Event Reviews

Workaholics, alcoholics, shopaholics, food addicts, gamblers... As therapists, we are all-too-familiar with clients who are struggling to break free from the pain of addiction. It seems any substance or activity that elicits pleasure can become a source of compulsion and an attempt to fulfill unmet emotional needs.

It is not surprising that in an increasingly technological world, online sex addiction is on the rise. Average people who would never feel bold enough “in real life” to venture into an adult sex-shop, can now watch exotic porn and experiment online with risky sexual behaviors in the privacy of their own homes. In fact, 65 percent of cybersex addicts have no prior history of sexually compulsive behavior and the majority of cybersex addicts are partnered or married.

What makes cybersex so enticing? For one thing: easy access. Most people now have ready access to the Internet. Another contributor is anonymity. Most people are under the illusion that their online usage is untraceable, so they do not feel accountable for their online actions. Hiding behind the anonymity of the Web, online users are able to conceal their age, gender, ethnicity and marital status, allowing them to create alternate identities. The third factor is instant gratification. With the emergence of high-speed Internet, users can escape into a world of rapid, intense, immediate stimulation with seemingly little risk involved.

Of course, not every person who uses the Internet to explore their sexual curiosities is considered a “cybersex addict.” Addiction may be defined as “a repetitive urge to perform an act that is pleasurable in the moment but causes subsequent distress, functional impairment and significant withdrawal symptoms if not engaged in.” To be considered an addiction, there are four primary criteria that must apply. The behavior must be: 1) Progressive, 2) Compulsive, 3) Obsessive, and 4) have negative Consequences (PCOC).

Let’s take a look at how this might play out... A man is surfing the Internet and discovers an erotic Website. He’s curious and begins to explore, one site leading to another, entranced by the limitless options. The next day — and the days after that — he continues to go online, spending hours at a time compulsively visiting one sexual Website and chat room after another, feeling like he cannot stop. He finds himself spending more and more time online, escalating his activity and experimenting with increasingly erotic material. As the compulsion grows, he feels a loss of control and is preoccupied with thoughts of getting online. He finds himself feeling increasingly irritable, anxious, and depressed. Spending so much time on the computer, he grows socially isolated and his intimate relationships suffer. Over time, if not treated, he experiences an overall gradual decline in his mental and physical health.

Contrary to what one might think, the “goal” of cybersex addiction is not orgasm, but to escape the ordinary, to escape the everyday pressures of life, and to satisfy underlying emotional needs. It is also driven by the desire for intense emotional, sexual, and sensory stimulation. The greater the user’s level of daily stress, the greater the level of stimulation needed to escape from his problems. In fact, most pornographic downloads occur between the hours of 9:00AM-5:00PM and the more erotic and “deviant” sites are primarily visited by high-powered, successful men. Women, on the other hand, tend to prefer chat rooms and the relational aspect of personals where there is a greater sense of safety and control (incidentally, women are more likely than men to go offline to meet someone they’ve met online).

Is cybersex considered an infidelity within the context of a relationship? According to experts in the field of sex addiction, the answer is “yes.” A virtual affair shares all the same elements of a traditional affair: broken promises, secrecy, lack of sexual exclusivity, denial, blame, anger, and shared intimacy with another person. Clinical findings show that the jealousy, hurt and betrayal of an online affair are equal to an actual affair.

For these reasons, initial therapy goals should focus on helping the couple contain intense emotions, managing the immediate crisis (i.e., ceasing high-risk sexual behaviors) and giving referrals (12-Step, individual treatment, support groups, etc). The therapist may also begin to assess for underlying mood disorders, substance abuse issues, and medical issues. As the couple stabilizes, the therapist may begin to facilitate the process of piercing through denial, reducing shame, providing psychoeducation about Internet sexual addiction, improving communication skills between partners, and helping the couple reestablish trust in one another. Perhaps most importantly, the therapist holds hope for the couple’s recovery. Through education and treatment, the couple may use the experience to heal their relationship and create deeper intimacy.

Presented by Elaine Brady, Ph.D., MFT

Reviewed by: Erin Pensinger, MFT

Erin Pensinger, MFT, has a private practice in San Mateo and works as a therapist at a private school in San Francisco

On Friday, November 21, 2008, Dr. David B. Feldman addressed attendees at the SCV-CAMFT luncheon held at Michael’s at Shoreline. The subject was “Post-Traumatic Stress Disorder At The End Of Life: What Therapists Need To Know.”

The end of life is something we all have to deal with, but has been a taboo topic. We are now beginning to recognize End of Life (EOL) as a separate phase of life distinct from old age. There is very little information available about the prevalence of Post-Traumatic Stress Disorder (PTSD) at the end of life, however Dr. Feldman asserted that it is fairly common for people in EOL to have PTSD, whether from old wounds, or from the realization that their illness is terminal and death is approaching.

Rates of PTSD are well-documented in other populations: cancer patients 35%; rape 40%; combat veterans 30%. Dr. Feldman suggested that a patient with a diagnosis of a terminal disease may be traumatized, and/or that the trauma of this diagnosis may trigger or reactivate old, buried PTSD.

Is EOL PTSD different from “ordinary” PTSD? First, a review of the diagnostic criteria for PTSD:

• Experienced trauma
• Re-experiencing symptoms, including: intrusive recollections, nightmares, flashbacks
• Avoidance symptoms, including: avoidance of thoughts/feelings/conversations; of activities, places, people; emotional numbness
• Increased arousal symptoms, including: insomnia, irritability and angry outbursts, hypervigilance, increased startle response

PTSD affects the EOL client differently, and significantly impairs the client’s quality of life. PTSD symptoms sabotage the client’s ability to deal with EOL issues in the following ways:

EOL Issue: Reliance on family/social support

PTSD Symptom: Isolation/detachment (If the client has isolated self and numbed emotionally, she or he is unlikely to have reliable family/social support.)

EOL Issue: Importance of life review, resolving unfinished business

PTSD Symptom: Avoidance of trauma memories and unfinished business (If the client cannot think about his or her life, he or she cannot review it, or resolve unfinished business.)

EOL Issue: Need for good doctor-patient communication

PTSD Symptom: Hypervigilance, distrust in authority, need for control (If the client does not trust the doctors, she or he cannot have good communication.)

EOL Issue: Need for acceptance of death

PTSD Symptom: Avoidance of trauma reminders (If the client cannot think about his or her approaching death, he or she cannot accept it.)

Why treat somebody who’s dying anyway? Why alter your established and familiar methods? These clients are suffering, often severely, and are at an extremely vulnerable time in their lives. Their PTSD symptoms reduce their already-compromised quality of life. If you don’t adapt your treatment to their needs, you may not help them during their final weeks or months.

