Hearts in a spiralDon’t wait for trouble to set in when it comes to the enriching elements of your life, such as sensuality and sexuality. Often, we are draining ourselves of the essence in our sexual, erotic selves through seemingly small, inconsequential thought and behavioral patterns.

This article addresses some of the most common drains to our sexual energy. I encourage you to use it as an awareness-raising exercise and to begin to investigate your own energy drains. In response to what you learn from your own self-reflection and investigations, you may begin to compile and act on antidotes to your drains.

So, what stories are you telling yourself? What habits need a little tweaking in order to replenish your sexual energy? I encourage you to monitor your own thinking and behavior patterns, and note what drains you and what replenishes you. Enjoy!

GoodTherapy | Distress Tolerance in Dialectical Behavior TherapyDialectical behavior therapy (DBT) distress tolerance skills address the tendency of some individuals to experience negative emotions as overwhelming and unbearable. People with a low tolerance for distress can become overwhelmed at relatively mild levels of stress, and may react with negative behaviors. Many traditional treatment approaches focus on avoiding painful situations, but in the distress tolerance module of DBT, clients learn that there will be times when pain is unavoidable and the best course is to learn to accept and tolerate distress.

[fat_widget_right]

A key ingredient of distress tolerance is the concept of radical acceptance. This refers to experiencing the situation and accepting the reality of it when it is something the person cannot change. By practicing radical acceptance without being judgmental or trying to fight reality, the client will be less vulnerable to intense and prolonged negative feelings. Within the distress tolerance module, there are four skill categories:

  1. Distracting
  2. Self-soothing
  3. Improving the moment
  4. Focusing on pros and cons

These skills are aimed at helping individuals cope with crisis and experience distress without avoiding it or making it worse.

Skill No. 1: Distracting
The first skill, distracting, helps clients change their focus from upsetting thoughts and emotions to more enjoyable or neutral activities. This skill is taught with the acronym ACCEPTS:

A – is for activities and distracting oneself with healthy, enjoyable pursuits such as hobbies, exercise, and visiting with friends.

C – is for contributing and doing things to help others, through volunteering or just a thoughtful gesture.

C – is for comparing oneself to those less fortunate, finding reasons to be grateful.

E – is for emotion; identifying the current negative emotion and acting in an opposite manner, such as dancing or singing when one is feeling sad.

P – is for pushing away, by mentally leaving the current situation and focusing on something pleasant and unconnected to the present circumstances.

T – is for thoughts; diverting one’s attention from the negative feelings with unrelated and neural thoughts, such as counting items or doing a puzzle.

S – is for sensations, and distracting oneself with physical sensations using multiple senses, like holding an ice cube, drinking a hot beverage, or enjoying a warm foot soak.

Skill No. 2: Self-Soothing
The second skill in distress tolerance is self-soothing; clients can use the five senses to nurture themselves in a variety of ways:

  1. Vision: Look at beautiful things such as flowers, art, a landscape, or an artistic performance.
  2. Hearing: Listen to music, lively or soft, or enjoy the sounds of nature such as birds chirping and waves crashing. Savor the voice of a relative or friend.
  3. Smell: Use a favorite lotion or perfume, light a scented candle, notice the scents of nature, or bake an aromatic recipe.
  4. Taste: Enjoy a hearty meal or indulge in decadent dessert. Experiment with a new flavor or texture, and focus on the food’s flavors.
  5. Touch: Pet an animal or give someone a hug. Have a massage, rub on lotion, or snuggle up in a soft blanket.

Skill No. 3: Improving the Moment
In the third distress tolerance skill, the goal is to use positive mental imagery to improve one’s current situation. The acronym for this skill is IMPROVE:

I – is for imagery, such as visualizing a relaxing scene or a successful interaction. Imagine negative feelings melting away.

M – is for creating meaning or purpose from a difficult situation or from pain, i.e., finding the silver lining.

P – is for prayer—to God or a higher power—for strength and to be open in the moment.

R – is for relaxation, by breathing deeply and progressively relaxing the large muscle groups. Listen to music, watch a funny television show, drink warm milk, or enjoy a neck or foot massage.

O – is for one thing in the moment, meaning the individual strives to remain mindful and focus on a neutral activity in the present moment.

V – is for vacation, as in taking a mental break from a challenging situation by imagining or doing something pleasant. This could also be taking a day trip, or ignoring calls and emails for a few hours.

E – is for encouragement, by talking to oneself in a positive and supportive manner to help cope with a stressful situation.

Skill No. 4: Focusing on Pros and Cons
In focusing on pros and cons, the individual is asked to list the pros and cons of tolerating the distress and of not tolerating the stress (i.e., coping through self-destructive behaviors). It can be helpful to remember the past consequences of not tolerating distress, and to imagine how it will feel to successfully tolerate the current distress and avoid negative behaviors. Through evaluating the short-term and long-term pros and cons, clients can understand the benefits of tolerating pain and distress, and thereby reduce impulsive reactions.

