When we think about anniversaries, we often think about celebrations and the observation of long-term commitments. However, some anniversaries aren’t necessarily well remembered and can be anything but welcome and joyous.

We often hear about the connection between mind and body, and one of the ways this connection is especially interesting is the way in which we store and remember traumatic memories.

We all know memories are stored in the brain, but what many people are not familiar with is the idea that our bodies also store memories at a cellular level. We experience the world through all of our senses—sight, smell, sound, touch, and taste—and all aspects of our experiences get imprinted into our cellular memory.

This is why the stimulation of certain senses can trigger a memory. For example, you may smell Elmer’s glue and be reminded of your elementary school classroom. Or you may taste a really great pumpkin pie and think of your grandmother. Or, more traumatically, someone may hear the sound of a car backfiring and feel terrified because of the time they witnessed a shooting.

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The specifics of how and where memories are stored is very scientific and outside the realm of my expertise; however, the simple concept of “our bodies remember” is important and can be useful to understand. Sometimes we may not be consciously aware we are coming up on the anniversary of a particularly traumatic or unpleasant event, but knowing our bodies remember can help us understand what might be going on when negative emotions get triggered.

I recently had an appointment with somebody I’ve been working with for a few years. She came to the session feeling uncharacteristically irritated and almost hostile. She was annoyed by my attempts to figure out what might be going on. She reported nothing was wrong, it wasn’t the time of month she often feels more down than usual, and nothing in particular had happened to set her off. But her mood and demeanor told a different story.

When I pointed out that she seemed more agitated than normal, she agreed she felt really “off” and was frustrated because she had no idea why. In an attempt to figure out where to go next, I asked if she was familiar with the idea of “anniversary reactions” or if she had heard of the term “cellular memory.” She replied no but looked interested.

The day you lost a loved one, found out about a betrayal, or experienced some event that made you feel as if your world was crashing down gets imprinted in your cellular memory, and you may find yourself feeling especially vulnerable on the anniversaries of these events.

I explained that our bodies have their own memory systems, at a cellular level, and sometimes our bodies remember things that may not necessarily be at the forefront of our minds. I talked about how I personally think back to what may have happened on a particular date in the past if I find myself feeling unexplainably anxious or upset. I saw an immediate shift in her mood as we began talking about what was going on for her a year prior.

Rather than responding with short, snappy remarks, she began talking about the painful breakup she experienced a year earlier. She revisited the pain, confusion, and anger we had discussed at the time, but this time she demonstrated a greater sense of perspective and gratitude for how she had grown in the months since she experienced the heartbreak. Making the connection to this potential explanation helped her to leave the session in a much more uplifted place.

Our bodies tend to hold on to experiences from the past, and we may find ourselves re-experiencing emotional or physical symptoms at a later date, perhaps when we are better equipped to effectively process and view the experience with a new outlook. The day you lost a loved one, found out about a betrayal, or experienced some event that made you feel as if your world was crashing down gets imprinted in your cellular memory, and you may find yourself feeling especially vulnerable on the anniversaries of these events.

If you notice yourself feeling unusually anxious, weepy, or down and can’t seem to figure out why, stop and consider whether the date correlates with anything particular in your past. Being aware of the concepts of anniversary reactions and cellular memory can help you weather the storm of these emotions. Acknowledging you may be experiencing an anniversary reaction may help you to regain a sense of control. With this recognition comes an option to accept the feelings and know they will pass, or begin to process them with some distance and perspective.

A majority of Americans likely give little thought to using a public restroom beyond where the nearest one is located (and perhaps a fervent wish that the soap dispensers and toilet paper will be stocked). Most people consider the process a simple one: find the facilities, use the facilities, and leave. A bill passed in North Carolina in March, however, along with legislation currently being pursued in Tennessee, South Carolina, Minnesota, and Kansas, is making the process far less simple—and likely distressing—for many.

The North Carolina law, which requires state residents to use bathrooms and locker rooms corresponding to the sex on their birth certificate, was passed in response to a February ruling in Charlotte that protected the rights of people to use the bathroom matching their gender identity. In February, a similar bill was narrowly defeated in Washington state. The Washington bill would have repealed a December ruling affirming a person’s right to use public facilities correlating to gender identity. For transgender people—individuals whose gender identity does not align with sex assigned at birth—this law creates several challenges.

