Event Reviews

On Friday, October 22, 2004, Dr. William C. Klindt addressed attendees at the SCV-CAMFT luncheon on the subject of brain scanning technology. Klindt shared numerous images of brains from his library, and spoke about what we can learn from brain imaging. He showed a series of pictures of normal brains, as well as providing images of brains damaged by stroke or injury, brains altered by substance abuse or chemical exposure, and brains of patients with a variety of psychiatric and behavioral disorders.

Fundamentally, with brain scanning technology, we now can know what "normal" looks like at various ages and stages of brain development. We can also see what's working properly inside the brain, and more importantly for us as clinicians, what's not working.

Because human brains are all basically similar, the library of images on file gives us a baseline for comparison. And because each brain has its unique variations, we can see them through brain imaging, and know pretty well what those shadows on the screen mean. A given area that, for example, is calm and quiet in a normal brain, may show excessive activity (appearing "hot") in a disturbed individual. That overactivity correlates to the behavioral manifestations that correspond to an anxiety disorder. A different area that would normally show moderate activity may be "cold" (underactive). The behavior of the individual will resemble that of persons who have suffered injury to that particular area of the brain. In both situations, proper diagnosis and treatment is made much easier because the scan shows clearly what needs to be treated.

It can be advantageous to use brain SPECT imaging when one sees or anticipates:

• mild to severe brain trauma
• dementia (including Alzheimer's, Pick's, and vascular dementias)
• cognitive decline
• seizure activity, including temporal lobe epilepsy
• atypical psychiatric disorders
• cerebral vascular disorders
• aggressive or violent behavior
• substance abuse
• exposure to toxic substances

SPECT imaging is also an extremely useful tool in situations where a forensic/legal evaluation is required. The procedure takes only about 10 minutes. The patient lies still on a bed, radioactive dyes are injected, and then the bed is moved so the patient's head is inserted into a cylindrical scanner. The scanner rotates around patient's head, taking successive "slices" of image. The radiation dosage is approximately equivalent to having a chest X-ray, and is 400 times less than the amount of radioactivity designated as "perfectly safe" by U.S. government agencies. Health insurance coverage of this procedure is mixed: PPOs often reimburse for it, while HMOs usually do not. MediCal may cover it in certain limited circumstances. The out-of-pocket cost is $1,100 for a single scan. Klindt prefers to do two scans, for a total cost of $2,200. Procedures other than SPECT, i.e. PET scans and MRIs, are much more costly. For patients without insurance, and without the financial resources to pay for scans, the Recovery Assistance Foundation in Southern California may grant funding.

Klindt shared numerous slides from his library of clinical images. There are several ways of "looking" at the brain. There are sectional views: horizontal (top-down view, in a sequence of images "stacked" one upon the other), sagittal (vertical front-to-back slices, in a sequence moving right to left), and coronal (vertical slices as viewed from the front). The isocontour view shows surface views of both the top and bottom surfaces of the brain. Color coding, such as depicted in Talairach space, indicates patterns and amounts of blood flow in various areas of the brain.

Using these images, we can see areas of the brain that are quiet and calm, and normally active areas, as well as under- or overactive regions. (Perhaps surprisingly, the cerebellum is usually the most active area.) In certain cases, a patient may need to stop taking medication before having a scan. The question of whether to go off meds, and if so, for how long, is answered depending on the patient's condition. This evaluation must be made by the physician in consultation with the individual patient.

The SPECT scan is already proving useful in diagnosing Alzheimer's Disease. In addition, Dr. Daniel Amen, working with Dr. Schenkel, at University of California, Irvine, has been developing newer techniques and better scans, allowing earlier diagnosis and treatment of Alzheimer's disease.

Through SPECT scans, we can see the effects of psychiatric disorders, substances, or prescription medications on the brain. The scans are especially valuable when working with ADD teens, because they can see it is really an issue relating to brain function, not an issue of them being "bad" or "stupid."