The distress tolerance skills are valuable tools in helping individuals maintain balance in the face of crises, teaching them to accept the distress and cope with it in healthier ways. By practicing the skills of distracting, self-soothing, improving the moment, and focusing on pros and cons, clients can weather stressful circumstances and decrease painful feelings and destructive impulses.

Children learn an enormous amount from their caregivers and parents. They learn through direct contact how to communicate, interact, and perform daily activities. They learn through exposure how to react and emotionally respond to situations. And whether parents are fully aware of this or not, a child’s behavior is in part the result of their parents’ response to it. According to a recent study led by Diana Morelen of the Department of Psychology at the University of Georgia, children and parents have a reciprocal emotional relationship. In other words, the way in which a parent responds to a child’s emotional reaction directly influences the way in which a child emotionally reacts.

The primary aim of Morelen’s study was to determine how reciprocal the child-parent emotional relationship was. Using a sample of 54 participants made up of fathers, mothers, and pre-adolescent children, Morelen examined how supportive emotional parenting (SEP) affected emotion regulation when compared to unsupportive emotional parenting (UEP). Specifically, Morelen wanted to know if SEP increased adaptive emotion regulation (AER) in children and if UEP increased maladaptive emotion regulation (MER). She then wanted to find out if these relationships were bidirectional. Morelen assessed the parents and children as they talked about four different emotions, anxiety, sadness, anger, and happiness.

She discovered that the way in which parents responded to their children’s emotions directly impacted the way in which children emotionally reacted. Morelen’s theory of reciprocity was confirmed when she found that SEP led to AER and AER led to SEP in all four of the discussion conditions. Also, MER predicted more UEP than SEP for fathers and mothers when discussing anger. However, when discussing the more vulnerable emotional states of sadness, mothers responded with SEP more than fathers when children exhibited MER. This finding could be partially explained by the male ideal of power and strength. This, in turn, may lead fathers to identify emotional vulnerability as a weakness. However, Morelen believes this is concerning because there is an abundant amount of research linking UEP to feelings of shame and inadequacy and patterns of emotional suppression, all of which can increase the risk for psychological impairment. Because of this, Morelen hopes interventions aimed at addressing family, child, and parent interactions focus on the emotional response of both mothers and fathers. “Programs could highlight the role that child behavior plays in soliciting parental behavior and coach parents on how to be mindful of the potential (positive or negative) influence of child behavior,” said Morelen.

Reference:
Morelen, Diana, and Cynthia Suveg. A real-time analysis of parent-child emotion discussions: The interaction is reciprocal. Journal of Family Psychology 26.6 (2012): 998-1003. Print.

Man unpacking moving box full of Buddhist itemsAnyone who has been through a divorce knows very well that it can invoke the worst parts of the self. Divorce is consistently associated with contention, negativity, bad behavior, and a sense of loss of integrity. This is completely understandable, since the experience of divorce so often invokes feelings of fear, shame, anger, and resentment. When a marriage ends, these dreaded emotional states uncontrollably surface without warning or even awareness. Learning to manage these intolerable states of being is a crucial aspect of transitioning through divorce with integrity and an intact sense of self.

Since divorce generates such an intense state of suffering, it seems logical to turn to the teachings of the Buddha to help turn this painful life transition into an opportunity for learning and growth. Coincidentally, the Buddha’s wisdom and the teachings of Buddhism stem from the young prince Siddhartha’s disillusionment when the reality of the pain and suffering in the world shattered the perfect world image his father had tried to impart on him. Not too different from the illusion we create for ourselves with the ever-after dreams of marriage and the harsh reality that comes with divorce.

“Buddhist teachings are not a religion, they are a science of the mind.” —The Dalai Lama

Here are six Buddhist teachings that can help you remain open, and reduce your suffering, as you manage the transition of divorce:

Attachments
When divorce strikes, the past, present, and future are all up for grabs. Everything you thought you knew to be true is now in question. In the face of ambiguity and uncertainty, your instinct will be to grasp at what you know and once had, but according to the Buddha these attachments create suffering. Learning to release your attachments to any particular outcomes in the past, present, or future will lead to a more peaceful existence. Trying to control things only invokes feelings of frustration because most of the things you are dealing with are completely out of your control. When you grasp and cling to what you think you “know,” you are creating unnecessary suffering.

Compassion
The Buddha recognizes that while it might be relatively easy to generate compassion for friends and loved ones, it is extremely difficult to have compassion for someone we dislike or who has mistreated us in some way. While the tendency might be to avoid this person (most likely an ex), the Buddha would see this person as the heart of his spiritual practice, a challenge to develop positive qualities. Compassion is the flip side of anger; it keeps the heart open when it wants to close off with fear. Compassion is fostered by remaining connected, no matter how painful it may be. Maintaining compassion through divorce is a feat, but it will ensure that your loving nature remains intact.