How Do the ‘Bathroom Laws’ Discriminate?

These new laws—and proposed changes to existing laws—effectively bar trans individuals who have not been able to obtain the documentation necessary to change their gender marker from using the facilities that fit their gender identity. Trans people who have not legally changed their gender marker must break the law—and face fines and/or imprisonment—every time they use the restroom.

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Not every trans person will change their gender marker. Some do not choose to, and some are unable to: as of 2015, four states—Tennessee, Ohio, Kansas, and Idaho—did not allow a birth certificate to be changed. Where it is possible to change one’s gender marker, the process is often lengthy, costly, and not easily pursued by some. Many states require gender confirmation surgery before they will issue an updated birth certificate. In some states, individuals who wish to change their gender marker may first be required to socially transition, or live as their gender for a period of time (commonly one year). Living as one’s gender requires using the correct bathroom. North Carolina’s law not only places hardship on trans people by denying them equal rights, it may also prevent them from being able to transition.

Supporters of the law, who claim their intention is not to deny trans people equal rights, appear to be largely united under one argument: Allowing trans people to use the correct bathroom may encourage sexual predators to pretend to be transgender in order to prey on women and girls. This argument is not currently statistically supported, and it discounts the reality that sexual predators who prey on women and girls are not likely to be deterred by a law that, at best, will be difficult to enforce. It also does not consider the experience of trans people, who face extremely high rates of violence and sexual assault: Approximately half of all transgender individuals will experience sexual assault at some point in their lives. 

Statistics gathered from national surveys show the perpetrators of sexual assault are predominantly male. Some female supporters of these “bathroom laws,” many of whom have survived a rape or other sexual assault, support the laws for this reason, saying they do not feel comfortable sharing a bathroom with men. While these feelings are certainly valid, they serve as a sweeping misgender of all trans people: Trans women are not men, regardless of the anatomy they were born with, and the trans men who will be forced to use women’s bathrooms are men. According to the National Coalition of Anti-Violence Programs (NCAVP), trans women are almost twice as likely to experience sexual violence as any other group of people, trans or otherwise, and thus may also feel uncomfortable sharing a bathroom with men.

When in public spaces, trans people frequently face discrimination, stigma, and harassment. They might be misgendered or otherwise invalidated. All of these can contribute to feelings of shame, gender dysphoria, low self-esteem, depression, or anxiety.Cisgender women (women who are not trans) greatly outnumber the entire trans population, and many people have argued cis women, as the majority, should not be placed in a position that makes them uncomfortable to accommodate relatively few trans people. (According to estimates based on survey data, roughly 0.5% of the population is trans, though the actual number is likely higher.) Yet many people may have already shared a bathroom with a trans person without realizing it. Others who shared a bathroom with a person they thought was trans and felt uncomfortable might consider asking themselves why they felt that way and whether the other person’s gender really matters.

Most people, trans, cis, intersex, or otherwise identified, have no desire to remain in a public bathroom any longer than necessary, and the National Task Force to End Sexual and Domestic Violence Against Women reports no increase in sexual violence or public safety issues in jurisdictions that have nondiscrimination laws. People who feel uncomfortable may wish to examine whether their discomfort (which is not the same as being in danger) is linked to rational fears of sexual assault or to the fear of something they do not understand and whether eliminating those moments of discomfort come at the cost of protecting the safety of another human being.

Many supporters of the bill maintain they do not view transgender people as potential sexual predators. Regardless, excluding trans people from the correct bathrooms is still likely to send the message that their identity is invalid, that they are not welcome as part of the community. These laws, which may suggest the safety and comfort of trans people is not as important as that of cis people, could be seen as discriminatory toward a minority group at risk while also failing to address the root cause for concern: sexual assault is common and might occur anywhere, among any population.

Trans People Often Face Adversity in Public Spaces

When in public spaces, trans people frequently face discrimination, stigma, and harassment. They might be misgendered or otherwise invalidated. All of these can contribute to feelings of shame, gender dysphoria, low self-esteem, depression, or anxiety. Many trans people may dread going out in public, especially alone. When public spaces cannot be avoided, they might instead avoid situations where they could be challenged, such as using public restrooms.

