offers her psychotherapy services and her professional consulting to licensed therapists either online or by phone. Though she will no longer be working with patients on the couch, she is pleased to reach folks through the convenience and flexibility that this technology offers. Opportunity here is found amidst the crisis.

At the time I am writing these words, Governor Newsom is beginning to talk about the steps we will take as a society to return to increased interactions. Marriage and family therapists have a role to play in helping process the traumas and manage the stresses of families remaining cooped up for weeks on end. Many of our neighbors have lost their jobs or significant income. Perhaps this experience of utilizing technology to connect with our clients will make our services more available to the community and more successful in the years ahead. With the challenges our society and our world face, all of us could use assistance.

Kent received his M.A. in Counseling Psychology from Santa Clara University in 2003. His clinical experience has included private practice, schools, and nonprofits. He completed the 2-year Palo Alto Psychoanalytic Psychotherapy Training Program in 2013, which involves working under the close supervision of senior analysts. In 2018 he founded Family Matters Counseling Services, a center for therapists to work in a facilitated private practice setting to meet the varied needs of the community for counseling services. He can be reached at kentcampbell@familymatters.expert.

Most of us would admit that having some extra support as we traverse our professional path is a helpful advantage. To that end, one of the benefits of your SCV-CAMFT membership is the mentorship program.

A mentorship is a semi-formal relationship between an individual who desires support (the mentee) and a more experienced clinician (the mentor) who can provide guidance and wisdom. It is semi-formal in the sense that it has defined parameters for engagement. It has a beginning, middle, and end. It entails a commitment of time and energy over a six-month period. Participants commit to mutually agreed-upon ground rules such as confidentiality, respect, and keeping commitments. As is fitting to the profession, a mentorship can develop into a very rewarding and potentially long-lasting relationship.

Although it may provide support around the following topics, mentoring is not the provision of supervision, case consultation, or therapy. It is also not an opportunity for doing business together or engaging in a private practice internship.

In an MFT career, there are many possible opportunities to benefit from a mentorship. As a student in practicum, entering the profession can be very uncertain. During the pre-licensed period, new questions emerge, such as whether to work in an agency or in private practice, or both, how to best prepare for the exam process, and what to do once licensed.

There are other transition points where mentoring can be helpful. You may be moving from agency work to private practice (or visa versa). You may want to learn more about a particular theoretical orientation or clinical topic. Larger issues such as defining your professional identity, incorporating more creativity into the work, or working on developing your strengths can also be addressed. These topics and more provide great opportunities to learn from someone who is further along on the path.

So, what do you need to do to participate in the mentorship program? The SCV-CAMFT website includes links (under the 'Membership' tab). There are program guidelines, instuctions, and brief articles on how to make the most of your mentorship experience.

Here is how it works. Once a member selects to be a mentor (on option in your membership profile), they type in their 'mentor description.' A mentee can then review the list of mentors in the mentor directory and can select a few individuals who match their interests and goals (based on the mentors' descriptions). The mentee makes contact with potential mentors and interviews them briefly to determine a good match. Once the engagement is agreed upon, both parties sign the mentorship program engagement agreement (available from our website), and email it to the chapter, so we can keep track of participation in the program. From there, meetings are set up between the mentor and mentee, and the process is on its way.

We hope that many members will take advantage of this valuable program. Mentorships benefit both mentor and mentee. It is a powerful tool that can help to develop contacts, confidence, competence, and clarity in the MFT journey.

Catherine is an LMFT in private practice in Los Gatos. She works with adults who have experienced childhood emotional neglect. CEN is about what didn’t happen in childhood. When emotional needs for connection and acknowledgement are not met, you can be left with a deep sense of deprivation, worthlessness and shame throughout your life, which may show up as depression and anxiety in adulthood. Healing is Possible. Catherine can be reached at www.insight4growth.com.

by Dominique Yarritu, LMFT

Although a Master's Degree in Counseling Psychology and Social Work require the completion of a class in crisis management, dealing with a full blown crisis as an associate can be daunting. As I have discovered through my work as a clinician with the Uplift Family Services Crisis Continuum of Service, it can be equally intimidating for professionals (school psychologists, counselors, and staff, doctors, psychotherapists, police officers) and parents.

