Articles

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.

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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. 

For eleven years until this past December, I led one of the two newly licensed support groups sponsored by SCV-CAMFT (the first year was an enjoyable co-led experience).

As one might imagine, over eleven years I met many newly licensed therapists. Quite a few of those are now therapists you recognize today in many facets of our professional life, including those in leadership, excelling in professional specialities, providing workshops, and other excellent contributions to our profession.

As a certified group therapist, I was moved by witnessing the transition of the therapists in my group, and how they would join the group and quickly feel connected with the other therapists, the topics, and struggles in a very affirming manner. Facets of a therapist's professional identity can feel isolating at times; notably levels of anxiety and fear about being newly licensed and creating a practice from scratch. Invariably, there was agreement that the business model of starting a practice was neglected in graduate school and in other settings in which these therapists found themselves. This group seemed to fill that gap in a connecting and affirming way. I think most newly licensed therapists would benefit from joining a support group like this, to help them get their grounding after the long process of getting their required hours and taking the exams.

I was pleased to witness and be a part of a their growing sense of competence and comfort level, chipping away at the list of tasks to create a professional identity. They were encouraged to reflect often on their original motivation, goals, and dreams that brought them to graduate school in the first place.

I was honored and enjoyed providing the space for this budding transition. The attendees provided most everything else: energy, empathy, encouragement, resources, resourcefulness, ideas, care, compassion, and continuity. I know long-term friendships grew between the attendees through meeting in this group, as well as many other professional connections.

The benefit for myself, contributing two hours a month, was to witness and be a part of a significant experience at the core of our profession: growth, support, and service. It was a great experience to be part of this group; one that helped solidify for me what groups are about and specifically, support groups focused on a very timely and important topic.

It was with mixed feelings that I gave up my role and passed the baton on to another capable leader. I feel strongly that this part of what SCV-CAMFT offers is quite vital and noteworthy, and hope it continues for many years to come. I also hope that those of you reading this article will consider recommending this group to those who may be looking for this validation and mirroring. From my experience, it is very helpful for those who attend.

The lesson for me is that by contributing a small amount of time and effort, the rewards can be immeasurable. The experience of leading this group for so many years has proven this to be true.

Jamie Moran, LCSW, CGP, is a long time member of SCV-CAMFT. He specializes in long term psychodynamic group therapy, consults with therapists about groups and teaches aspects of groups in communities at large as well as being on the faculty of The Psychotherapy Institute's Group Therapy Training Program in Berkeley. Jamie has a private practice in Menlo Park. His website is jamiemoran.com.

Please note that I refer to dogs in this article, but any animal can be a therapy animal. I also refer to pet owners, rather than guardians, pet parents, etc., because that is still the legal term used (with a few exceptions).

Emotional Support Animal? Therapy Dog? Animal Assisted Activities Therapy Dog? Service Dog? Animal Assisted Psychotherapist? You've probably heard a few of these terms and wondered what they mean. It can be confusing, but there are differences between these roles. This article addresses the additional training and experience a therapist who wants to bring their dog into the therapy office needs in order to comply with certain laws. But first, let’s describe the roles dogs serve in the field of mental and/or physical health that you’re likely to encounter, as they are not interchangeable.

Emotional Support Animal

An emotional support animal (ESA) is a pet who provides a high level of support to its owner. Most of us love our pet and consider them a part of our family, yet an ESA takes on an even bigger role in their owner’s life, such as helping to decrease loneliness or isolation, severe depression, high anxiety, or other mental health issues. The client most likely has a small and/or weak support system, and their pet provides that additional support.

The law specifies only two rights that owners with an ESA are entitled to: they are allowed to travel on an airplane with their pet and allowed in homes that otherwise don’t allow pets. They are not allowed in any other place that a dog/pet is not allowed.

The ESA pet does not have specialized training, but does need basic obedience training. Landlords and airlines are legally permitted to remove a pet that misbehaves or causes a disturbance or nuisance to other people. While there’s no certification process for the animal, the owner must provide a letter from a physician, psychologist, or psychotherapist stating that the pet is needed for a client’s emotional support.

Be very cautious about providing these letters, and know your client’s needs well. It’s against the law to provide a letter to a client who doesn’t really need their pet for this level of emotional support and who you haven’t already established a strong therapeutic relationship with.