Karma
The law of karma is the universal principle of actions and reactions or causes and effects. Everything you do or say in your daily life is the cause of your own suffering or your own happiness. Buddha would advise that you not look for answers outside of yourself, nor should you believe that you are a victim of a random universe. While you may feel like a victim of your divorce, karma is your key to taking responsibility for what comes in and out of your world. The word karma means “action” or “deed”—actions and deeds that impact only you and the space you inhabit on this earth. Once you take responsibility for your actions, you can actively change your karma, and ultimately your present and future circumstances.

“Pain is inevitable in life, but suffering is optional.” —The Buddha

Mindfulness
Mindfulness is the capacity to remain in the present moment. It is the ability to pay attention and to become aware of the intention behind what we do. The Buddha would recommend that you utilize the clarity that mindfulness brings to stop clinging to the past and the future, to live presently in the here and now. When we are not mindful, we remain in a state of being that is encumbered with criticism, judgment, and a need to be right. Mindfulness and its nonjudging, respectful awareness can help you to respond and to gain perspective, balance, and freedom. Stepping back and being an observer of events provides the greatest opportunity for acting with complete integrity and honor.

Aversion
One of the most fundamental teachings of the Buddha is that pain is an unavoidable part of the natural world, and suffering is our reaction to the inevitable pain of life. Divorce is one of those unavoidably painful life experiences, but as the Buddha would attest, it doesn’t have to involve suffering. Like touching a hot stove, our first reaction to pain is to move away. Our aversion to the pain creates more suffering and reduces the opportunity to heal. Suffering is directly related to resisting the reality of what you are dealing with. Instead, the Buddha would suggest doing what you can to restore balance, to let things take their course. Complete avoidance will only prolong the pain.

Impermanence
In Buddhism, impermanence is referred to as Anicca— the truth of impermanence. It is the belief that all of our experiences are constantly changing, and that nothing is permanent. One of the greatest causes of pain during divorce is the feeling that things will never be the same, and that what you feel now will last forever. The Buddha would apply the wisdom of Anicca to maintain a sense of calm and perspective through the grief and loss of divorce. Remembering that nothing in life is permanent will help you to not feel bogged down or to lose yourself in what feels like an eternal experience of pain and discomfort.

School is often the only safe place for young children who live with domestic violence. Witnessing or being exposed to physical abuse can have a significant impact on the well-being of a child. Whether it is sexual, verbal, or physical abuse, when a child witnesses this type of abuse between their parents or caregivers, the effects can be far-reaching. Many children who are exposed to violence are fearful and anxious. They may also have difficulty forming relationships in school or performing academically. A teacher can be the first person to recognize these signs in a student. Although teachers, educators, and educational psychologists (EPs) receive extensive training to arm them with the tools necessary to address these issues in their students, it is unclear how this type of disclosure affects these professionals.

Gemma Ellis of the Luton Burough Council at Unity House in the UK recently led a study to gain the educators’ perspectives on domestic violence revelations from their students. Ellis wanted to find out if the professionals felt capable of identifying a child experiencing domestic abuse, and if they were comfortable receiving that information and responding to it. She also wanted to know how they felt about training, what fears they had, and what changes they would make to the current procedures in place.

Ellis interviewed a group of elementary school educators and found that one important need was that of more time for the teacher to emotionally process what the child revealed. Many teachers explained that they were overwhelmed and struggled with having to send the children back to a potentially abusive home. Ellis believes this finding is in line with secondary trauma theories, which suggest that confidants of abuse victims may themselves experience trauma. The teachers and EPs in this study benefited from the procedures in their schools. In an uncontrollable and emotionally taxing situation, having a protocol to follow helped them contain their own emotions so that they could best serve their students.

They did, however, have fears related to family retaliation. In particular, the teachers relied heavily on parent participation for the success of the child. They worried that accusations against the family would decrease participation. They also feared that the abusers would turn their abuse toward the teachers. Ellis believes these findings provide insight into the concerns teachers and EPs have with regard to supporting abuse victims and that this study will serve as a preliminary step in future discussions. “It is hoped and expected that through the dissemination process the topic of domestic abuse will be elevated in both teachers’ and EPs’ consciousness,” Ellis said.

Reference:
Ellis, Gemma. The impact on reachers of supporting children exposed to domestic abuse. Education & Child Psychology 29.4 (2012): 109-20. Print.

Perceptions of safety affect a person’s psychological state. If someone feels threatened or fearful, they may have increased levels of anxiety. If someone feels safe and protected, they may have high levels of self-confidence and feel more independent than someone that feels unsafe. The community in which a person lives can have a large impact on their mental well-being. People who live in high-crime, low-income neighborhoods are at increased risk for many negative outcomes, including drug abuse, relationship problems, violence, unwanted pregnancy, and depression. In fact, existing research has demonstrated a clear link between depression or anxiety and the environment in which a person resides. In particular, people living in communities in which they feel unsafe are more likely to have poor mental health outcomes than those in safer communities.