There are evident crises when youth are visibly dysregulated, out of control, in extreme pain, unable to return to baseline, or in a state of grave disability, and at a risk for themselves and others. In these latter cases, the decision to write a 5150 hold is unequivocal. (For minors, a hold is technically a 5585, but everyone uses the “5150” language). However, the severity of a crisis can be difficult to assess when the youth has not mastered the vocabulary to express accurately what they are experiencing; or when a teenager describes their intent to self-harm or harm others with a dismissive or matter-of-fact demeanor. Many questions may surface such as how to evaluate the intensity of the youth’s symptoms, how to best intervene to help them de-escalate, and how to provide them and their families with the best support—in the moment, and in the days and months to come. This process can be compounded by concern for the youth’s mental health and the urgency to comply with the legal obligations to report danger to self and others.

In all these circumstances, the Crisis Continuum at Uplift Family Services can help. More than a crisis assessment service to the community, the Continuum is a three-fold process known as the Continuum of Crisis Service, which includes the Child and Adolescent Crisis Program (CACP), the Crisis Stabilization Unit (CSU) and the Community Transition Services (CTS) program. These three services “work together to help children recover from traumatic experiences in a safe and caring environment” (Uplift, 2017). Full-time and on-call clinicians (associate and licensed psychotherapists and social workers) are available around the clock on the Mobile Crisis Team to provide “intervention to children and teens . . . who are in acute psychological crisis” (Uplift, 2017). So how does it all work?

When someone calls the crisis line (a professional, a parent, a police officer, or sometimes a youth), they are connected via a call center to a clinician who runs through a comprehensive list of questions to understand the presentation, symptomology, safety concerns, and other pertinent items about the current event. For low risk situations, the crisis clinician can provide emotional support to the youth and caller and offer resources and consultation. However, if the clinician determines that the case presents a high risk to the safety of the youth and others, they initiate an in-person crisis intervention to evaluate these safety concerns. The crisis clinician may also consult with the mobile crisis team to consider how to best support the youth. On-site interventions are provided on school campus, at home, at hospitals, at the CSU if the family feels safe driving the youth to us, or anywhere the youth is located.

All the clinicians have been certified by Santa Clara County to write psychiatric holds. The response time varies depending on the location of the youth and the average duration of an intervention lasts two to four hours. Once on site, the team of clinicians meets with the youth, the professional who requested the intervention (if relevant), and the parents. Clinicians use this time with the youth to de-escalate the immediate crisis, evaluate the risk factors, identify coping skills and support systems, and decide how to best ensure safety. The on-site clinicians confer with each other first, and then with an Uplift consultant, to make a joint decision on the best outcome for the youth. The intervention can lead to safety planning in collaboration with the youth and the caregivers or to write a 5150 hold. In a situation where safety planning alone is indicated, the team offers referrals for ongoing support of the youth and the family. If the youth has Medi-cal coverage, they can be referred to Uplift services. Otherwise, referrals can be given if the youth’s family has private insurance. On the other hand, if the youth is put on a 5150 hold, the team organizes transport and transfer to the CSU at the Campbell campus for further psychiatric evaluation. It is important to note that if the youth needs to be medically cleared (the youth has physically hurt themselves), they must be transported to a hospital in the county before being admitted to the CSU.

The Crisis Stabilization Unit (CSU) is an around-the-clock service with nurses, clinicians, family specialists, and a psychiatrist on staff. If needed, this service is the second phase of the intervention and “is available for children and teens on a psychiatric hold who receive short-term emergency assessment and stabilization instead of going [directly] to the hospital” (Uplift, 2017). This second assessment is more in depth. It is performed by another clinician, a nurse, and a psychiatrist and includes a period of stabilization of a maximum length of less than 24 hours. After the visit with the psychiatrist, the team decides whether the youth needs to be on a longer hospitalization to ensure immediate safety or whether they can safely return home. Throughout their time at the CSU, the youth is fed, supervised, and provided crisis stabilization services. The team contacts, meets, and supports the parents during the second phase of the process. Similarly, if the youth has mental health services already in place, the CSU team communicates with these providers to gather additional information, work collaboratively to support the youth, and coordinate the next steps. If the youth has returned to baseline and shows no immediate risk of self-harm, suicide, or harm to others, the team meets with the youth and caregivers together to develop a viable safety plan for the youth to be released into the care of their parents or caregivers.