All people deserve a restroom they can use safely, without fear of harassment or violence. According to the NCAVP and Rape Response Services National Statistics, trans people face high rates of homicide, sexual assault, and violence. Trans people of color are at even higher risk: in 2013, 67% of hate violence homicide victims were trans women of color. Preventing trans people from using the facilities they feel most comfortable in may make it necessary for them to put themselves at greater risk (and also possibly out themselves as trans) in order to use the restroom.

The backlash to these rulings, and other similar rulings across the country, has been considerable, especially as transgender students across the country fight similar discriminatory measures for equal access to bathrooms and locker rooms in public schools. Critics point out not only are these laws likely to cause humiliation and distress, they clearly violate the Civil Rights Act.

Several entertainers and organizations have boycotted trips to North Carolina in support of transgender rights, and the Obama administration issued a decree in May 2016 ordering all public schools to allow trans students access to facilities corresponding to their gender identity rather than sex assigned at birth. A number of school districts across the country have refused to accept the decree, citing concerns about boys in girls’ locker rooms and the discomfort of female students.

What these school districts do not seem to address is the discomfort and distress of the transgender students who are required to either use the wrong facilities or change alone in the nurse’s office or other designated facility. In either outcome, these students may face prejudice, harassment, and abuse from other students as well as feelings of shame and isolation, among other issues. Many trans students report avoiding the restrooms entirely, an action that may affect emotional well-being as well as physical health.

Proposed Solutions to Discriminatory Bathroom Policies

Awareness of trans issues is increasing across the nation, and many young trans people have the support and encouragement of their families, but many still do not. Along with the likelihood of discrimination and ostracism at the hands of peers or family members, trans teens and preteens also face the onset of puberty and the emergence of physical features and bodily changes that may lead to gender dysphoria or exacerbate existing feelings. Many teens who wish to take hormones and begin transitioning cannot start this process without parental support. Some have the support of a mental health professional, but many lack even that.

School-level legislation that further denies the identity and existence of transgender youth may contribute to depression, anxiety, and other mental health concerns. It may also increase the risk of suicide in this population, which is already high. Among trans youth, nearly 50% have considered suicide with serious intent, and 25% report at least one attempt. The rates of suicide and other mental health concerns experienced by transgender youth are shown to decrease when they receive acceptance and support.

All-gender restrooms, already prevalent in many countries, may be the logical destination of progress, as gender becomes more understood and the male-female binary is recognized to be an outdated concept.Some point to all-gender or family bathrooms as a solution. While some trans individuals might use these restrooms when they are available, as any other person might, being allowed to only use these restrooms can still be exclusionary and may contribute to feelings of dysphoria. Others say creating bathrooms exclusively for transgender people to use would be an ideal solution, but as Attorney General Loretta Lynch pointed out in a statement announcing a federal lawsuit against North Carolina, “Not so long ago … states had signs about restrooms … keeping people out based upon a distinction without a difference.” Others have similarly drawn comparisons from the bathroom debate to the Jim Crow laws segregating people of color.

Some organizations and companies, such as Target, have responded to these laws by vocalizing their support of trans people with inclusive policies encouraging customers and employees alike to use the restroom that aligns with their gender identity. At Cooper Union College in New York, student activists removed all gendered signs on the bathroom. New placards read “restroom with urinal and stalls” and “restroom with only stalls.” Other colleges have similarly implemented all-gender restrooms with the goal of making public spaces safe and accommodating for everyone. All-gender restrooms also serve to welcome non-binary individuals, who might not feel comfortable in either men’s or women’s restrooms.

Everyone Has the Right to Safety

Many trans people across the nation still cannot use the restroom without facing threats to their personal safety. A woman in Washington, D.C. was assaulted by a security guard when she tried to use the restroom at a grocery store, and students in one North Carolina school district are now allowed to bring pepper spray to campus, which one board member claims may be a “valuable tool” for females who use the restroom on campus. Other schools encourage students to report their transgender classmates if they use the “wrong” bathroom.

Such instances of harassment and prejudice against trans people are likely to do little for the community other than foster fear and transphobia. Even if legislators and others who do not support bathroom use according to gender identity claim they are not targeting transgender people, these measures may invalidate the identity of trans people and perpetuate stigma. They also do not address the high rates of assault and violence trans people experience. Safe public restrooms are a necessity for all, and trans individuals prevented from using the correct restroom may not only face threats to their bodily safety, but also diminished mental and emotional well-being due to stress, anxiety, shame, and dysphoria.