Two Common PTSD Therapies

Cognitive-Behavioral:

• Treatment mechanisms: exposure and cognitive restructuring
• Number of sessions: 8-16 (60-90 minutes each)
• Efficacy: leads to decrease in symptoms

EMDR:

• Treatment mechanisms: bilateral stimulation, exposure, reprocessing of trauma memories
• Number of sessions: 8-12 (90 minutes each)
• Efficacy: leads to decrease in symptoms

Problems with the Above Standard Therapies:

• Require too much time and too much patient stamina (often, a very ill or aged client simply doesn’t have the strength to sit up in session for 60 to 90 minutes)
• Often lead to short-term distress
• Focus on long-term outcome (with a dying client, you need to focus on short-term outcome)
• Can ignore important symptoms such as isolation, anger, and guilt
• Do not address EOL issues
• Have little role for family or caregivers
• Less effective in older adults due to cognitive deficits

Problems with Pharmacotherapy:

Antidepressants (SSRIs and TCAs) may be useful in relieving PTSD symptoms. However, they may take six to eight weeks to take effect and may lead to increased agitation. Furthermore, in an aged client, the effects of prescription medications may be less predictable than in the general population.

In this Situation, You Need a Method of Therapy that:

• Does not require multiple sessions
• Does not require long sessions or lead to fatigue
• Has immediate benefits
• Does not cause short-term distress
• Addresses guilt and anger
• Addresses influences of PTSD on dying
• Includes family
• Is suitable for geriatric populations

Feldman proposed a therapeutic model more suitable for this population. The staged model for treating EOL PTSD is much like what you do now but in a different order.

Stage I: Palliate immediate discomfort. If this works, stop now! If not, continue to Stage II, assuming the client is healthy enough, and likely to live long enough, to do it.

Stage II: Enhance coping skills and social supports. If this works, stop now! If not, continue to Stage III, again assuming the client is healthy enough, and likely to live long enough, to do it.

Stage III: Treat specific trauma issues.

Details of Each Stage of Treatment

Stage I. Methods for palliating immediate discomfort:

• Active listening — use empathy and validation
• Reassurance (e.g. providing information to soothe patient’s anxiety)
• Direct assistance in solving practical problems (Don’t bother “teaching a man to fish” when he does not have a future lifetime to exercise his new fishing skills.); Solve problems for the client if you can, keeping boundaries clear and maintaining good ethical relations
• Educating healthcare providers and family about how to avoid triggering PTSD symptoms (e.g. talk to hospice nursing staff)
• Mediating discussions with medical providers (e.g. go to the doctor with your client, and intervene if necessary)
• Mediate family conflicts and address concrete concerns with family

Stage II. Ways to provide coping skills and social supports (“teaching the client to fish,” assuming there is time):

• Provide psychoeducation regarding PTSD symptoms with patient and family
• Teach concrete coping skills (relaxation, breathing, mindfulness, thought-stopping, etc.)
• Provide problem-solving interventions (teach the client to come up with his/her own solutions)
• Improve communication and social skills
• Work with family members on above skills

Stage III. Suggestions for treating specific trauma issues (do not bring up trauma in Phase I or II):

• Don’t use prolonged exposure
• Use a reminiscence-based approach
• • Treatment should be patient-paced, probably with frequent, short sessions
  • Provide a safe environment
  • Use active listening (reflect, clarify, validate)
  • Facilitate reframing and meaning-making
  • Encourage forgiveness of self and others

Note that the above model of treatment probably doesn’t work as well as the standard model, overall — but it does decrease chances of making matters worse. Remember: “First, do no harm.”

During the question and answer period, members of the audience asked several important questions.

One question asked how to recognize if Stage I “works?” Feldman looks for indicators that it is not working, i.e. lack of symptom reduction and decrease in distress. If you get 80% success with symptom reduction in Stage I (palliation), perhaps that’s enough, and you may not need to move on to Stage II.

Feldman remarked that as a therapist working with this population, it’s best to stay with natural empathy, rather than focusing on all the therapeutic tricks we know and applying good-but-mismatched techniques. Be aware of your own fear of death. If you have it at a conscious level, you have a better chance of talking about it; but if you have it submerged, you will probably miss opportunities to address important concerns.

Another question asked how does one deal with resistance? (“I don’t need a shrink, I don’t have any mental problems!”) A good response is something like, “Okay, my purpose is to see if I can make your life better. How can I help? What would you like to talk about?”

David B. Feldman is an assistant professor of counseling psychology at Santa Clara University, Santa Clara, California. He holds a Ph.D. in clinical psychology from the University of Kansas and completed a fellowship in hospice and palliative care at the Veterans Administration Palo Alto Health Care System.

Author:  Melissa Miller, MFT
Presented by: David B. Feldman, Ph.D.

On Friday, July 25, 2008, Dr. James Kent addressed attendees at the SCV-CAMFT luncheon, held at Los Gatos Lodge. He spoke about California’s Victim Compensation Program (VCP), and its current outreach effort to providers.

James Kent received his Ph.D. in child psychology from the University of Michigan. Since 1991 he has worked in Sacramento as a consulting psychologist with the VCP. Two representatives from the Santa Clara County Office were also in attendance at the presentation: David Tran, Victim Advocacy Unit Supervisor, and Tiffany Stevens, Senior Compensation Analyst.

The VCP was established in 1965; every state has a similar program. By federal law, VCP is the payer of last resort for non-reimbursed out-of-pocket losses resulting from crime. It is not necessary for a claimant to exhaust Medi-Cal or Medicare benefits before qualifying for VCP services. The program is funded not by taxes, but by state and federal penalties and fines paid by criminals.

Kent emphasized that the purpose of the program is to provide services to as many clients as possible (unlike insurance programs, whose goal is to minimize their expenses). With a new electronic billing program coming on-line, claims for qualified cases should be paid within 30 days, much faster than in the past.

Covered crimes include murder, robbery, battery, physical and sexual assaults, child abuse/molest, domestic violence (DV), elder abuse, and vehicular offenses (DUI, hit and run, vehicular manslaughter, fleeing the scene of a crime, and assault with a vehicle). Victims are eligible for services if the crime occurred in California, or to a California resident victimized in another state. The individual must have no involvement or participation in the crime, and must cooperate with law enforcement authorities and the Victims Compensation Board (VCB).

An individual requesting services may qualify as a direct/primary victim. The victim must have been subjected to a crime, an injury, or threat of injury, and typically be named on the crime report, child protective services report, or on the declaration page of a restraining order. All that is necessary to qualify for services is to be a victim of a crime — no clinical diagnosis is required. An Axis I Diagnosis is not necessary; V-codes are reimbursable. Note: New CPT codes are available. Go to http://www.camft.org to download the new information.

Services are also available to derivative/secondary victims. Members of this category include the immediate family of the primary victim, members of the household at the time of the crime, and others in close relationship to the victim. Problems with immigration status will not disqualify an applicant.

In child abuse and neglect cases, where neglect/endangerment is sustained, services to the child are reimbursable. In DV cases, the child living in the home where DV took place is eligible; the child does not have to be present when the reported incident occurred. The non-offending parent of a victim of child sexual abuse (CSA) or physical abuse also qualifies as a derivative victim.