The last phase of the continuum of care consists in referrals to the Community Transition Services program that provides “skill development, parenting support, behavior analysis, access to ongoing community-based mental health services” (Uplift, 2017). However, only youth who benefit from full scope Medi-cal coverage are eligible for this service. Once they are enrolled in the CTS program, the youth and family work with the CTS team to develop a treatment plan to address any ongoing safety or behavioral concerns. This support consists of a “weekly child and family team meeting [to] ensure the appropriate services are being provided to the child or teen” (Uplift, 2017). This last phase of crisis intervention and support lasts up to 90 days. If ongoing therapeutic support is needed, the family is linked with the appropriate care.

I hope that this brief overview of the Uplift Crisis Continuum will provide clarification on the process of crisis intervention for children and teens. For consultations, requests for assessment, referrals, and interventions, contact (408) 379-9085 any time of the day, any day of the year.

Continuum of crisis care. (2017). Uplift Family Services. Retrieved from www.upliftfs.org

Dominique Yarritu is a newly licensed marriage and family therapist who focuses her practice on adults and couples using a psychodynamic and Jungian approach. She is a doctoral candidate at Pacifica Graduate Institute in Depth Psychology with an emphasis in Somatic Studies and is currently training in somatic experiencing. She is affiliated with Uplift Family Services where she works on-call at the Mobile Crisis Unit, assessing children and teenagers in crisis, and sees clients at Family Matters Counseling Services. She can be reached at dyarritu@familymatters.expert.

by Nannette Thomas, LMFT

We are all aware of the concerning increase in depression, anxiety and general mental health issues in the adolescent and young adult population. In my practice, I see teens, young adults and their families and, of course, I see teens and young adults with anxiety and depression. I also see many of the side effects of rising mental health problems. For example, parents in general have become more anxious. They become anxious when they hear of suicides within their school or community. They also become anxious hearing stories of seemingly well-adjusted teens who appear to suddenly refuse to come to school or get out of bed. The adolescent mental health system has also become overwhelmed, so when parents are worried about their child or teen and start looking for services, they encounter long wait times, full practices and very expensive options, which leads them to feel even more anxiety. This parental anxiety alone has many implications.

In addition, when parents call their child’s school, they frequently find more reason to be anxious. The schools are often overwhelmed by calls from concerned parents. Many parents have told me stories of teachers and administrators not returning their calls or not having useful suggestions for how to handle problems. Schools and the training programs that educate teachers have traditionally focused on educating children. The sudden need to manage children’s mental health is a new and unexpected challenge for schools and their staff. A call to a teacher or principal used to calm many parents as they shared the wisdom of their extensive educational experience. Today, this calming experience seems less common as the issues extend beyond education and as the school staff themselves are often more anxious.

In my practice, I also see the challenges of families trying to adjust and work with teens returning from treatment. Whether this treatment was a few days in residential care, an IOP program or a year at a wilderness program followed by a therapeutic boarding school, trying to figure out how to return to a new, healthier normal is difficult.

In all of these scenarios, anxiety is high. The parents’ anxiety is high, creating more anxiety within the family. The teachers and administrators are anxious trying to handle the safety of kids in an environment where suicide is not uncommon. In Bowen family systems theory, one of the goals of working with families is to reduce the family’s overall anxiety. Bowen also talks about the many ways that anxiety can contribute to unhealthy family functioning such as triangulation and emotional cutoffs (Sharf, 2016). Family anxiety is both a cause and an effect of the increase in adolescent mental health issues.