Until now, no study has looked at contributing factors that could increase or potentially protect individuals in unsafe neighborhoods from anxiety or depression. To accomplish this, Jaime Booth of the School of Social Work at Arizona State University led a study that examined isolation, powerlessness, and mistrust as predictors of feeling unsafe or safe in a sample of 4,196 participants. The results revealed that the more unsafe someone thought their neighborhood was, the worse they fared psychologically. Lack of safety was directly related to increased distress.

When Booth looked at the three secondary factors, the findings suggested that the distress from feeling unsafe could be enhanced or diminished. All three factors of powerlessness, mistrust, and isolation directly increased feelings of psychological stress. However, when participants reported high levels of trust, social support, or empowerment, they had lower levels of psychological stress. This suggests that increasing these domains in high risk individuals could lessen their feelings of helplessness, regardless of how safe their neighborhood is. “Understanding specific neighborhood factors that impact mental health enabled us to design more effective interventions and is crucial to addressing mental health disparities,” said Booth. The results of this study are one more in the continual pursuit of that goal.

Reference:
Booth, Jaime, Stephanie L. Ayers, and Flavio F. Marsiglia. Perceived neighborhood safety and psychological distress: Exploring protective factors. Journal of Sociology & Social Welfare 39.4 (2012): 137-56. Print.

Man in small space hugging selfMost people have experienced brief periods of anxiety while riding in an elevator, stuck in the midst of a large and tight crowd, or even while playing hide-and-seek. But for people with claustrophobia, the fear of being trapped in a small space can be so debilitating that it interferes with regular life activities.

In fact, the distinction between “normal” anxiety about enclosed spaces and phobic-level fear is the fact claustrophobia tends to interfere with life activities such as climbing a stairwell or riding in an elevator for work, playing with one’s children, or going to certain locations.

What Is It?
Claustrophobia is categorized by a chronic and unreasonable fear of being trapped in a small or enclosed space with no hope of escape, and it is classified as an anxiety disorder. People with claustrophobia also frequently experience a related fear of suffocation. Being in a small space can cause people with the issue to fear that they won’t be able to breathe, and for this reason, people with claustrophobia sometimes experience fear in settings that don’t seem enclosed or frightening. For example, a person with claustrophobia sitting in a dentist’s chair might be so afraid of confinement that the person becomes convinced that he or she will suffocate if he/she remains in the chair. People with the issue may experience extreme anxiety, panic attacks, difficulty breathing, profuse sweating, and difficulty concentrating when they are in a small space.

People with claustrophobia tend to experience anxious reactions in a variety of settings rather than just one particularly frightening setting. For this reason, claustrophobia tends to become generalized and may worsen over time. A person who was once afraid of elevators might generalize his or her fears to closets, apartments, doctor’s offices, and small stores. In extreme cases, people with claustrophobia may be so afraid of confinement that they refuse to leave their homes or travel to unfamiliar locations.

What Causes It?
Claustrophobia is one of the most common phobias, with about 5% of the population experiencing it to one degree or another. Some scientists believe that this indicates an evolved, genetic fear of closed spaces. The reasoning for this explanation is that being trapped in a small space can be dangerous, so the brain has evolved a special fear of these situations to prevent people from taking potentially life-threatening risks. However, there is also evidence that claustrophobia is learned. People who have been trapped in a small space—such as people who were trapped in an elevator or who were locked in their bedrooms as children—are more likely to become claustrophobic, and children of people with claustrophobia are more likely to become claustrophobic. This is probably due to a combination of genetics and parental modeling.

How Is It Treated?
Although phobias can be debilitating, they are generally fairly easy to treat. Counter-conditioning and exposure therapy work by gradually exposing people with claustrophobia to triggering circumstances to help them build a tolerance and learn coping mechanisms for their fears. People with mild claustrophobia sometimes benefit from deep-breathing techniques and distracting thoughts, and people with severe claustrophobia may take anti-anxiety medications to help them function until therapy can help them address the underlying causes of the phobia. Some people with claustrophobia also benefit from cognitive behavioral therapy, which helps them identify the negative thoughts that lead to fear-based reactions and to slowly adjust these thoughts to more positive, less fear-inducing ones.

References:

  1. Claustrophobia. (n.d.). Epigee. Retrieved from http://www.epigee.org/mental_health/claustrophobia.html
  2. Kahn, A. P., & Doctor, R. M. (2000). Facing fears: The sourcebook for phobias, fears, and anxieties. New York, NY: Checkmark Books.

Woman peaking out her windowFood Network chef Paula Deen is known for her bubbly personality, so many fans were shocked when she explained in her biography that she had agoraphobia for 20 years. Deen is hardly the only celebrity to experience this potentially debilitating condition, however. Kim Basinger and Woody Allen also reportedly have experienced it, and the father of modern psychiatry himself—Sigmund Freud—may have struggled with the issue as a young man.