All-gender restrooms, already prevalent in many countries, may be the most logical destination of progress, as gender becomes more understood and the male-female binary is recognized to be an outdated concept. Until then, allowing individuals to choose a restroom based on their gender—and perhaps caring a bit less about who is using what restroom—may be the best solution to an issue that was never really a problem.

References:

1. Banchiri, B. (2016, February 23). Charlotte passes transgender rights law: Will North Carolina let it stand? Retrieved from http://www.csmonitor.com/USA/Politics/2016/0223/Charlotte-passes-transgender-rights-law-Will-North-Carolina-let-it-stand
2. Bellware, K. (2014, July 18). Gender-neutral bathrooms are quietly becoming the new thing at colleges. Retrieved from http://www.huffingtonpost.com/2014/07/18/gender-neutral-bathrooms-colleges_n_5597362.html
3. Borrello, S. (2016, April 22). Sexual assault and domestic violence organizations debunk ‘bathroom predor myth.’ Retrieved from http://abcnews.go.com/US/sexual-assault-domestic-violence-organizations-debunk-bathroom-predator/story?id=38604019
4. Carollo, L. (2016, April 25). What happened when I tried to comply with North Carolina’s new bathroom law. Retrieved from http://www.vox.com/2016/4/25/11490498/north-carolina-bathroom-law-transgender
5. Changing birth certificate sex designations: State-by-state guidelines. (2015, February 03). Retrieved from http://www.lambdalegal.org/know-your-rights/transgender/changing-birth-certificate-sex-designations
6. Cobb, J. (2016, May 30). Opening doors. The New Yorker. Retrieved from http://www.newyorker.com/magazine/2016/05/30/north-carolinas-retrograde-step
7. Connelly, J. (2016, February 10). ‘Bathroom bill’ aimed at transgender persons fails in state Senate. Retrieved from http://www.seattlepi.com/local/politics/article/The-bathroom-bill-blocking-toilet-use-by-the-6821841.php
8. Facts about suicide. (n.d.). Retrieved from http://www.thetrevorproject.org/pages/facts-about-suicide
   Hate violence against transgender communities. (n.d.). Retrieved from http://www.avp.org/storage/documents/ncavp_transhvfactsheet.pdf
9. Levin, S. (2016, May 12). Obama orders public schools to allow transgender students access to restrooms. Retrieved from http://www.theguardian.com/society/2016/may/13/obama-public-schools-transgender-access-restrooms
10. Lopez, G. (2016, April 18). 9 questions about gender identity and being transgender you were too embarrased. Retrieved from http://www.vox.com/2015/4/24/8483561/transgender-gender-identity-expression
11. Lowder, J. B. (2016, April 27). Breitbart proves what we already knew: Trans women are not bathroom predators. Retrieved from http://www.slate.com/blogs/outward/2016/04/27/breitbart_helpfully_shows_trans_women_are_not_bathroom_predators_cis_men.html
12. Miller, C. C. (2015, June 08). The search for the best estimate of the transgender population. The New York Times. Retrieved from http://www.nytimes.com/2015/06/09/upshot/the-search-for-the-best-estimate-of-the-transgender-population.html?_r=0
13. Ng, A. (2016, May 11). North Carolina schools let students bring pepper spray to class–in case transgender students use bathrooms. Retrieved from http://www.nydailynews.com/news/national/n-schools-students-bring-pepper-spray-class-article-1.2633430
14. Pearson, M. (2016, May 10). AG Loretta Lynch moves into spotlight with NC bathroom law speech. CNN. Retrieved from http://www.cnn.com/2016/05/10/politics/loretta-lynch-north-carolina
15. Rape Response Services National Statistics. (n.d.). Retrieved from http://www.rrsonline.org/?page_id=944
16. Redden, M. (2016, March 29). New York college moves to strip gender markings from all bathrooms. The Guardian. Retrieved from http://www.theguardian.com/world/2016/mar/29/gender-bathrooms-cooper-union-college-new-york
17. Tan, A. (2016, May 19). Security guard arrested after allegedly assaulting transgender woman trying to use women’s bathroom. ABC News. Retrieved from http://abcnews.go.com/US/security-guard-arrested-allegedly-assaulting-transgender-woman-womens/story?id=39227006
18. Transgender Bathroom Hysteria, Cont’d. (2016, April 18). Retrieved from http://www.nytimes.com/2016/04/18/opinion/transgender-bathroom-hysteria-contd.html?_r=4&mtrref=undefined&gwh=459A290B6C63807CACCEAADDE4A5626A&gwt=pay&assetType=opinion
19. Understanding the Perpetrator. (n.d.). Retrieved from https://sapac.umich.edu/article/196