In working with families today, my goal is to contain and reduce the anxiety. Regardless of the situation, we need to listen carefully to each other and work slowly to effectively respond to the issue at hand. I use the metaphor of a container when working with parents. We want to create a safe container for children and teens to grow. The first and primary aspect of this container is the container itself, which is the limits that parents (and schools and the community) set to keep the child safe and on track. The second aspect is the space inside the container, which allows the child or teen the room they need to figure things out. In this space, all of their feelings are acceptable and they can determine their strengths, their weaknesses and their preferences. They can experiment to see how life works and who they are, who they want to be. We cannot do this work for a child.

In setting limits, parents often need help. My first focus is on safety. If there are safety issues with the child, these need to be addressed first. Depending on the safety issue, I often work very behaviorally with the parents to make sure we take action to keep everyone safe. There is a common misconception that the way to handle a depressed or anxious child is to be supportive and not ask too much. While at times we may need to do this for an afternoon or a few days, I believe that generally children and teens feel better when they are contained and have appropriate limits. Often parents have tried to be supportive and not ask much until they hit a crisis and suddenly they must take action and the child encounters strict limits. An example would be a child with disordered eating who has lost more and more weight. The parent finally becomes concerned enough that they take the child to the pediatrician and the child is hospitalized. The hospital is extremely structured and sets limits on all aspects of the child’s functioning. If the family had been able to find a way to set limits before this crisis, the child might have avoided the shock of going from overly permissive parents to a completely restrictive hospital regime.

Setting limits is difficult, especially with the internet and devices, and can bring out anger and conflict that parents have been avoiding. I work closely with parents to understand them, their child and their family and see how we can gradually and effectively set limits and create a safe container. For example, parents often say, “I don’t care about my child’s grades” and I reply that “I do care.” In general, children and teens do not feel good about getting Cs, Ds and Fs and if they are getting these kind of grades, I want to know what is going on. Limits are not about punishment. They are about knowing when to be concerned and to take action. If a child is getting grades that do not seem to reflect their abilities and we say that is acceptable, the child may hear the message that they are not very capable or that they do not matter very much. When working with grades and school work, I often recommend a book called The Learning Habit (Donaldson-Pressman et al., 2014). This book details a common sense approach to a homework routine. Structure and routine are a type of limit that can be very helpful for many busy families.

In working with parents on the space within the container, I teach them to listen and empathize, to reflect and summarize, to name emotions, and then to allow their child space to figure it out. Part of this work is skills training with parents, but part is helping them to manage their own anxiety so that they can become a “nonanxious presence” (Friedman, 2007). A parent who can provide a nonanxious presence can listen and connect without becoming too involved in the child’s emotions. Another of my favorite parenting books to provide to clients is The Self-Driven Child (Stixrud and Johnson, 2019). This book contains a chapter on becoming a nonanxious presence by first managing your own emotions.

In all of this work, I am creating a container for the family. In my practice, it is critical that I manage my own anxiety as a therapist. I rely on my own therapy and effective consultation to make sure I have the support that I need. Schools and communities used to provide a container for families. Today, though, the whole system seems to be straining under the pressure of increasing demand. Therapeutic work with families requires good containment for the therapist under these circumstances. The therapist can then both provide and teach containment for the families, children and teens that are their clients.

Nannette Thomas is a licensed marriage and family therapist practicing in downtown Los Altos. She sees adults, couples, older teens and families. She previously worked as an engineer and manager in the tech industry and has volunteered for many years as a lead on the Mountain View Los Altos (MVLA) K-12 Parent Education Speaker Series.

References

Donaldson-Pressman, S., et al. (2014): The learning habit: A groundbreaking approach to homework and parenting that helps our children succeed in school and life. New York, NY: Penguin Group.

Friedman, E.H. (2007): A failure of nerve: Leadership in the age of the quick fix. New York, NY: Seabury Books.

Sharf, R. S. (2016): Theories of psychotherapy and counseling: Concept and cases. Boston, MA: Cengage Learning.

Stixrid, W., & Johnson, N. (2019): The self-driven child: The science and sense of giving your kids more control over their lives. New York, NY: Penguin Random House.