In an increasingly busy, crowded, and connected world, anxiety can be overwhelming even for famous people, and agoraphobia will affect about 1.4 percent of the U.S. population at some point, with 40% of cases reported being “severe,” according to the National Institute of Mental Health.

What Is It?
Agoraphobia means “fear of the marketplace,” and is commonly associated with a shut-in lifestyle and social avoidance. However, agoraphobia is distinct from social phobia and characterized by a chronic fear of feeling anxiety or panic in a place where one is unable to escape or get help. For this reason, many people with agoraphobia are hesitant to leave their homes, unwilling to go out alone, or visit only familiar locations. Some people with the condition experience panic, generalized anxiety, and other issues classified as anxiety disorders.

Although everyone experiences anxiety in unfamiliar or social settings from time to time, people with agoraphobia experience overwhelming anxiety and panic on a regular basis. They might feel dizzy, restless, short of breath, or confused in unfamiliar settings. Agoraphobics are often fearful of feeling out of control, and the physical symptoms of anxiety can exacerbate this fear.

What Causes It?
Agoraphobia is typically a side effect of panic disorder. People who have had panic attacks in public settings may fear that they’ll have another panic attack and grow increasingly fearful of going out in public. Sometimes agoraphobia is caused by other circumstances, such as a traumatic event in a public place, social anxiety, or other mental health conditions that cause anxiety and panic. The disorder may be caused by a combination of genetic and environmental factors. Children of parents with panic disorder are more likely to develop agoraphobia; this could be due to either genetics or parental modeling.

How Is It Treated?
Because people with agoraphobia are often terrified of having panic attacks, one of the most important steps in treatment is giving the person a sense of control over his or her tendency to panic. Relaxation techniques can help many people regain a sense of control. Medication is also highly effective. Anti-anxiety medications and antidepressants can also help people with agoraphobia.

Sometimes agoraphobia causes so much fear that people refuse to leave their homes. People with severe agoraphobia sometimes need several months of progressive desensitization to fearful settings. For example, a person might start by walking outside, graduate to getting in the car, progress to driving to a parking lot, and ultimately master going to the grocery store. Most people with agoraphobia undergo some form of psychotherapy. Cognitive behavioral therapy can be especially helpful, and some people with the issue benefit from group therapy. Group members often share coping strategies and can help an agoraphobic feel less isolated; the group setting itself can also serve as a form of desensitization to unfamiliar people and settings.

References:

  1. A.D.A.M. Editor Board. (2011, November 18). Panic disorder with agoraphobia. PubMed Health. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001921/
  2. Agoraphobia among adults. (n.d.). NIMH RSS. Retrieved from http://www.nimh.nih.gov/statistics/1AGOR_ADULT.shtml
  3. Agoraphobic celebrities. (n.d.). The Daily Beast. Retrieved from http://www.thedailybeast.com/galleries/2011/12/13/photos-paula-deen-kim-basinger-and-other-famous-people-with-agoraphobia.html
  4. Mayo Clinic Staff. (2011, April 21). Agoraphobia. Mayo Clinic. Retrieved from http://www.mayoclinic.com/health/agoraphobia/DS00894
  5. Moskin, J. (2007, February 28). From phobia to fame: A southern cook’s memoir. The New York Times. Retrieved from http://www.nytimes.com/2007/02/28/dining/28deen.html?pagewanted=all

AdobeStock 417139383Couples who have been married for decades seem to know the secret to successful relationships. But when couples bicker and fight after years of being together, is it a sign of an unhappy relationship or cognitive decline? According to a recent article, children and caregivers of couples who exhibit tension and anger may merely be witnessing what has always been there, just with different eyes. When children reach adulthood and enter into their own relationships, they may begin to view their parents’ relationship with different, often more critical, eyes. This could shed new light on not-so-subtle patterns between their parents that have always existed.

But when fighting, arguing, or hostility are new behaviors, they may signify a deeper problem. Mild cognitive impairment (MCI) is an insidious, subtle offender that creeps up on people. Individuals who begin to forget things, or become overwhelmed by things that used to come easily, may hide their impairment from those closest to them out of fear and shame. When a wife who used to be able to tackle all the household chores suddenly stops doing them, her husband may think she is being lazy. Likewise, when a husband who used to enjoy socializing becomes reclusive, his wife may respond with anger and hurt. These mixed signals can increase hostility and tension in the relationship.

Other indications are suspicion and jealousy. Delusions of infidelity or callousness can cause someone to become accusatory of their spouse. This can lead to resentment. And even though they may be unfounded, they set the stage for anger and conflict. The same can happen with physical health declines. Many illnesses can decrease sexual arousal and stifle sexual intimacy. Without that type of connection, couples can become emotionally and physically distant. Dr. Nancy K. Scholssberg, a professor of counseling psychology at the University of Maryland, knows that even though fighting isn’t the answer to the fear or uncertainty that accompanies illness, it is often the most commonly used coping strategy. “Fighting may come from a misguided notion that you can regain power by asserting it over your spouse,” said Schlossberg. “It doesn’t work, it’s false power – but they’ll [spouses] try anything.” Add to that the stress of caring for an ailing spouse, and you’ve got a recipe for disaster. Even though MCI may not be to blame for the battles in most relationships, it is especially important for clinicians to explore this possibility when working with older couples.