The relationship a person has with a therapist is unique. Some people question why they should seek professional guidance when they can talk to their loved ones for free, while others who are already in therapy wonder about the unspoken etiquette, ethics, and rules of this special relationship. It is critical for those in or seeking therapy to understand the dynamics and boundaries of the therapeutic relationship. The distinction could mean the difference between a deeply healing experience and wasted time and money or, worse, retraumatization and new relational wounding for the person seeking help.

Dynamics That Bring About Healing, Change, and Growth

Unlike relationships with friends or family, the therapeutic relationship is a professional one that happens to be based on deeply personal material. Much like other health or medical professionals, therapists are bound by codes and ethics that not only lay out rules about confidentiality, but also ensure the relationship maintains the emotional safety and best interests of the person seeking help. This is different from the relationship with family and friends in that therapists have nothing to gain personally from the relationship. Any advice, questions, and even opinions expressed by a therapist are based solely on the best interests of the person in therapy. In return, people in therapy owe therapists only a sincere willingness to work toward their goals, basic relational courtesy, and previously agreed-upon fees. Although loved ones typically have your best interests at heart, they also often have their own biases based upon family traditions, cultural understandings, personal history, and the effects various outcomes may have on their lives.

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Additionally, while those closest to you may know you better than a professional therapist (at least at the beginning of a therapeutic relationship), this can be a drawback when it comes to getting clear or unbiased feedback. Those who have known you over a period of time may have preconceived notions of who you are, what you should do, or how you should behave.

In contrast, therapists endeavor to see people in therapy as clearly and objectively as possible, allowing for growth, change, and healing to occur in a way that best serves a person’s needs and well-being. Specifically, therapists are trained to maintain a nonjudgmental stance with unconditional positive regard for the basic humanity of the people who seek their services. Through skill, expertise, and their own self-awareness, therapists hone their ability to support and guide people so they may achieve their highest potential. Through the therapeutic relationship, people in therapy can experience a nurturing presence that helps them feel they are being seen, heard, and responded to appropriately.

Why Boundaries Within a Therapeutic Relationship Matter

In order for the therapeutic relationship to work, it is important the therapist maintain an unprejudiced stance by setting orderly boundaries. In the absence of such boundaries, it may be challenging for the therapist to maintain neutrality and for the well-being of the person in therapy to remain the priority over the duration of the therapy. Additionally, without clear boundaries it can be harder for people in therapy to feel safe, build trust, and focus on their needs.

Boundaries are based as much on judgment as they are on guidelines set forth by various professional codes of ethics. As such, it is less helpful to describe specific dos or don’ts here, as those can be found elsewhere. What should be understood here is the intent and effect of boundaries. Yet, anytime a person in therapy feels uncomfortable about boundaries, whether they consider them too strict or too lax for their needs, they should address their concerns with their therapist. In turn, therapists should respond to conversations about the therapeutic relationship in an open and non-defensive manner so the person in therapy feels their concerns or questions have been heard, answered, and addressed fully and respectfully.

When Boundaries Are Violated or Cause Relational Disconnect

Through the therapeutic relationship, people in therapy can experience a nurturing presence that helps them feel they are being seen, heard, and responded to appropriately.

While therapists are bound by codes of ethics, and must carry state licenses and malpractice insurance, some therapists may exhibit behavior that disregards best practices and violates boundaries to the point it can be harmful to the therapeutic relationship or to the emotional well-being of the person in therapy. If you have experienced therapy in which you felt misunderstood, upset, or used in any way, it is important that you tell your therapist. It may be a simple misunderstanding or feelings that are being projected onto the therapeutic relationship, providing a tremendous opportunity for a breakthrough conversation that leads to growth and healing.