Service Dogs

A service dog is a dog that is trained to perform a specific task for a person who has a verified disability, either physical or mental health related, as specified under the American Disabilities Act (see www.ada.org for more information). Guide dogs for the blind, diabetes or epilepsy alert and response dogs would be included here, as well as people dealing with panic attacks or PTSD.

These dogs are extensively trained, sometimes up to 12-18 months depending on the disability. I heard of someone with PTSD and was triggered in crowds. The dog was trained to detect when she was about to have a panic attack and bark so that she could leave the situation quickly - she just told people she had to tend to her barking dog. As a side note, many people don’t realize that it’s illegal for the public to try to pet or try to socialize with a service dog who’s in public, as the dog is working.

Therapy Dogs

Therapy dogs fall into two categories: certified therapy dog or pet-assisted therapy dog. My dog is a certified therapy dog who provides Animal Assisted Activities (AAA). We are contracted with one of the local therapy dog agencies, and join other volunteers on planned visits to schools, libraries, retirement homes, hospitals, and other places that would benefit from therapy dog visits. We are volunteers for the agency we’ve joined as part of a therapy dog team, and never make visits on our own.

There are several local organizations that provide pet-assisted therapy services, and the specific policies/requirements are different at each one. In general, your dog must be well trained in obedience and under your control at all times. Many organizations require your dog to have earned their Canine Good Citizen certification, a special obedience test given by certified examiners from the American Kennel Club. Your dog must be unflappable, even tempered, and predictable in any type of situation.

In addition to the obedience requirements, an animal behaviorist from the agency you’ll be working with will do a thorough assessment to make sure your dog has the right temperament. Just because your dog is friendly, doesn’t mean they are suited to be a therapy dog. My Newfoundland has had a curious toddler stick her finger up his nose, his tail has been run over by someone’s walker numerous times, 15 or more people often crowd around him all at once to pet him, yet he remains quite calm through it all. And he thrives on all of the attention, another essential component.

By contrast, my other Newfoundland is very friendly, loves people, but after a minute she’s ready to leave the people behind and is distracted by everything else going on - she reminds me of someone with ADHD! Although not essential, it’s a great idea to have this type of experience with your dog before deciding to bring them to work with you.

Getting Your Pet Certified

So you’ve read this far, and have decided that you want to take the next step to become a pet-assisted therapist, bringing your own dog to work with you to help some of your clients. This is considered a specialty of psychotherapy, so what extra training do you need?

It’s of vital importance to remember that one of the laws we as psychotherapists must follow is Scope of Competence. Have you taken the steps to be in compliance with this law? Have you received additional training, education, experience, and supervision? Why are you using the dog as a part of the treatment plan? What is the purpose and goal for the session? There must be a therapeutic reason. It could simply mean providing the calming and peaceful presence of your dog for your client. It could mean helping a child learn how to deal with frustration by learning how to be calm while interacting with your dog. Maybe it’s helping someone learn how to be more assertive, build confidence, or reduce fear. The list and the interventions are endless.

What additional training do you actually need and where can you get that training? There are several organizations and associations that can provide you with the additional education, training, and experience you will need to embark on this work. A few universities offer post-graduate programs for graduate level therapists. But before you pay thousands of dollars for the training, check their references and the training and education they actually offer. As with anything else online, there are some scams out there.

I’m currently pursuing my certification at Animal Assisted Therapy Programs of Colorado, www.animalassistedtherapyprograms.org. It consists of 6 semester-length classes and when done I’ll earn my Certificate of Education in Animal Assisted Psychotherapy. I’m learning about the Human Animal Bond, the Legal and Ethical Issues in AAP, Animal Behavior and Training, AAP and Theory, as well as Treatment Planning/Interventions. These are all requirements to earn this specialization. At the end of it all, I’ll write a publishable paper showing my original work using the concepts learned with one of my own clients.

You don’t have to go to this extreme, though. At this same website there are training videos that therapists can study to document that they’ve taken the time to get the additional training required to pursue this specialty.