The evolution of mainstream society and the influx of social media are greatly influencing the visibility of the transgender community. As new terms for pronouns, gender identities and affection orientations are being constructed, our teenage (and middle school) clients are certainly keeping us updated on the constantly changing labels. Working specifically with transgender teenage clients is a unique subset to the umbrella acronym of LGBTQ+ community because it blends gender equality AND sexuality—two intrinsically critical aspects of the developing self. The exploration of gender and sexuality within the teenage population is overlaid with the general maturation process. Indeed, these clients are transitioning from children to teenagers—a process that generally is not easy even for cis-gendered, heterosexual teens. Someone whose gender identity matches the sex they were assigned at birth is considered cis-gender.

How does a therapist who has never worked with the transgender population navigate gender within the therapeutic relationship? It begins with being very real. Transgender teens are likely to be reluctant to share feelings about their gender dysphoria with a person they perceive as a cis-gendered therapist. Therefore, the first session is absolutely critical for establishing trust and transparency. This begins with the therapist. Given the current statistics of transgender-identified persons, the therapist most probably identifies as cis-gendered. Therefore, it is important that the therapist come out to their teen client. A brief statement such as “I am very interested in working with you to navigate your transgender journey of self-exploration. I feel it is important for you to know I am cis-gendered and while I have knowledge of what a transgender journey may look like, every journey is different and I am most interested in learning about your specific experience.” However, we are NOT looking to our transgender clients to educate us about what it means to be transgender. We should do our due diligence as professionals to become educated through consultation and additional trainings.

Open-ended questions allow for the teen client’s story of their gender identity to be revealed. I suggest starting with a very broad question. This allows the therapist to observe where the client starts their narrative, whether it is chronological, situational, somatic, or something else. The question can be as simple as “what is it like to be in your body?” or “what is it like to be at home or at school?” The client’s response is a source of information on their family of origin, their history of anxiety/depression, somatic symptoms, anatomical dysphoria, family and social support (or lack thereof). Their response also reveals the client’s level of self-awareness, their capacity for communication, and a plethora of other relevant information. It becomes the launchpad for further exploration.

Lean in to approach the uncomfortable. When they meet with a therapist, transgender teens possibly have already disclosed at least a limited amount of their discomfort to their family of origin. However, the therapist—an adult professional—will likely be the first adult outside of their family to hear the depths of their transgender exploration. Discussions that include dysphoria about genitalia, desire for or fantasies of being in the other gender, grief about the medical process taking too long or for being misgendered in public, are simply a few of those tough topics. To preface a potentially sensitive question, I suggest saying “I would like to ask you a very personal question that you may or may not have thought about before. I am thinking that it may be helpful to explore it here in this safe place. If once I ask you feel uncomfortable, just say so and we can discuss something else.”

Although it may be challenging to admit not knowing, it is important to do so for the client. As therapists, we will never be well-versed in all possible life circumstances that our clients share with us. Within the bounds of personal non-disclosure, we may give ourselves permission to be vulnerable with our clients. We certainly do not expect our clients to have all of the answers about their journey either, so in a lighthearted (and possibly playful) way, we can say “you brought up an interesting perspective, one that I will need to ponder and learn more about.” We may even verbalize thoughts by sharing “you know, when I am not sure about something, sometimes I need to reflect on it and possibly seek other opinions. I do not always have the answer right away either. I certainly do not expect you to know all about your gender today, next week, or even next year. Gender is always in flux and our opinion of it evolves as well.”

There could be a medical component to a teenager’s transgender exploration, including hormone blockers, hormone replacement, top surgery, electrolysis, and others. If working with the transgender population is not a specialty area of your practice, I suggest becoming connected with local medical care providers who support this population. In parallel, it is very helpful to ask the teenage client to share what they know about the medical process. This gives the therapist insight into the teen’s knowledge, its source, and the accuracy of the information. Most importantly, it exposes the gap areas in that very knowledge. It gives the therapist the opportunity to step in and help to educate, challenge, and further explore the process with the client.