Visible overactivity in a given area corresponds with the behavioral and emotional manifestations of a particular disorder. For example, anxiety, depression, and bipolar disorder all have distinctive "footprints" in the brain. In a case where there is a brain infection or tumor, that disease will show clearly in the brain imagery. The physician can therefore make much better decisions about what treatment and/or prescription medication might be most effective. One of the significant advantages of SPECT scanning is that, when a patient can see that there is something wrong inside the brain, the patient is much more likely to comply with treatment. Thus, a SPECT scan can successfully cut through denial in substance abuse clients, leading to better progress toward recovery.

Substance abuse clients, after seeing the real picture of "this is your brain on drugs" are (appropriately) concerned, and frequently ask how their brain will look after they clean up. In other words, can the brain recover and return to normal? Yes, the brain can recover to some extent, if the individual gets clean, but there is a permanent long-term effect. Additionally, the brain will be much more vulnerable to further damage because of the prior abuse it suffered. One relapse will promptly return the brain to its pre-recovery state, and it will usually take 6 to 12 months to get the brain back to its "new normal" condition.

In certain conditions, in addition to improved nutrition, hyperbaric oxygen treatment can be helpful in restoring better brain function. Oxygen therapy can also be valuable in treating patients after a stroke. When should a therapist refer a client for a brain scan? When repeated prescription medications and talk therapy do not work, when diagnostic detail is desired, and whenever there is any history of brain trauma, a referral is highly appropriate. It is worth noting that a dose of caffeine initially stimulates the brain. However, after three to four hours, caffeine acts as a powerful vasoconstrictor, which results in decreased blood flow to the brain, and hence, foggy-mindedness. Klindt offered the names of the following local physicians who will refer patients for a brain scan:

• Bruce Wermuth, M.D., Psychiatrist, Los Gatos
• Sharadha Raghavan, M.D., San Jose
• Saad Shakir, M.D., San Jose
• Matthew Stubblefield, M.D., Palo Alto

Review by: Melissa Miller, MFT

Many of us are familiar with Kubler-Ross's stages of grief, but as clinicians it can be difficult to know how to apply that knowledge in our therapeutic relationships. Martha Clark Scala, MFT, taught some useful tools for doing just that at the September 2008 SCV-CAMFT luncheon. From intake and assessment to treatment approaches and taboos, we walked through the sobering needs of grieving individuals.

Grief, as Scala describes it, is the presenting problem that nobody escapes. Questions to ask new clients would be: "What kinds of losses have you experienced recently?" "What kinds of losses have you experienced in your life?" "How were you impacted or not impacted by this loss?" "How did you respond, or not respond, to what happened?" Current losses can compound previous losses. It is good to keep in mind that there are issues that people grieve that may not require the loss of a loved one. Some examples could be losing one's virginity, a job, money, driver license, independence, ability, safety, etc. The list of possible losses goes on and on.

Scala advises therapists to handle their own grief by: 1) taking time off; 2) being in therapy; 3) seeking out clinical consultation; and, 4) paying attention to one's caseload in advance (it can be very difficult to personally grieve if you have a large caseload of grieving clients). Another suggestion, for therapist and clients alike: Do something creative.

Creative expression is not limited to a person's skill. As you suggest activities or artistic expressions for a client, you may be met with a lot of resistance. Try to give clients space to give expression to what they are experiencing and assure them that they need not show it to anyone. Perfectionism and self-censorship will be the clients' biggest hurdles. Yet the hope is for the benefits to surpass those obstacles. They will be able to externalize what is inside of them. Scala used the metaphor of allowing creativity to metabolize the grief. As one externalizes it, they allow the good from it to nourish them and are able to excrete anything un-useful. Possible benefits may include self-affirmation and allowing for previously untapped creativity to surface and to bring relief from trauma. We must treat trauma before we can treat the grief.