Kent stated that if an application for services is refused, an appeal process exists.

In certain cases, a Late Filing Application is appropriate. An adult victim of CSA can file if he or she: (1) never previously received compensation from VCP for the crime in question, and (2) has some supporting documentation. Documentation might be a police report, but could also be a Child Protective Services (CPS) report, a social worker’s records, a restraining order with a statement from the victim, or other documents. If no documentation exists, the applicant can, through the appeal process, say “I am the only one who can speak, as no documentation or evidence exists.” A victim can apply at any time, even many years later in certain circumstances (consult with a Victim Advocate at the VCP office in your county).

Benefits covered by the program include but are not limited to:

• Medical/dental/mental health services
• Income/support loss
• Crime scene cleanup
• Relocation expenses
• Funeral and burial expenses

A direct victim is eligible for 40 therapy sessions without challenge. A derivative victim may receive up to 30 sessions. A foster parent may receive 15 sessions. If a client has qualified as a derivative victim, and later it emerges that the client has actually been a direct victim, the category can be changed.

Providers are no longer required to complete a treatment plan (TP) at the end of their client’s fifth session. However, providers are expected to have a TP in the client’s file and readily available, if requested by the VCB. A TP outlines the focus of treatment, the methods to be used, and the means of measuring progress. The TP may be revised at intervals if appropriate.

The client may apply for additional sessions if he or she has exhausted the approved number of sessions. The therapist will submit the TP and an additional treatment plan (ATP) in support of that application.

There are limits to the total value of services provided ($70,000), as well as to mental health services ($10K for direct victim, $3K-$5K for indirect). In an especially severe case, one can apply for additional sessions (detailed documentation will be required). Even if full recovery is not expected, a victim may receive continuing maintenance treatment.

If the victim has insurance, the therapist submits a claim to the insurer first. Once the insurer pays (or doesn’t), VCP will cover co-payments, out-of-network provider fees, etc. For a faster turnaround in processing bills, the therapist should include an explanation of benefits (EOB), a document showing what the insurer has/has not paid; VCP can also verify this information by contacting the insurer. VCP’s reimbursement rates for an insured client are based on the insurer’s rate structure.

Visit http://www.vcgcb.ca.gov/ for rates and details about which practitioners may be reimbursed for what kinds of services. Note that certain services are non-reimbursable, including court appearances and related expenses, note taking, billing, research on the client’s condition, missed/canceled appointments, travel time, and treatment not necessary as a direct result of the crime. Pre-existing conditions are also not covered — except that often, pre-existing conditions come as part of the package. VCP deals with this ambiguity by refusing to consider this problem during the first 30-40 sessions; thereafter, they will look at pre-existing conditions or “downstream effects” (e.g. child has to change schools as a result of mother being a victim of DV) more carefully.

Therapists should contact their local VCP office to make sure the office has their current and correct address information. The VCP is in the process of converting to a new system. Payment procedures and address updates may take a little extra time, but once the transition is complete, updates to the referral list and payment of claims will be processed more quickly.

Visit http://www.victim.org/ and http://www.vcgcb.ca.gov/ to learn more about the program and to download forms and manuals.

Santa Clara County claims should be filed at 777 N. 1st St., Ste. 220, San Jose, CA 95112; or faxed to 408/289-5430. David Tran, 408/295-2656 ext. 335, is the Victim Advocacy Unit Supervisor, and Saher Stephan, 408/295-2656 ext. 316 is the Compensation Unit Supervisor.

San Mateo County claims should be filed at the San Mateo County District Attorney’s Office, Victim/Witness Assistance Center, 650/599-7479. San Mateo County has two locations: North County Municipal Court Building, 1050 Mission Rd. South San Francisco, CA 94080. South County Hall of Justice, 400 County Center, 3rd Floor, Redwood City, CA 94063.

Author: Melissa Miller, MFT
Presented by: Dr. James Kent, Ph.D.

On Friday, March 28, 2008, Dr. Mark Stanford presented SCV-CAMFT’s Mid Region luncheon, “Making the Difficult Possible: A Paradigm Shift — Treating Addiction as a Chronic Illness.”

Science shows us that drug abuse is a preventable behavior, and addiction is a treatable disease. Evidence from research demonstrates that addiction is a biologically-based brain disease. Prolonged drug use changes the brain in fundamental and lasting ways.

Nonetheless, myths persist: that addiction is a moral weakness; that you have to hit rock bottom to recover; that you have to want treatment for it to be successful; and that alcohol is not really a drug. We still presume (wrongly) that drug abuse is more common among minorities; that total abstinence from all psychoactive drugs is the goal of addiction treatment; and that methadone is just drug switching.

What is addiction, really? According to Dr. Nora Volkow, Director of the National Institute on Drug Abuse, a good working definition is “when you are unable to stop when you want to, despite being aware of adverse consequences...”

Addiction is a complex chronic illness, with both a genetic and environmental basis influencing development and manifestation. Recovery from it is a long-term process requiring repeated treatment. Relapses can occur during or after successful treatment episodes. Participation in self-help support programs during and following treatment can be helpful in sustaining long-term recovery.

People take drugs to feel good (to have novel sensations/experiences and share them) or to relieve symptoms such as anxiety, depression, and hopelessness. Initially, they take the drug hoping to change mood, perception or emotional state, i.e. to change the brain; later, they may not be able to stop because drug use rewires the brain.

Why do some people become addicted while others do not? Heredity and environment each play a part. If an individual has a family history of alcohol abuse, plus a lower-than-usual response to a normal dosage of alcohol when first trying it, studies show a long-term risk of alcohol dependency of 60%, versus 15% for a normal to high response (Marc Schuckit, University of California, San Diego, 2002).

There are many drugs available, but few with abuse potential: of the approximately 15 million substances in the world, about 55,000 are available for human consumption. Of these, only about 25 have the potential for abuse, because they mimic natural substances made in our bodies, but usually with far greater intensity. There are:

• Uppers (CNS stimulants) including amphetamine, methamphetamine, cocaine;
• Downers (CNS depressants) including alcohol, benzodiazepines (e.g. Valium), barbiturates (e.g. Seconal), inhalants, etc.;
• All-arounders (Hallucinogens): LSD, mescaline, MDMA (Ecstasy), psilocybin (magic mushrooms), PCP, etc.; and
• Pain Killers (Opioids) including heroin, codeine, morphine, Vicodin, Fentanyl, Oxycontin, and so on.

The substances that have abuse potential stimulate the brain’s natural reward system. The brain has pleasure circuits that reward the necessities for survival, such as water, food, sex, and nurturing. Drugs and alcohol affect the same areas in the brain’s reward pathways, but in a way that is dangerous and potentially fatal! Drugs feel better than sex, food, or nurturing.

Repeated use of drugs and/or alcohol saturates the brain’s reward pathway to the point that a person becomes conditioned to the intense level of drug-induced pleasure. Normal levels of natural rewards are no longer experienced as very pleasurable, and after chronic use, the brain’s reward system becomes depleted so nothing is pleasurable — not even the drugs!