Reference:
Seliger, Susan. In the middle: Why elderly couples fight. (n.d.): n. pag. The New York Times. 17 Dec. 2012. Web. 30 Dec. 2012. http://newoldage.blogs.nytimes.com/2012/12/17/in-the-middle-why-elderly-couples-fight/

file folder labeled "confidential" in filing cabinetThere is a question that has been asked of me multiple times over the past few months that I would like to answer. The question is: “Should a child’s foster parent(s) be granted access to their child’s psychotherapy notes?” The answer is not as straightforward as it may seem.

The short answer is: “No, a child’s foster parent(s) should not be granted access to their child’s psychotherapy notes.”

First, we must understand what the HIPAA privacy rule is, as it will ultimately answer the question. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, is a federal law which resulted in the establishment of the HIPAA Privacy Rule in December 2000. The HIPAA Privacy Rule is designed to protect information about individuals’ health care treatment. To understand privacy protections in the United States, you must start with this federally established framework and then consult state laws to determine whether there are any additional requirements to observe.

Second, we must understand what the HIPAA Privacy Rule has to say about “individual personal representatives.” An individual personal representative is any person with the authority to receive or access another individual’s protected health information (PHI).

In some cases, adults and emancipated minors have individual personal representatives, such as someone holding “power of attorney” or in a court-appointed adult guardianship or conservatorship. Otherwise, adults and emancipated minors do have uniquely boundaried privacy protections, whereas minors (children under 18 years old, with the exception of children—typically 16 or 17 only—who have been formally “emancipated” from dependency status by a court of law) always have at least one individual personal representative.

Children and adolescents in foster care tend to have many individual personal representatives, including representatives from Child Protective Services, attorneys, designated child-placing agency representatives such as case managers, foster parents acting as medical consenters, and, in some cases, juvenile probation officers. In rare cases, even court-appointed special advocates (CASA) may obtain status as medical consenters through a court and would, then, hold the distinction of an individual personal representative.

In addition, foster kids benefit from an extensive continuum of care including doctors, dentists, psychiatrists, clinical psychologists, school psychologists, school counselors, collaborative treatment team participants such as child-placing agency treatment directors (such as myself), and other consultants (at my agency, we have psychiatric fellows and residents as well as a program manager, intake coordinator, and, in some cases, a higher-level program administrator who all may participate in the ongoing treatment staffing related to a child’s case planning), therapists (individual, sibling, family, group), early childhood interventionists (speech, physical, and occupational therapists), and skills trainers. Each of these treatment providers freely accesses PHI of other providers in the course of treatment, which is necessary and beneficial for collaborative treatment.

Ultimately, these supports are beneficial, but often, along this stream of care, the “minimum necessary requirement,” a best-practices principle generally recognized and affirmed through the HIPAA Privacy Rule, is not sufficiently revered, and foster kids’ private and protected health information may not always be protected in practice with the same degree of diligence that it is in so many other sectors of health care. It is in this current that foster parents often believe that they, too, are entitled to the most private of health care information, their child’s therapy providers’ psychotherapy notes. I know this to be true from my own professional experience.

The third thing that you must understand to answer this question is that psychotherapy notes are given unique privacy protections within the HIPAA Privacy Rule, more so than all other protected health information (PHI), including purely diagnostic or evaluative information, case notes, other treatment services such as developmental therapies (speech, physical, occupational), as well as other treatment summaries or reports. Even reports via email from a therapist summarizing general or overall progress of therapy—or any other generalizing or summarizing report—are not given the same protections as psychotherapy notes themselves (U.S. Department of Health & Human Services [HHS], 45 CFR 164.508, 2006).

There is one final piece of this puzzle: The HIPAA Privacy Rule clarifies that, in certain circumstances, parents are not privileged to act as their minor children’s personal representatives—with respect to certain protected health information—and thus neither control the child’s health care decisions nor the protected health information related to that care:

  1. If no existing state statute or binding legal precedent requires a parent’s consent prior to a minor child obtaining psychotherapy treatment, and if the minor child then consents to his or her own psychotherapy treatment without the expressed consent of a parent, then, with respect to the minor child’s participation in that psychotherapy treatment, no parent acts as the child’s personal representative and, thus, the parent(s) will not be provided access to the psychotherapy notes without the child’s written consent.
  2. If a court grants or other law authorizes another adult to act as the personal representative for a minor child as it relates to the child’s health care, then the minor child may obtain consent for such psychotherapy treatment from another personal representative, as provided, without consent from a parent. Similarly, in this case, with respect to the minor child’s participation in that psychotherapy treatment, the parent(s) will not be provided access to the psychotherapy notes without the child’s written consent.
  3. If a parent provides a written and signed waiver expressly relinquishing his or her own right to participation in a confidential relationship between their minor child and a psychotherapist, then the privacy of the psychotherapy notes—as well as, in some cases, other protected health information—will remain boundaried and protected between the provider and the minor child, and parent access will be restricted unless the minor child provides written consent to the access of these protected records.