However, if you do not get a genuine and satisfactory response from your therapist or your feelings continue over a period of time, you may choose to find a therapist who better meets your needs. Ultimately, the therapeutic relationship should be nurturing, fulfilling, healing, and reparative for you, the person in therapy, within the context of professional boundaries and mutual respect.

A Professional Relationship That Comes from the Heart

Finally, I want to make a note about the therapeutic relationship from the therapist’s perspective. Although it is a professional relationship and there are clear boundaries and parameters, the connection and desire to help is no less heartfelt or genuine than in any other relationship that exists outside the office.

Appropriate boundaries allow therapists to do good work in a safe manner, but they should not be a barrier to meaningful relational connection within the therapeutic setting. Ultimately, finding a skilled therapist with whom you feel safe and connected can provide the foundation for a powerful and life-enhancing therapeutic experience.

Posttraumatic stress (PTSD) can severely interfere with functioning, resulting in intrusive memories, depression, disrupted sleep, anxiety, and avoidance of situations that bring back memories of the trauma. But the symptoms of some trauma survivors, particularly those who have experienced prolonged abuse or captivity, don’t neatly match traditional symptoms of PTSD. In the 1980s, some therapists and researchers began to advocate for recognition of a new variety of PTSD called complex posttraumatic stress disorder or C-PTSD. Although C-PTSD is not listed in the Diagnostic and Statistical Manual of Mental Disorders, therapists are increasingly recognizing the issue, which requires different treatment and produces different symptoms.

What Is Complex PTSD?

PTSD is a reaction to a threatening event, and the event is usually a single event that occurred for a brief duration. Traumatic events that might cause PTSD include watching a loved one die, witnessing a violent act, rape, assault, and military combat. C-PTSD, by contrast, is more likely to occur when a person experiences multiple or ongoing traumas or when a single trauma lasts for a long time and leads to feelings of captivity. Survivors of concentration camps, people who were regularly abused as children, domestic violence survivors, military personnel who are exposed to ongoing violence, people who have experienced repeated sexual assaults, and kidnapping victims may experience C-PTSD.

While PTSD typically causes disturbances—such as flashbacks, avoidance of locations or situations that remind a person of the event, or chronic fear and depression—to the traumatic event, C-PTSD is more likely to cause identity and personality disturbances in addition to the symptoms of traditional PTSD. This is because people exposed to prolonged trauma may begin to view the trauma as a core part of their identity or as something they caused, and sometimes they might question their own memories—believing, for example, that perhaps the trauma didn’t really happen.

Symptoms of Complex PTSD

C-PTSD has many of the same symptoms as PTSD, including intrusive memories or flashbacks, depression, anxiety, avoidance, and changes in personality. However, people with C-PTSD also experience symptoms that people with PTSD don’t normally have. These include: [fat_widget_trauma_ptsd_right]

• Chronic fear of abandonment. Many people with C-PTSD are diagnosed with an attachment disorder, and neediness, fear of abandonment, and even regression during times of stress are common in C-PTSD.
• Difficulty controlling emotions or changes in personality.
• Disturbances in self-perception and persistent feelings of shame.
• Obsession with the perpetrator and frequently changing perceptions of the perpetrator. A sexual abuse survivor, for example, might go back and forth between viewing the abuser as evil and loving, and might continue an unhealthy entanglement with that person.
• Emotional flashbacks: Rather than intrusively remembering the traumatic event, a person with C-PTSD might instead simply get emotionally overwhelmed and re-experience the emotions he or she felt during the traumatic event without ever actually recalling or thinking about the traumatic event. This is particularly common during periods of stress. A person might, for example, begin sobbing or feel terrified during a minor disagreement with his or her partner.

Treatment for Complex PTSD

Because C-PTSD is a relatively newly recognized condition, there’s still some debate about how it should be treated. Exposure therapy, which is highly effective with PTSD, is still being studied for its effectiveness in treating C-PTSD. As C-PTSD may mean dozens of traumatic memories or years of trauma, some clinicians have argued exposure therapy is impractical. C-PTSD researchers have generally recommended a stage-based treatment approach that includes the following phases:

1. Establishing safety and helping the client find ways to feel safe in his or her environment or eliminate dangers in the environment.
2. Teaching basic self-regulation skills.
3. Encouraging information processing that builds introspection.
4. Helping the client to integrate his or her traumatic experiences.
5. Encouraging healthy relationships and engagement.
6. Strategies designed to reduce distress and increase positive affect.