The passage of time is the most important healer for addiction: within two-four weeks, the brain will have done a lot of recovery from drug use. However, for chronic high-dose drug use, expect six months to pass, and for chronic heavy marijuana use, one to three years, before the brain finally settles down. After chronic amphetamine use, the brain images look very much like clinical depression; furthermore, it will take two years before the forebrain begins to resemble baseline function levels. Note that the course and events of recovery vary greatly depending on the substance abused, the duration and intensity of use, and the individual’s biochemistry.

Prevention of relapse behavior is a critical part of addiction treatment. Drug craving behaviors are triggered by a conditioned response of the nervous system when re-exposed to an environmental cue it has associated with drug use. Memories appear to be a critical part of addiction. Relapse is usually triggered by external stimuli, people, places, and things. The conditioned responses can last a lifetime.

Decades of long-term studies show that substance abuse treatment is effective. It seems ineffective because we have been treating addiction as if it were only an acute condition — stabilize the patient, and discharge him. Compare what would happen if this were the standard treatment for other chronic diseases such as diabetes, hypertension, or asthma! Clearly, a disease-management approach is appropriate for addiction. Instead of looking only at outcomes immediately post-treatment, we need to look at the effect of ongoing interventions (meds, lifestyle changes, and self-management). In addictions, as with other chronic conditions, treatment effects are significant but don’t persist after discharge unless some level of continuous care is provided.

The standard of care for addiction has been as an acute care problem; the standard of care needs to be revised. HMOs and lawmakers both need to understand and change their perspective.

Improving chronic illness care requires a treatment model of Sustained Recovery Management (SRM): once the patient is stabilized, over time the provider can build the client’s personal responsibility and decrease treatment intensity. Truly, you can never close the case when treating addiction. Eventually, phone checkups can be an effective way of keeping the patient on track.

Lessons Learned:

• Having multiple acute care episodes is not a continuing care strategy — it’s expensive and wasteful. Patient education is necessary — client/therapist planning for some type of continuing care is essential.
• Patient retention is critical: make treatment attractive, offer options and alternatives, increase monitoring and management.
• Evaluations of continuing care should occur during treatment, including interim performance markers.
• Patients who are not in some form of post-treatment monitoring are at elevated risk for relapse.
• Monitoring is part of health care: phone and Internet contact is useful in reducing the number and severity of relapses.
• Frequent contact with the therapist is essential from both the outcomes and cost perspectives, as experiences in the care of other chronic illnesses demonstrates.

Useful Web Links:

• National Institute on Drug Abuse (NIDA) — http://www.drugabuse.gov (they provide lots of free downloadable tools, plus useful printed materials with free shipping)
• Santa Clara County Department of Alcohol and Drug Services — http://www.sccdads.org
• American Society of Addiction Medicine — http://www.asam.org

Mark Stanford, Ph.D., is the Medical and Clinical Services Manager for the Addiction Medicine and Therapy Division of Santa Clara County Department of Alcohol & Drug Services. He is a member of the Association for Medical Education & Research In Substance Abuse (AMERSA). Dr. Stanford is also a clinical research educator in the behavioral neurosciences, Associate Professor in psychopharmacology at Cal State Hayward, UC Berkeley Extension, and Lecturer at Stanford University Department of Family and Community Medicine. He has been in the addictions treatment area since 1976 and has been a provider within the modalities of residential, day treatment, outpatient and medication-assisted treatment programs.

Author:  Melissa Miller, MFT
Presented by: Dr. Mark Stanford

Dr. Teri Quatman opened the SCV-CAMFT luncheon with a discussion about eating disorders, a condition that she and Susan Martin have been treating together for over three years — people who, in DSM IV TR terms, have an Eating Disorder NOS. Martin has been working with eating disorders for over 20 years and Quatman has treated patients for 20 years and teaches at Santa Clara University.

Quatman described some of the characteristics of their patients. These patients are chronic dieters as well as compulsive over-eaters. They are people who have tried, among other diets, Optifast, Weight Watchers, and Jenny Craig. Many have gained, lost, and re-gained 100 lbs or more and have done so more than one time. Diets have failed these patients. During binge episodes, calorie consumption can be thousands of calories in a sitting. Two-thirds of their patients started using food during childhood to manage psychic distress.

Treatment modalities include providing nutritional education, group therapy and individual psychoanalytic psychotherapy. This multidimensional treatment offers a place to re-gain hope, dignity and a healthier relationship with food.

Martin discussed a case that illustrated the concept: “the food addict is born from trauma.” Food addicts learn, due to early trauma, that they will not survive if dependent upon human beings, and we all come into the world as dependents. Psychoanalytic ideas from W. Bion, Gianna William, and others detail the idea that early damage continues to have a voice if not addressed. When the relationship between the mother and the infant is one where the infant is not able to be psychically held, or contained by the mother in a safe way, the infant suffers trauma. As infants, often these patients are traumatized (not held or cared for adequately) and are unable to feel safe while dependent on their mother.

While many addictions stem from early damage to the relational system, everyone needs food in order to survive. These patients suffer from damage to the capacity to receive and regulate food consumption, as well as an inability to relate to their feelings or be conscious that they are experiencing feelings in their bodies.

As children, these patients became the container for the parent's projections rather than being able to safely project their parts of self into their primary caregiver. The case presentation discussed a patient’s fear of taking something in that was not under his or her control. Images described by clients include: drowning, losing the skin boundary, and a dream description of an invading insect.

Quatman and Martin described addiction as a relational disease. Feeding disorders, like merycism — when a child regurgitates food repeatedly — can cause the infant to starve. Quatman’s and Martin’s patients suffer a form of psychic starvation and use food to keep themselves together. Through their clinic, the presenters help people locate emotional experience — feelings in their bodies — and then learn to relate to these emotions over time. Participants learn to feel safe with other group members and the therapists. As with many early trauma cases, healing happens over time while the patient, therapist and group develop a safe, containing relationship.

For more information or to refer a patient to services, contact Dr. Teri Quatman and/or Susan Martin at the Haunted by Hunger Treatment Recovery Program for Chronic Dieters and Compulsive Overeaters, 408/366-1980.

Presented by: Teri Quatman, Ph.D., and Susan Martin, M.S., M.A., MFT
Author: Lara Windett

With the heightened media exposure of postpartum mood disorders we are finding an increase of people seeking therapy for such issues. Perinatal is a term often used to describe the stage between conception to one year postpartum. Many individuals or couples seek help during this time because pregnancy, birth and parenting are life-altering events. It is important for the therapist, as well as the parent(s) to recognize this and to realize that there is no way to have life resume as “normal” once these events have occurred.