Further clarification in the Code of Federal Regulations (CFR) should be noted: “Even in these exceptional circumstances, where the parent is not the ‘personal representative’ of the minor, the Privacy Rule defers to state or other laws that require, permit, or prohibit the covered entity to disclose to a parent, or provide the parent access to, a minor child’s protected health information. Further, in these situations, if state or other law is silent or unclear concerning parental access to the minor’s protected health information, a covered entity has discretion to provide or deny a parent with access to the minor’s health information, if doing so is consistent with state or other applicable law, and provided the decision is made by a licensed health care professional in the exercise of professional judgment”(U.S. Department of Health & Human Services [HHS], 45 CFR 164.502, 2003).

Because foster children do not require the consent of foster parents before they can obtain psychotherapy services—and may obtain consent, if required, by way of other representative adults (such as child welfare caseworkers, child-placing agency case managers, etc.), whether the child independently consents or secures a nonparent consent to participate in such therapy, then, under the HIPAA Privacy Rule, the foster parent(s), for the purposes of this particular health care service, will not be provided distinction under the law as the child’s personal representative, and, thus, will not be provided the right to access documentation from the treatment record.

However, again, it is not that the HIPAA Privacy Rule expressly denies that foster parents have access to their children’s therapy notes, and, in fact, a “covered entity,” or provider (meaning, the child’s therapist) does retain prerogative to provide or deny a parent access with discretion if doing so is consistent with state and other applicable laws. Yet, this should be justified therapeutically.

In most cases, it is difficult to make a case that it is in the best interests of the child, therapeutically, to take away what is typically the only confidential outlet a foster child or teen has within the convoluted and institutional system in which they live and, thus, it is best practice in my state (K. Teutsch, personal communication, January 4, 2013) and in every state to preserve the therapeutic relationship by preserving the boundaries of confidentiality within that relationship and of privacy concerning the psychotherapy notes.

References:

  1. K. Teutsch, Division Administrator for Medical Services, Texas Department of Family and Protective Services, personal communication, January 4, 2013.
  2. U.S. Department of Health & Human Services – Office for Civil Rights (2006). HIPAA Administrative Simplification: Regulation Text [45 CFR 160, 162, & 164]. Washington, DC: US Government.
  3. U.S. Department of Health & Human Services – Office for Civil Rights (2003). OCR HIPAA Privacy: Personal Representatives [45 CFR 164.502(g)]. Washington, DC: US Government.

GoodTherapy | What It's Like Inside a Depressed Person's HeadWhile not everyone’s experience is the same, when people have a major depressive episode, generally the world looks, feels, and is understood completely differently than before and after the episode. During a major depressive episode, the world can literally seem like a dark place. What was beautiful may look ugly, flat, or even sinister. The depressed person may believe loved ones, even their own children, are better off without them. Nothing seems comforting, pleasurable, or worth living for. There’s no apparent hope for things ever feeling better, and history is rewritten and experienced as confirmation that everything has always been miserable, and always will be.

[fat_widget_right]

When this reality shift happens, it’s difficult to remember or believe what seemed normal before the episode. What the person believes during the episode seems absolutely real, and anything that conflicts with it is as unbelievable as a memory or message telling him or her that the sky is purple. For example, if the person is unable to feel love for a spouse, and someone reminds the person that he or she used to feel that love, the person may firmly believe he or she had been pretending to himself/herself and others—though at the time he or she really felt it. The person can’t remember feeling the love, and can’t feel it during the episode, and thus concludes he or she never felt it. The same process happens with happiness and pleasure. Attempts to tell the person that he or she used to be happy, and will feel happy again, can cause the person to feel more misunderstood and isolated because he or she is convinced it’s not true.

What was challenging feels overwhelming; what was sad feels unbearable; what felt joyful feels pleasureless.

Even if nothing was wrong before the episode, everything seems wrong when it descends. Suddenly, no one seems loving or lovable. Everything is irritating. Work is boring and unbearable. Any activity takes many times more effort, as if every movement requires displacing quicksand to make it. What was challenging feels overwhelming; what was sad feels unbearable; what felt joyful feels pleasureless—or, at best, a fleeting drop of pleasure in an ocean of pain.

Major depression feels like intense pain that can’t be identified in any particular part of the body. The most (normally) pleasant and comforting touch can feel painful to the point of tears. People seem far away—on the other side of a glass bubble. No one seems to understand or care, and people seem insincere. Depression is utterly isolating.