References:

1. Complex PTSD. (n.d.). National Center for PTSD. Retrieved from http://www.ptsd.va.gov/professional/pages/complex-ptsd.asp
2. ISTSS complex PTSD treatment guidelines. (n.d.). International Society for Traumatic Stress Studies. Retrieved from http://www.istss.org/AM/Template.cfm?Section=ISTSS_Complex_PTSD_Treatment_Guidelines
3. Walker, P. (n.d.). Emotional flashback management in the treatment of complex PTSD.Psychotherapy.net. Retrieved from http://www.psychotherapy.net/article/complex-ptsd

Have you ever had a dream so powerful it changed your life? You are not alone. Over the years, I have worked deeply with people and their dreams, and I’ve discovered that, in many instances, these “big dreams” will appear under the heels of life transitions, questioning of identity, and major losses such as the death of a loved one or a breakup. The dream is often of an initiatory nature where the dreamer is highly impacted and the experience life-altering.

What Is an Initiatory Theme?

If we look at the stories we grew up with, we find many motifs that point to initiation. In most myths, the protagonist is faced with a situation that completely transforms them. They may have been swallowed by a sea monster (Jonah and the Whale, Pinocchio) or sent into the underworld or underbelly of Mother Earth (Persephone, Inanna, White Buffalo Calf Woman).

Others may have been dismembered and put together again (Handless Maiden, Skeleton Woman, Osiris), struck by lightning, or visited by a guide in the shape of an animal, spirit, or ancestor (Thor, Gandalf, Thunderbird).

For others still, their rite of passage may have been an illness, animal bite, or near-death experience that evoked superpower abilities (Catwoman, Spiderman, Wolverine).

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Why Do We Have Initiatory Dreams?

These themes are the language of the psyche, and in our modern times we are sadly removed from the initiatory practices and rituals of our ancestors. It is the dream (the final frontier!) that bestows us access to “soul knowledge,” namely in the form of big dreams.

Coined by Carl Jung, these dreams evoke high emotional intensity and extraordinary power that strike a chord in the dreamer that continues to resonate throughout their life. When these dreams occur, the dreamer may transcend into a higher awareness or reality that can be directly reached in the sleeping state.

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In the book Extraordinary Dreams and How to Work with Them, Stanley Krippner, Fariba Bogzaran, and Andre Percia de Carvalho address the many variations of these dreams, including healing, precognitive, lucid, etc., and how these dreams can be spiritual awakenings or initiations that can often lead to a dramatic transformation in the dreamer.

What Are Some Types of Initiation Dreams?

The most the vital aspect of the initiation dream is its emotional impact on the dreamer. The feelings of pure joy and love, even to the point of ecstasy rarely experienced in waking life, are a definite indication.

However, this is not always the case. Initiation dreams more often evoke terror and take nightmarish forms, especially if we are asked to face our biggest fears in order to be transformed by them.

There are certain common elements to these initiation dreams, including but not limited to:

• Apocalyptic scenes
• Encounters with guides or otherworldly beings
• Animal bites (usually on the hand)
• Visitations from the deceased/ancestors
• Struck by lightning
• Engaging in a ritual/rite of passage
• Confronted or swallowed by a sea monster or creature
• Dismemberment
• Alchemical death and rebirth motifs
• Mythological/archetypal themes
• Journeys to different worlds/states of consciousness
• Lucid, hypnogogic, or out-of-body states

Many of the people I work with have a big dream either right before or at the beginning stages of therapy. This is the time when the initiate is being propelled into the mysteries of profound change, whether externally (loss of a loved one, home, or community) or internally (an inner stirring that “something is not right”).

Many of the people I work with have a big dream either right before or at the beginning stages of therapy. This is the time when the initiate is being propelled into the mysteries of profound change, whether externally (loss of a loved one, home, or community) or internally (an inner stirring that “something is not right”).

Here is one example of an initiation dream:

I am a young girl in an ancient landscape that reminds me of Persia, India, or Babylonia due to the architecture of mosaic columns, pools, and courtyards. There is a particular pool of water where women are lounging about. I dive into this water and retrieve hair adornments from the bottom of the pool for these women, which pleases them immensely. After this ritual, I look down and notice blood on my dress. I realize three of my ribs have been taken or are missing! I am suddenly filled with ecstasy, like I know this is a good omen or sign of initiation. The girl seems to “know” more than I do, but I am her. As I wander this area, there’s a shift as I try to discover the symbol, the meaning of the missing three ribs.