New parents are dealing with changes in identity, learning to adjust to the role of parent, heightened or newly discovered problems in the couple relationship, and financial, career or housing issues add to the stress they face. In fact the most common time postpartum mood disorders present themselves is two to three weeks after the birth of a child, which coincides with the end of initial post-birth support of friends and family. This is also a time when fathers will typically go back to work. Social isolation, problems in couple relationship, history of depression, low socioeconomic status, lower education, and age (below 20 or above 40 years old), as well as hormone imbalances are among the list of factors which may increase a person’s likelihood of developing a postpartum mood disorder.

Postpartum mental health problems include anything from the baby blues, depression, anxiety, OCD, bipolar disorder, psychosis and PTSD. Many of these issues were presented during the luncheon. First, it is important to recognize the difference between “the blues” and postpartum depression. The onset of the blues typically occurs one week after birth and 80% of women experience this. The symptoms last for up to three weeks and they present as weepiness, sadness, concerns around being a good parent or how to care for the baby, lack of concentration and feelings of dependency. In contrast, postpartum depression occurs in 15-20% of women. The onset is more gradual and can occur until one year after birth, and the symptoms are irritability, feeling overwhelmed, loss of focus or concentration, hopelessness, anhedonia, discomfort around the baby, lack of self-care, and suicidality (this could present as believing someone could do a better job raising the baby).

Anxiety is one of the most common present problems during the postpartum period, but that does not mean that it is normal. Anxiety can lead to hypervigilance around the baby. Because depression and anxiety go hand-in-hand, here are some good assessment questions to ask:

• What is your sleep pattern? How often do you awaken? Do you awaken refreshed?
• When was the last time you ate? What have you been eating?
• Tell me about your response to learning that you were pregnant?
• What is your experience of parenting?
• Is this your first pregnancy? Birth? Baby? Experience with breastfeeding?
• Have you ever had an experience with a mood disorder in the past?
• Tell me about your couple relationship.
• Are you experiencing a difference in your thought patterns? Are your thoughts critical? Racing? Frustrated? Angry? Frightening?
• Are you having thoughts of hurting yourself?
• What are your thoughts about returning to work or school?

With the last one in particular look for feelings of guilt they may be experiencing.

Postpartum manifestation of obsessive-compulsive disorder is unique. It is important to ask about frightening thoughts or fantasies that the client knows are irrational, especially if those thoughts are disruptive to the client’s day. These thoughts can be anything from accidentally drowning the baby while bathing it, having accidents involving the baby, the baby falling, or other situations that the mother avoids. It can also involve “waking nightmares”. OCD may lead to further isolation and shame. Some assessment questions to assess for OCD are:

• Do you ever have frightening thoughts concerning the baby or someone you care about?
• Are the thoughts disruptive to your day or to the choices you make?
• What happens when you have these thoughts?

The difference between OCD and postpartum psychosis is that people experiencing OCD are more aware that those thoughts are wrong.

Postpartum psychosis is relatively rare, occurring in only 1 or 2 per thousand mothers. However, almost every woman thinks she has it, and many are hesitant to seek help. They may fear the stigma of being a bad mother, or perhaps they fear that their child(ren) will be taken away from them. Postpartum psychosis presents with visual, auditory and/or olfactory hallucinations and delusional thinking. The content is often religious in nature (for example, Andrea Yates believing her children were possessed by the devil and she had to rid the world of them). They do not realize it is abnormal; it is very hard for them to determine what a reasonable fear is and what it is not. Postpartum psychosis is a crisis that requires hospitalization. The baby, mom, or other family members are in danger. This will require a multi-modal care team to treat.

Research indicates that bipolar disorder that was sub-clinical before birth is often the cause of postpartum mood disorders. It is important to assess for previous mania and a family history of bipolar disorder. Some questions that can be asked are:

• Is there a history of mood disorders in your family?
• How would you describe your mood after the birth of the baby?
• What has your sleep pattern been like since the baby’s birth? Can you sleep when the baby is asleep?
• Have you ever seen or been aware of something that no one else can perceive?

One should be aware that sleep deprivation may lead to psychosis, and should be ruled out. Also, a client with bipolar disorder will generally seek help in a depressive stage, so be sure to assess for manic episodes.

People may experience post traumatic stress disorder due to the birth of their child. It could be something traumatic about the birth itself, or something resulting from their childhood, whether consciously remembered or not. If epidurals were used during the birth, the body is generally numb and the woman will be aware that something is happening around her lower extremities but will be unable to do anything about it. If she has been sexually abused, she may dissociate, which in turn may scare her and/or her partner. Men may also experience trauma because they are unable to fix whatever is happening or the pain their partner is experiencing. Hospital workers, caretakers, the father, or other family members may experience secondary trauma when the mother is unaffected. Ask questions about the history of conceptions, pregnancies and births:

• What were your expectations of birth during pregnancy?
• Were there any complications during pregnancy/birth?
• Is there a history of trauma?
• How did being a part of pregnancy and birth affect your partner?
• Are there any mixed feelings?

As addressed in the above paragraph, fathers also experience perinatal-onset mood disorders and traumas. Paternal problems occur at approximately half the rate they occur in mothers, though these problems may be underreported. Additionally, maternal disorder increases the likelihood of the father having a disorder. As practitioners, we most likely will not see men present themselves, but when counseling couples you will see it. Many times the problems will present as the father indicating difficulty attaching to the baby. Ask the father about his experience of fatherhood and the birthing process.

While assessing for postpartum mood disorders, follow your normal procedure paying particular attention to ways disorders may manifest during this unique time. Look for a history of substance use, suicidality, cutting behavior, or eating disorders, as those issues tend to manifest again after the birth of a child. Remember that birth is a sexual event; so pay particular attention to trauma concerns. Other assessment tools to use to specifically screen for postpartum mood disorders are the following:

• Postpartum Depression Screening Scale
• Edinburgh Postnatal Depression Inventory
• Center for Epidemiologic Studies — Depression Scale
• The Burns Anxiety Inventory

Suicide is one of the top three leading causes of death during the postpartum period, therefore the most important intervention is safety planning. Continually reassess the risk, check on family support, medical support, and educate the client and partner. Have suicide and crisis numbers available at all times. Group therapy decreases isolation, decreases the “myths of motherhood,” and will put the individual/couple in touch with local resources. Therapy may help the couple realize they cannot ever get back to “normal,” but they will redefine what “normal” means with a child, facilitating reconnection and communication. Individual therapy can help define what a “good mother” is, teach adjustment/mood stabilizing techniques and address and encourage self-care. For those who have experienced trauma it will be important to address it in therapy. Medication can be left up to the individual whether they want it or do not, as few studies have proven its efficacy.

For more information on postpartum mood disorders please refer to the following organizations:

• Postpartum Support International
• North American Society for Psychosocial Obstetrics and Gynecology
• Coalition for Improving Maternity Services
• Association of Pre- and Perinatal Psychology and Health
• Trauma and Birth Stress

Presented by: Angie Nunes, MFT, and Sharon Storton, MFT

Reviewed by: Amy Sargent

At ten percent mortality rates, eating disorders are the deadliest of any disorder in the Diagnostic and Statistical Manual (DSM). Only a quarter of those who suffer from eating disorders recover. Another half continues to struggle with relapses. The other quarter never recover. The average age of people with eating disorders is getting younger and younger. More boys are starting to develop them as well as women well into middle age.