There is terrible shame about the actions depression dictates, such as not accomplishing anything or snapping at people. Everything seems meaningless, including previous accomplishments and what had given life meaning. Anything that had given the person a sense of value or self-esteem vanishes. These assets or accomplishments no longer matter, no longer seem genuine, or are overshadowed by negative self-images. Anything that ever caused the person to feel shame, guilt, or regret grows to take up most of his or her psychic space. That and being in this state causes the person to feel irredeemably unlovable, and sure everyone has abandoned or will abandon him or her.

It’s difficult to describe all of this in a way that someone who’s never experienced it can make sense of it. I can’t emphasize enough that when this happens, what I am describing is absolutely the depressed person’s reality. When people try to get the person to look on the bright side, be grateful, change his or her thoughts, or meditate, or they minimize or try to disprove the person’s reality, they are very unlikely to succeed. Instead, they and the depressed person are likely to feel frustrated and alienated from one another. I do believe cognitive therapy has an important place, but generally not in the throes of a major depressive episode.

Support for People with Depression

So what does a person whose reality has shifted in this way need? Please keep in mind that I am talking about a major depressive episode—severe depression that has lasted more than two weeks. I would take a different approach for someone with milder depression, or one that is a response to a terrible loss.

For some people in a major depression, psychotropic medication works and is the only thing that works. The same could be said for electroshock treatment, though it’s not for everyone. Many people will emerge from major depression in time, though episodes seem to make more episodes more likely, so if medication works to end the episode, it’s usually prudent to take it. Nutrition, acupuncture, and other body-based treatments as well as therapy can help without the side effects of medication.

What Loved Ones Can Do

Loved ones can gently hold and show love and commitment to the depressed person, try not to take on the person’s reality, but also not argue with him or her about it. They can also gently remind the person that depression causes his or her perspective on everything to change, and he or she is unable to think outside of depression mode at the moment. It is a time for the person to avoid making decisions, or avoid doing anything significant that requires a nondepressed perspective. If this is a repeated experience for this person, it can be helpful to discuss all of this between episodes so he or she is more prepared when caught in the quicksand.

As someone who loves a person with depression, it can be emotionally difficult or stressful at times to support that person. It can be beneficial to focus on your own needs and self-care, and to reach out for help if you need it such as seeking the support of a counselor or therapist.

Sexism is overtly exhibited in nearly every aspect of modern society. Women and adolescent girls, in particular, are especially likely to experience the deleterious effects of sexism. Whether it is a model in a magazine, an actress on television, or a mannequin in a store window, images of how women should look, dress, act, and even react are everywhere. Adhering to society’s unrealistic and often varied models of the ideal woman makes it difficult for women to find and accept their own identities and bodies. In fact, the sexist beliefs associated with women, both negative and positive, have been linked to numerous physical and mental health issues for women, including depression, anxiety, binging, purging, and anorexia. Young women are also heavily influenced by the opinions and judgments of those closest to them, including their family members, friends, and coworkers. Understanding how the beliefs of others and internalization of those beliefs affects a woman’s body image is necessary in order to help women overcome any challenges related to self-worth, self-esteem, and positive self-image.

[fat_widget_right]

Debra L. Oswald of the Department of Psychology at Marquette University in Wisconsin wanted to explore the negative and positive (hostile and benevolent) sexist attitudes toward young women and how these attitudes affected their beliefs about their own body images. In one study, Oswald assessed how a father’s benevolent sexist beliefs, those that positively affirmed the traditional female role and appearance, shaped daughters’ self-image. In a second study, Oswald looked at how subtle and overt hostile sexism affected self-image. She found that overall, hostile sexism from peers, friends, and family members led to negative body esteem. However, hostile sexism from parents did not. Oswald also discovered that a father’s benevolent sexism was directly linked to positive body esteem in daughters. This finding is concerning because it suggests that although young women may feel good about themselves when they conform to traditional female roles, when they step out of those roles, they may be met with hostile sexism which could decrease their sense of self-esteem and negatively affect body image. The results of this study also imply that sexism contributes greatly to a woman’s physical and mental self-image. “We hope this research highlights the complexity of these cultural beliefs and encourages researchers and clinicians to take this wider cultural context into consideration when examining and treating women’s body esteem issues,” said Oswald.

Reference:

  1. Oswald, Debra L., Stephen L. Franzoi, and Katherine A. Frost. Experiencing sexism and young women’s body esteem. Journal of Social & Clinical Psychology 31.10 (2012): 1112-137. Print.
Important Notice

GoodTherapy is not intended to be a substitute for professional advice, diagnosis, medical treatment, or therapy. Always seek the advice of your physician or qualified mental health provider with any questions you may have regarding any mental health symptom or medical condition. Never disregard professional psychological or medical advice nor delay in seeking professional advice or treatment because of something you have read on GoodTherapy.