Supporting a teenage client through their transgender journey is a wonderfully unique experience. It is filled with the inevitable highs and lows of any life experience including increased communication skills, establishment of close friendships and family ties, building self-confidence through gender expression (clothing, hair, accessories), formalizing a legal name and/or gender change, and change in pronouns. It is crucial to remember that our role as clinicians is to be present, curious, thoughtful, and a beacon of support to the client and their family. Bearing witness to transformation—in this case gender—is a life-altering experience for both the client and the clinician.

For further resources, consultation, or questions about working with transgender clients, Sean Garcia may be reached at www.seangarciatherapy.com.

Sean Garcia is an associate marriage and family therapist who has worked in a variety of settings including clinical, educational, and is now in private practice. As one of a handful of trans-identified clinicians in silicon valley, Sean is extremely passionate about supporting transgender people and their families. This population is the primary focus of his practice and he is currently expanding his clinical influence by developing and facilitating transgender sexual wellness programs for teens, a Trans Brotherhood adult support group, and a transgender tween support group. Sean is actively involved as a speaker and facilitator for educational training and enrichment for parents, staff, and students at local high schools.

You have probably noticed more discussion in the news recently about gender and pronouns. You may have encountered terms you don’t recognize, such as “cisgender” or “non-binary.” Having a close family member who identifies as transgender (which I’ll define below), I have made it my business to educate myself on my family member’s experience. As a therapist, I also care deeply about inclusive and compassionate therapy with all people. I hope that my journey can be helpful to you. While recognizing that I am not an expert, I’ll review some basics and share how I am learning to be more aware and more active in creating safe spaces for people who identify as trans, genderqueer and non-binary.*

Most of us have grown up with the belief that there are two genders, called the gender binary, and people are either strictly male or female. Under this view of the world, whatever sex you are designated at birth is correct and final. It is important to understand the difference between “sex” and “gender.” The term “sex” generally refers to the genitalia and genetic differences between males and females, whereas “gender” refers to your sense of your gender identity as well as the social construction of the roles of males and females in the society where you live.

If your experience of your gender matches your sex assigned at birth, then your behavior, appearance, dress, and genitals “match” how you feel about yourself and how everyone around you treats you. However, this sense of “matching” has never been true for everyone and many have suffered with shame and silence for not fitting into the strict binary system. Consider the discrimination and violence transgender people continue to face today.

We call someone whose gender identity matches the sex they were assigned at birth “cisgender.” For example, I was born a girl and feel that the female gender fits for me, expresses who I am inside, so I am cisgender. “Transgender” (or trans) is a term used broadly for people whose gender identity does not match the sex assigned to them at birth.

It is also important to know that “gender” and “sex” are different than “sexual orientation.” If someone identifies as gay, bisexual, lesbian, or heterosexual, this refers to their sexual orientation, or who they are attracted to and who they have sex with.

Transgender or trans people may be “non-binary,” meaning they don’t identify exclusively as male or female (and there is not a precise definition of non-binary, it can mean different things to different people). Trans can also describe people who do identify on the binary system, but as the opposite gender of the one they were assigned at birth, i.e. a trans man or a trans woman. Whether someone has medically transitioned is not determinative of their trans identity.

Let’s talk about pronouns and gender neutral pronouns. “Pronouns are just a substitute for a noun that you don’t know the identity of, or a shorthand when the person/place/thing you’re talking about is understood.” (A Quick and Easy Guide to They/Them Pronouns, by Archie Bongiovanni and Tristan Jimmerson, p. 11). We’ve been taught to use masculine or feminine pronouns when referring to individuals in casual English, but as we are seeing, this guessing may be incorrect. There is increasing support of and usage of pronouns that are not gendered. Generally, when you refer to another person by their pronoun rather than their name, you typically guess which pronoun to use, masculine or feminine, based on name, hair, clothing, deportment, and then use the corresponding gendered identifier he or she. The trans community argues persuasively that it is oppressive and harmful for anyone to simply assume someone’s gender and to “gender” them using he/she pronouns. This constant reinforcement of the binary gender code creates pressure for all of us (and especially trans people) to express ourselves in certain ways in order to be accepted and safe. Being “misgendered” serves to invalidate and make invisible people who don’t fit into the gender binary. It says, “you aren’t for real, we know who you really are, we get to say who you are.”