Culture plays a huge role in this phenomenon. Although eating disorders have been documented from the 1800s the occurrence of them was very rare. Even in the 1970s they were not common, and were not yet a classified disorder in the DSM. Then, the women’s movement started to change women’s roles. And media came to have a large impact on the way women view themselves. This was evident from the example of Fiji. When this remote island country had no media access, people were quite large and obesity was not looked down upon. However, when television and magazines were introduced incidences of eating disorders skyrocketed over 100%.

Dr. Herb described the impact of television, magazines and the Internet as being brainwashed by the media. She gave the example of New Year’s resolutions being to lose weight so for a while in January everyone seems to be on a diet and going to the gym. There is a sense of pressure for a while to lose weight and become thin. That sense of urgency that we feel then for a limited time, is what adolescents feel constantly. They face pressure every day when they are at school, sports, dance, other extra-curricular activities, social or peer groups. The pressure to be thin has created a phobia, and prejudice, about being fat.

Cultural influences are only one factor of many that lead to a person developing an eating disorder. There are family issues to be considered, genetic factors, environmental factors, unresolved abuse or trauma, individual factors, as well as stress and other factors. The key variable is that something has caused an obsession with a person’s body image.

There is a spectrum of eating or body-image issues. People suffering from anorexia nervosa have a distorted body image where they truly do not see how thin they are. Eventually after starving themselves enough, their sense of hunger goes away so they are not ever aware of their own need for food. People with bulimia eat to make themselves feel better. Not only is the food a source of comfort, but there is also a chemical that is released in the brain after vomiting that makes the person feel better. Binge eating disorder, which is currently in the appendix of the DSM, helps the person numb themselves from the food. There are also sub-clinical features such as yo-yo dieting, skipping meals, using diuretics and pills, among other types.

Assessment

One helpful assessment tool is to have the person draw a “weight life line” on a piece of paper. They should indicate points in their lives for which they remember how much they weighed at the time. This can be a good tool to find out about events that may have triggered any large weight changes. By finding out the triggers or the patterns you will be able to do the deeper work necessary. Because these disorders have an obsessive-compulsive component the person will know this specific information.

Eating behavior should be explored, not only currently but also ask about when they were younger. Have them recall what dinner time was like in their home. Get a description of where everyone in the family was, what relationships the people had, where they were eating, what has happening during dinner, and the like. Dinner time is the worst time for people with eating disorders. Finding out about their early dinners or memories around food and eating will help uncover unresolved issues.

Other histories should be taken such as dieting behavior, food cravings or their relationship with food, emotional/affective histories, especially around depression, phobias, anxiety, anger and past traumas. A cognitive assessment should be done regarding self-esteem, their negative self-talk or criticisms, cognitive distortions (especially around body size/weight), family history of emotional problems, abuse issues, family communication and dynamics, especially regarding an emphasis on family cohesion and control or restrictive values. Also look for impairment in relationships, poor communication skills, lack of assertiveness, inability to handle conflict and whether the person is able to receive nurturance from others. Because of the potential of physiological damage there should be a medical assessment.

Treatment

In treating people with eating disorders the therapist should think of themselves as a case manager. Dieticians, psychiatrist, physicians, physical trainers (who know eating disorders), and massage therapists should all be included as a team caring for the individual. Working with the person’s significant other and family systems would be beneficial, especially if they can be a source of support for them. Group and individual therapy would be good concurrently, if possible. Treatment plans should be highly individualized though, as the needs of each person will be very different.

People with eating disorders feel they have no choice but to persist with their behavior. We cannot take away their symptoms without giving them another way to cope. Teach them that they have another choice. You should not tell the person they have to give up their eating disorder behavior. Instead, you should tell them that they do not have to give it up, which paradoxically will let them be able to. Empower them by giving them choice. Dr. Herb said the most important thing is to get them “living in their own body and feeling power.”

Help them build new cognitions instead of the negative/critical ones that tell them they are not good enough, not thin enough. Write out affirmations and tell them to “fake it until you make it.” Behaviorally they have a lot of anxiety so they need to learn how to relax. Using guided imagery or meditation would be good. Remember that treating eating disorders is a long process so each of these things should be done in very small steps. Also, we should normalize relapse because perfectionism is rampant in this population. By admitting mistakes of their own, the therapist can be a role model to those with eating disorders.

Work toward resolving the deeper issues that drive the person toward eating disorder behavior. If a client cannot talk about something, use art therapy with them. Allow them to be creative because this will give them a voice. This is especially useful for those who may have cognitive impairment due to physiological damage from the disorder. If they are intimidated by artwork, allow them to put together collages. Cutting things out and pasting them can be less threatening.

In order to be able to do this work we need to be comfortable with our own bodies and our own eating behaviors. Dr. Herb indicated that, for general eating disorders, therapists who take the time to become educated on these issues will be able to treat them. However, those suffering from chronic eating disorders that have had many relapses should be referred to a specialist. To get more information about eating disorders visit www.bulimia.com. For more information on Dr. Herb’s “Health at Every Size” approach visit www.therapy4women.com.

Presented by Ellyn Herb, Ph.D., CEDS

Reviewed by: Amy Sargent

One of the many benefits of using the Enneagram in therapeutic practice is the development of awareness and the ability to notice habits of mind — ours and our clients’ stories, assumptions, and beliefs about the world; our internal map of reality. So, when Ben Saltzman and Donna Fowler started their presentation of the Enneagram with a breathing meditation to help us be centered and aware, they were setting the stage for a talk that was not only informative, but also experiential in many ways.

Saltzman is a teacher and author of several books; he currently teaches at the Institute of Transpersonal Psychology and facilitates coaching seminars at John F. Kennedy University. Fowler is a Master Certified Coach for individuals and business executives, and was coaching even before it became a recognized discipline. She has been a Certified Integral Coach with New Ventures West since 1997.

Enneagram Basics

Saltzman explained that the Enneagram is a system that bridges the psychological (ego structure or personality) and the spiritual (essence that transcends the ego). Our ego structure represents our internal map of reality and is the filter through which we see the world. It is a map to our motivations and consequent behaviors. The Enneagram provides the option of working with essence instead of personality. Bringing essence to the therapist/client interaction is a powerful way to work. Clients come to therapy with a story or an expected outcome; the goal in using the Enneagram is to work at the deeper level of essence.

Fowler gave us the Enneagram basics. She explained the 9-pointed star-like Enneagram symbol. Each point of the star represents a core personality (ego) structure with its particular filter of the world. While we all possess some bits of all of these traits, we tend to identify more with one particular point. A person does not reside at a fixed point on the Enneagram, but instead moves to other points depending on other factors (not covered due to our limited time). The Enneagram is a multi-level system, and the points are further divided into various triad groups.