The treatment guidelines Scala provided were to listen, listen, and listen, and then reflect back to the client what you've heard. Refrain from giving advice or concrete suggestions unless asked. The exception is in crisis situations. Avoid platitudes. Tailor your interventions based on your assessment of the client's response. Encourage creative expression. Manage countertransference and seek consultation and support if necessary; and, as always, make appropriate referrals. The tangible suggestions offered in Scala's handout correlated with Kubler-Ross's stages.

In the show and tell stage (shock), the mourner needs to have his or her grief and loss seen and witnessed by others, to tell the story over and over again, and to memorialize the loss using tributes and eulogies. Encourage the client to give either an unrehearsed or prepared monologue about the person or pet they have lost. Encourage them to augment their monologue with any visual or audio aids they want. Key ingredients are: talking about how he or she died and the client's unique relationship to him or her; sharing specific memories, be they positive, negative, or both; and revealing thoughts, feelings, and reactions in the aftermath of this death.

In the busy stage (denial), the mourner needs to take necessary action (disposal of body and belongings), to keep functioning, and to cope with difficult emotions. Creative activities for this stage can include creating a collage that captures images or elements of all the activities that need to be done or accomplished after someone dies or creating a sentence completion exercise with sentences that begin with something like: "I am coping with this loss by..." "I am NOT coping with this loss by..." "I am avoiding my feelings by..." or "If I stay busy, I don't have to notice..." Plan a time-out where all responsibilities can recede and sacred time can be created to slow down and absorb or integrate what has happened. Some clients may want their time-out to be alone, while others may want the company of people they trust.

In the mad stage (anger), the mourner needs to acknowledge angry feelings toward the deceased, toward those who overlook their loss or treat them like they're "contagious," and toward those whose condolences seem empty or trite. Creative activities for clients in this stage can include: writing an uncensored letter to the deceased and unleashing the anger or other negative feelings they're feeling; creating a collage of good and bad photos of the person who has died; designing a universal badge, emblem, or protocol (like wearing black) that will signal to the world that you are grieving; or to set a timer for at least 10 minutes and perform an uninterrupted rant to unleash anger at whomever you're mad at.

In the sad stage (depression), the mourner needs to experience the pain and suffering of the loss, to acknowledge the empty space left by the deceased, to weather tough times (anniversaries, holidays, birthdays), and to hold on, attempt to stay connected, yet to let go. For clients in this stage, you may use sentence completion exercises that begin with: "I miss you because..." "I don't know what to do without you here because..." "I am lost when..." "I am sad that..." "I am lonely for..." Creative activities for this stage may include drawing or painting a particular place or part of your house where you specifically notice the dead person's absence or planning a ritual or activity to remember the deceased on the anniversary of his or her death, or on a holiday of particular importance to him or her.

In the bad stage (bargaining), the mourner needs to process guilt or regrets and to adjust to the absence of the deceased. Activities for this stage can include: writing a letter of apology that makes amends for whatever the client feels they may have done to contribute to this person's death and putting it under their pillow and inviting the person who has died to "respond" to them in their dreams; drawing or painting a picture that shows how their family or group has changed now that the person is gone; and finishing whatever conversation they might not have finished prior to the deceased's death.

In the glad stage (acceptance), the mourner needs to get through to the other side of grief, acknowledge and accept the loss, derive meaning from that loss, hold and share sweet memories of the deceased, and maintain connections to the deceased. Activities for this stage include: acknowledging what the person has gained or learned as a result of their loss and as a result of knowing that person; writing a thank-you letter to the deceased; creating a scrapbook that captures memories of their relationship; or planning how they will sustain their connection with the deceased.

The luncheon was a time for honoring those we've lost, those we work with who have grieved or are currently grieving, and a time for preparing to handle grief in the future — be it our own or our clients'. For additional information on this topic, or to reach Martha Clark Scala, MFT, you may visit her website at: www.mcscala.com. Please be sure to let her know if you found this information helpful.

Author: Amy Sargent
Presented by: Martha Clark Scala, MFT