Although it may be time-consuming and expensive, our very own Ann Tran-Lien, JD, at CAMFT wrote an article in the September/October 2017 issue of The Therapist about a California LCSW who had strong disciplinary action taken against her for incompetence and gross negligence when her dog bit a child client at the end of a therapy session. This article should motivate therapists who want to use their dogs in therapy sessions to get that extra training.

I’ve had so much fun over the years taking my dogs to obedience classes, seeing the joyful effect they have on the people we visit, and someday using my own dog to help clients. One last reminder - be safe, make sure you’ve got the extra training and experience, and make sure your dog is properly assessed by someone other than yourself. Even though I’ve taken many workshops and training classes over the years with my dogs, I like knowing that they’ve been assessed by a certified animal behaviorist who has put them through the ropes to make sure they’re as suitable for this work as I think they are.

Elizabeth Basile, LMFT, practices in Mountain View. She works with pre-teens, teens, adults, individuals, couples, and families, addressing domestic violence, sexual assault, trauma and PTSD, illness, and eating disorders. She also has a certification in eating disorders. She’s looking forward to integrating her dogs into her practice with some of her clients. Her website is www.elizabethbasilemft.com.

Nancy Wesson, PhD, is a Licensed Psychologist psy9621, Certified Group Psychotherapist and founder of the Center for the Study of Group Psychotherapy (CSGP), a nonprofit group therapy training organization.

In my 30 years leading psychotherapy groups, I find that group psychotherapy is a very effective treatment modality. In this brief article I offer some pointers for starting a group and for keeping it going successfully.

“The joy of group therapy for me is watching group member connections, relationship building, and identification, that is, when members no longer feel alone with their psychological issues. This is one of the most important healing factors for group therapy. When describing the group, members will easily tell others that the group is not ‘the group’ but ‘my group’.” (Yalom & Leszcz, 2005).

Before starting the group

• Receive training in group psychotherapy to be able to effectively handle leadership challenges such as monopolizing, absenteeism, conflict, etc.

• Choose the type of group you would like to lead: process, psycho-educational, psychoanalytic, or a combination, and if you want a short-term or long-term group.

• Develop a written group agreement for the clients which includes confidentiality, time commitment expectations, absences, fees, acceptable group behavior (norms), and termination issues.

• Develop a marketing plan for attracting new group clients. For example, connect with individual therapists who are likely to refer their clients to your group.

Organizing the group

Once you have chosen the type of group you would like to lead, you need to find the right clients. Decide what criteria you are looking for in clients and interview them to make sure they will fit. It is important to consider if a client is appropriate for your group. Conduct a phone interview initially, and if they seem appropriate, conduct an in-person interview (if possible). It is also important to prepare the client for how the group will work and how it will feel to be a group member. This preparation will help your client feel more comfortable and committed to the group.

Starting the group

Begin your group when you have at least 4, preferably 5 clients who are ready to join the group. To create cohesion and connection, start the first session by encouraging members to connect with each other and to take time to discuss their lives and personal goals.

Most clients join groups not just for information but also for connection. You can encourage connection between group members by including time for group members to interact. The relationships between group members and the sharing of similar issues will bring your group members back to group each week.

It is helpful to see the “group as a whole,”(Bion, 1962) and not only as a collection of individual clients. Each group is an entity in and of itself, comprised of relationships as well as individual clients and help the group maintain it's own identity.

Maintaining the group

Keep the group stable, safe, and dynamic by addressing any issues in your agreement that come up in the group. If a member is not participating in the group, explore this gently in the group. (They may not think their contribution is important).

The group agreement is central to keeping the group safe and members committed. If a member is often late or absent, bring this to the group for exploration. If a member is very frequently absent and does not respond to group feedback, then meet with that member privately. Frequent absences by one member can easily lead to more member absences. The same is true for lateness and impulsive angry outbursts.

Encourage empathy, positive feedback, support, and the expression of feelings in the group. This will help group members feel connected to others in the group. Group members need to feel they are each an important part of the group.

Nancy Wesson, PhD, Licensed Psychologist, psy9621, CGP, has been trained by Irvin Yalom, M.D. and the American Group Psychotherapy Association. She is the founder of the Center for the Study of Group Psychotherapy, a nonprofit training organization (CSGP). She has led two psychotherapy groups for 28 years. For more information contact DrNWesson@CSGP.org, or visit the CSGP website at www.CSGP.org.