For example, there is a triad group for how people know the world. The body types (points 8, 9, and 1) know the world through their bodies (their guts), the heart types (points 2, 3, and 4) through feelings (or emotions), and the head types (points 5, 6, and 7) through thinking about things.

Recognizing someone’s point and how they know the world facilitates working at the essence level. Because the Enneagram enables clients to be truly seen, healing can take place. Using the Enneagram, the therapist can address the motivations underlying the story and thereby accelerate change. Fowler presented “The Deep Change Coaching Model” as a tool to help uncover motivations and change behavior.

The Deep Change Coaching Model

The basic premise of the model is that behavior is a result of our inner map of reality, of how we see and interpret the world. When we intervene at the level of behavior we get marginal results that often do not last. When we shift a client’s internal map the changes are deep, lasting and transformational. Shifts at this level allow the client to experience the world and themselves differently. The two interventions used with this model are language and practice. These interventions help clients uncover motivations, shift their inner map, change behaviors, generate new tangible results in the world.

Interventions — Language and Practice

Therapists introduce a new language to clients, which opens them to previously unknown states of being and concepts which result in ‘aha’ moments. Clients then reinforce these insights by practice (or homework). For example, Fowler told her personal story of fear of public speaking. For her to have sustainable long-term change, she needed to bring unconscious material into consciousness. Using the Deep Change Coaching Model, she was able to see that her issue was that she perceived that “the mob” was dangerous to her. This realization was facilitated by Fowler’s awareness that she was a six on the Enneagram, the core point of the fear triad, and that this fear was outside of consciousness.

Fowler was able to experience the very first “hit” of what made her scared. Just talking about it would not have helped her make the change. She had to imagine being in a group, and what was being provoked within for her to experience the thought pattern. She could then change her thoughts of “the mob” into “individuals” and thus reduce her fear. Other points on the Enneagram might experience fear of public speaking in different ways. A three might be afraid of looking bad, not fulfilling the image of public speaker. The issue for a three would be self-deceit — that one’s image is the real self. So, the language and practice used with a three would be different.

Our Peers in a Live Demo

One of the best ways to understand the Enneagram is to listen to people being themselves — their Enneagram points revealed through the questions of an experienced coach. Saltzman and Fowler arranged for a panel of three volunteers, Beverly Kam (point one), Bonnie Faber (point two), and Bea Armstrong (point seven). What follows are partially edited excerpts from the interviews. Saltzman used the question “What is the trigger for your anger?” as a way to access information representative of their respective Enneagram points.

Saltzman: “The core belief of a two is that love needs to be earned. Attention is drawn towards others’ needs. Twos take pride in believing they are special and can be of service. Bonnie, what is the trigger for your anger?”

Faber: “Twos don’t get angry, except perhaps when I give more than I want to. I am resentful; I think people are withholding and somehow I’m not worthy. When I’m in a group, I’m always scanning for peoples’ needs; I lose myself completely.”

Saltzman: “What has growth looked like for you?”

Faber: “Becoming aware of what my needs are. To ‘be’ and not ‘do’. And being able to receive — I’m not supposed to have needs; it’s selfish. So, a major practice for me was being alone and being with my own needs.”

Saltzman: “The core belief of a one is that there is perfection in the world. Ones reach for perfection, and want to help everyone else to be perfect, too.”

Saltzman: “What is the trigger for your anger?”

Kam: “It’s not right to let my anger out. But, there are so many triggers (laughs). For example, I was driving my son to school, counting all the people who don’t use their turn signals — I think, “I’m doing it, why can’t they?” I get angry at my son for not obeying etiquette rules. My son kept acting out at school. And, I’m mortified. I’m a therapist! I realize that I need my family to act out for me... It’s like I have to contain the id impulses, like swearing, acting goofy, being dirty; it’s all held in and then propelled out onto my son.”

Saltzman: “What has growth looked like for you?”

Kam: “Having compassion. Ones are always assessing — so healing is releasing the critic by being present and not paying attention to it.”

Saltzman: “The core belief for sevens is that they are the epicures of the world. Their passion is gluttony; they want to experience everything. Bea, what triggers your anger?”

Armstrong: “What anger? It’s short-lived when I’m feeling thwarted or something is keeping me from getting stuff done. It’s been years since I yelled at someone.”

Saltzman: “What is a busy day for you?”

Armstrong: “A typical busy day would be: go to the bank, pilates class, get the car washed, take the car to the dealership, run three errands, go to the office, do case notes, have dinner with friends.”

Saltzman: “What drives the activity?”

Armstrong: “The world is a smorgasbord. I want to get away from limitation.”

Saltzman: “How do people limit you?”

Armstrong: “I grew up in an abusive home. Busy-ness means no one is going to constrain or control me. It alleviates the anxiety from being trapped.”

Saltzman: “What has growth looked like for you?”

Armstrong: Giving myself downtime — pajama Sundays; a whole day relaxing, reading; meditation was a huge change for me — to find quiet time.”

Saltzman concluded with some examples of how different points on the Enneagram respond to situations in different ways. If a father leaves a child who is a four, the child might think, “He abandoned me”. Whereas, if the child is an eight, the child might think, “He turned on me.” We are born with these tendencies and at some level they are hardwired. Our points manifest when there is loss of the “holding environment”. Our compensation for distress in our lives is our ego structure and shows up on a continuum based on the severity. So, our ego organizes itself to get back what seems to be lost in our lives.

Presented by Benjamin Saltzman and Donna Fowler

Review by: Pamela Eaken

Is therapy appropriate for children before they are even five years old? What could be so wrong with someone so young? And how could a therapist begin to help?

These and other questions were asked and answered at January’s SCV-CAMFT South Region Luncheon. Members of the Santa Clara County Infant Mental Health Collaborative discussed the important mental health research increasing our understanding of the significance of early trauma, attachment and brain development (particularly of the cerebral cortex). The panel included Howard Doi, MFT, current Chair for the Infant Family Mental Health Collaborative for Santa Clara County; Julie Kurtz, MFT, Director of Mental Health Services at Kindango; Charlene Canger, MFT, LCSW, BCD, social work consultant at Stanford’s Division of Neonatology; and Sharla Kibel, MFT, of County Mental Health as part of a First 5 Early Learning Initiative.

Kurtz acknowledged the “whys” and “hows” of therapy with very young children. “How messed up can they be at that age?” she challenged her audience, but it soon became apparent that we were all asking ourselves the wrong question. A better question is “How helpful can therapy be to such young children?” Studies of animals have demonstrated that development in the brain’s cortex is most rapid in young animals that receive generous nurturance, stimulation and are able to exercise some control over their environment. These vital brain-developing elements must be provided to human infants by a loving caregiver. A compassionate, responsive caregiver also helps a very young child develop the key skills needed in self-regulation, arousal and self-calming.