One change that we can make to make space for everyone is to ask people what their pronouns are, and to practice consistently using people’s self-identified pronouns (whether they/them or another gender neutral pronoun, of which there are a number).** At the beginning of a group meeting is a good time to open up space for people to identify their pronouns. This may be particularly relevant when working with groups of younger people, who are much more aware of a gender spectrum. A good way to start that conversation is to volunteer our own pronouns when we introduce ourselves to someone or to a group (“Hi, I’m Rowena and I use she/her pronouns”), and then invite people if they are comfortable to share their pronouns when they introduce themselves. We can also routinely use they/them pronouns when we don’t know first hand what someone’s pronouns are or what their gender identity is. Interestingly, some companies are already using gender neutral pronouns in their communications.

In my own journey, it has taken me time to get used to using they/them pronouns, which my family member uses to identify themself. For awhile, I would use they/them when I was around my family member, but would revert to their historical pronouns when talking with others, in part because I wanted to respect my family member’s privacy and also because it still felt uncomfortable. Eventually, I specifically checked with them and received permission to use they/them pronouns all the time when referring to them. I made a commitment to be consistent. While I continued making lots of mistakes, I became more comfortable over time and they/them started coming easily off my tongue. I also made sure when I made mistakes that my family member knew how important this was to me to get it right.

A significant milestone for me was becoming more comfortable using they/them pronouns with friends and family, when speaking about my family member. I learned to simply say, “they use they/them pronouns,” and to leave it at that. Sometimes people asked more questions and I would answer briefly. I am still finding a balance between respecting my family member’s privacy and being open and proud of their journey by using correct pronouns.

Language is powerful, it conveys the values of a culture. Therefore, I encourage us to take this issue of human dignity and respect very seriously. We have made other language changes in the past that signified the increasing strength and power of marginalized people, and the growing awareness in the population of important justice issues. We can make changes in our own language and knowledge right now that will speed along these changes in the wider culture. We’ve discussed becoming more aware of our gendered pronouns. We can also become much more aware of how we use gendered language everyday in ways that we might not notice. For example, saying “ladies and gentleman,” or “boys and girls” when addressing a group, or calling people “sir” or “ma’am.” These assumptions about gender are also harmful in the same way we have discussed, they make people who identify differently feel excluded and invisible. Someday soon, with our efforts, gender neutral pronouns and language will be the norm along with respect and acceptance of people all along the gender spectrum.

In summary, here are ideas for how to move this revolution along and to be part of positive change. Most importantly, when someone specifically requests that we honor their pronouns, we can make this change immediately and consistently (even while knowing that we will make mistakes). We can use they/them pronouns as the default until we’ve more specifically checked with someone about their pronouns. We can use they/them pronouns when we are speaking of someone in the third person whose gender identity we don’t know. We can practice getting more comfortable saying, “I use ______ pronouns, what are your pronouns,” when introducing ourselves, and then consistently using the pronouns someone has indicated.

Other ideas that we can try to incorporate over time are to become more aware of and find good neutral alternatives to gendered language that creeps into everyday usage. We can include our own pronouns in the signature portion of our email messages and in our therapy practice documents, where applicable, which signals inclusiveness and invites people to share their pronouns. We can educate ourselves—a website I recommend is mypronouns.org. We can encourage organizations that we’re involved with to be gender neutral in their materials.

This is a journey, it takes time and will feel uncomfortable. I encourage you to be kind to yourself as you are learning and experimenting with these ideas. I believe it is fully worth the effort. Being more aware of our language and our assumptions around gender is a powerful way that we can make the world safer for each other.

*This is not an exhaustive list of terms for identities along the gender spectrum.

**For other gender neutral pronouns and lots of other great information, including suggestions for correcting inevitable mistakes with pronouns, please check out the website mypronouns.org.

Resources used in writing this article:

• A Quick and Easy Guide to They/Them Pronouns, by Archie Bongiovanni and Tristan Jimmerson.
• mypronouns.org.
• Transgender identity terms and labels, plannedparenthood.org

Rowena Dodson 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.