When a parent and baby experience difficulty engaging or “bonding” with each other in the early days of life, parents will find themselves less “tuned in” to their infant, resulting in a cycle of unmet needs and frustration. This lack of attunement between parent and child also results in lost opportunities to develop vital self-regulation skills and cerebral cortex growth. The first three years of life are a critical period of building the “architecture of the brain,” according to neuroscience research presented by Canger. Early development is not merely about “walking by one and talking by two,” she explained, but developing a secure attachment that supports the ability to tolerate stress and sets the stage for the ability to develop empathy later in life. Persistent neglect in the early years potentially can leave children less resilient to setbacks for years to come.

Families at risk for poor attunement and related far-ranging problems include those with parents who are overwhelmed by the circumstances of their own lives, which can include trauma, depression, chaos, and addiction. Such obstacles might stand in the way of effective attunement in some families. Sometimes a child has special needs that overwhelm a parent’s ability, such as severe neurological problems, Down’s syndrome or Autistic Spectrum Disorder.

Not all parents of children with special needs have difficulty meeting the needs of their young children. A heartwarming example of such a case was shared by Doi. A mother was told repeatedly that due to the severity of her child’s disability, institutionalization would be required. She refused. Instead, she worked with her child herself with love and patience, returning a year later and stunning the health care providers with the child’s developmental progress. The power of a mother’s dedication, determination and love, and her ability to sustain hope despite overwhelming circumstances served as a powerful example that love grows the brain, not just in babies, but for the parents, too.

For families at risk early intervention is critical. The next question was, “How does a therapist work with such a young child?” The answer is, of course, to work with the whole family, and on many levels.

Therapy with young children and their families is not a neat and tidy process contained in a fifty-minute hour in an office. Most of the work is done with the children and families in their homes and community, on tables, floors and playgrounds. This form of therapy must meet families’ needs on several levels, one at a time or simultaneously.

Santa Clara County Infant Family Mental Health Collaborative recommends multiple levels of support in therapy with young children’s families:

1. Concrete support to relieve stress and meet immediate needs for housing, money, childcare and other specific needs through active use of community resources.
2. Strength-based support coupled with non-dydactic parent education: recognizing and appreciating the positive and finding opportunities to support steps to create small changes to help parent and child alike. A therapist must observe, build and join with the family before gaining the credibility to challenge the family to see more possibilities.
3. Building parents’ insight into their own background and how life experiences help and hinder effective attunement.
4. Emotional support from the therapist, who engages the family in a healthy relationship to support the parents to form stronger bonds with their children. In some cases, this can involve actively and repeatedly reaching out to families to help meet needs and find opportunities to support a stronger connection.

Intervening while a child is very young is vital for developmental and physical growth, and families must be approached on a variety of levels to enable them to meet their own unique set of needs. How can we know where to begin?

Kurtz emphasized the importance of ongoing assessment, as therapy begins and occasionally during the course of therapy, since children can progress so rapidly at such a young age. Valuable tools for effective early childhood assessment, the Ages and Stages Questionnaire (ASQ) and Ages and Stages Questionnaire: Social-Emotional (ASQSE), were recommended for identifying red flags and making appropriate referrals. These questionnaires are designed for parents and childcare providers to answer themselves, in order to determine an appropriate course of action with a therapist’s assistance. These questionnaires, available in English and Spanish, and the ASQ Treatment Planner can be found through Brookes Publishing at www.brookespublishing.com.

The presentation in January challenged the way we, as therapists, think about the mental health care of infants, toddlers and preschoolers. Many organizations in Santa Clara County, through the support of the First 5 Early Learning Initiatives, are working together to expand services to families with young children. Nationally and throughout the state, conferences are being held to get the word out. Zero to Three: National Center for Infants, Toddlers and Families will be holding a certification workshop in Sacramento in March. More information can be obtained at www.zerotothree.org.

Is therapy appropriate before the age of five? Absolutely! According to the Santa Clara County Infant Mental Health Collaborative, the earlier the better!

Review by Marté J. Matthews, M.A.

Marté J. Matthews, M.A. is an MFT Intern at Community Health Awareness Council in Mountain View. She has also been a parent educator since 1995 and a behavioral interventionist for six years.

At the September luncheon, Dr. Robert Navarra gave us some of his insights from his research and work with a therapy population that has rarely been studied: couples in long-term recovery from alcoholism. He began by giving an overview of the impact of addiction on family functioning, including:
 

• Poor boundaries (overly rigid or overly disengaged)
• Alcohol as an organizer of family roles and behavior
• Claudia Black's "don't talk, don't trust, don't feel" family rules
• "Wet systems" (when the alcoholic is actively drinking), which usually cause more family stress and alternate unpredictably with "dry systems." However, some families operate better when the alcoholic is drinking (i.e. when the drinker becomes more mellow, passes out, or disengages)

Summarizing the results of his own research and that of Stephanie Brown and Virginia Lewis, Navarra discussed early recovery as a period of destabilization of the entire family system, including the couple. This collapse, while painful, is a prerequisite to recovery. And this destabilization continues long after sobriety begins.

Once organized around alcohol, now recovery is the new family organizer. Contrary to the happy (and often unrealistic) expectations a couple may have about recovery, this reorganization traumatizes the family system. There is a kind of freeze in working on couples issues while the alcoholic and family member are encouraged to separately "work their own programs."

If successful, the couple moves through stages of recovery, which Brown and Lewis have labeled as drinking, transition (when the person believes they may have a problem), early recovery (when they become committed to abstinence), and ongoing recovery. The couple's navigation of these stages may depend on a number of factors, including their couples typology (Brown typed couples based on whether one, both or neither member is in recovery).

After studying transcripts of a monthly focus group of couples in long-term recovery that met for five years, it was concluded that in long-term recovery couples begin to maintain individual and couple recoveries concurrently. The researchers saw on-going couple development begin to be addressed, and identified three main components of this development:

• Shifting: a dramatic movement toward the centrality of the couples relationship, and shifting of identities, roles, and boundaries from what they had been prior to recovery
• Intergenerational Reworking: An increased awareness of and filtering out of harmful "old tapes" from family of origin, leading to "shedding" of current destructive patterns
• Attending: The ability to attend to one's own needs AND be available to one's partner

This model, labeled the Couples Reciprocal Developmental Approach (CRDA), is a way of conceptualizing couples in recovery, and can be used within a variety of therapy treatment approaches to assess and treat these couples. When treating couples with this model, it is helpful to:

• Ask yourself and your couple: where does the couple stand with each of these three components?
• Normalize these components to clients as part of the rocky road of healthy recovery
• Delay working with relationship and intimacy issues until after early recovery is successfully navigated
• Remember: movement through recovery stages is very slow and typically non-linear; in fact, the average amount of time between when an alcoholic acknowledges s/he has a problem and when s/he does something about it is two to three years. Therefore, we therapists need to be VERY patient!

Robert Navarra, Psy.D., MFT is the Clinical Director of the Center for Couples in Recovery, which is associated with the Mental Research Institute in Palo Alto.

Review by: Barbara Griswold, MFT