Working with Initiation Dreams in Therapy

One of the most difficult challenges in dreamwork is to make sense of what is being given. This is especially true for the initiation dream.

There are ways to process the material, especially after the fallout of such dreams. It can be an uncomfortable process for people, not only due to the highly charged content but also the fear of making dramatic life changes that may call for a sacrifice in the form of jobs, loved ones, identity, belief systems, and way of life.

If you are experiencing big or initiatory dreams, I highly recommend seeking a trained professional who specializes in dreams and depth work. Having a therapist to hold the container and be a guiding force to bring context as well as support for these powerful experiences in a compassionate and nonjudgmental way is vital. What makes dreamwork so effectual is that the material has an emotional impact and comes directly from the person, not an outside source.

Here are some points of entry and inquiry to consider when working therapeutically with these dreams:

• If you were bitten by an animal, it would be suggested to engage with the animal’s energy and habits. What animal gifts can be integrated into your life?
• If you dream of death and resurrection, what part can shift in your life to make room for a new birth and way of being?
• In apocalyptic and alchemical motifs, the elements are keys to understanding what’s being asked. Is it fire, water, tornado, earthquake? The element can shed light on the nature of the call and the type of transformation taking place.
• If you have a visit from a guide or deceased loved one, what messages are being told to you? In what form?

The most important thing to remember is change is a part of life. If we can engage in the dreaming process in a conscious way, we not only live more authentic lives but can make healthier, more mindful choices.

In Part II, I will focus on the dreams of the bereaved and how they can bring healing in the face of grief.

References:

1. Campbell, J. (1976). The Hero with a Thousand Faces, Bollingen Series 17. Princeton, NJ: Princeton University Press.
2. Eliade, M. (1958). Rites and Symbols of Initiation (Birth and Rebirth), trans. W. Trask. London, England: Harvill Press.
3. Jung, C. (1963). Memories, Dreams, Reflections. London, England: Collins and Routledge.
4. Krippner, S., Bogzaran, F., & Percia de Carvalho, A. (2002). Extraordinary Dreams and How to Work with Them. Albany, NY: State University of New York Press.
5. Murdock, M. (1990). The Heroine’s Journey. Boston, MA: Shambhala Publications.
6. Pinkola-Estes, C. (1992). Women Who Run with the Wolves. New York, NY: Ballantine Books.
7. Sparrow, G. S. (n.d.). The Dream as a Path of Initiation. Edgar Cayce’s ARE, Virginia Beach, VA.

As a family systems therapist, it’s been my experience that when parents bring a child to my office due to acting-out behaviors or social challenges, it usually comes back to the dynamic in the parental relationship. Typically, what’s going on (or not) between Mom and Dad is at the root of the issue, regardless of whether the parents are married, separated, or divorced.

Marital dissatisfaction and parental conflict, in my experience, are often correlated with how well children adjust to situations. In addition, parental attitudes and approaches can impact children. Children may experience anxiety, depression, shame, or other issues when conflicted parental relationships result in dysfunctional parenting practices. Parental conflict can result in reduced parental involvement, harsh discipline practices, lack of praise and acknowledgement, and increased parent-child conflict.

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A common scenario that often plays out in families with parental conflict is when a child is blamed and scapegoated by the parents, which in turn may cause the child to act out. This nonadaptive parenting style creates a dynamic of discord that is enmeshed, reciprocal, and reinforcing.

When overt or covert (silent or aggressive) parental conflict is present, there may be a tendency to create “alliances” or “collusions” among family members, which typically only alienates healthy family relationships. Additionally, some parents who do not actively engage in conflict in front of their children may allow their negative feelings toward each other to guide their decisions. These decisions, when motivated by resentment and not the best interests of the children, may be equally harmful.

Naturally, parental conflict also can result in reduced emotional availability toward children. Generally speaking, the lower the level of parental conflict, the more positive parent-child relationships tend to be.

Suggestions for Managing Parental Conflict Around Children

Conflict is a natural part of relationships. It is important for children to see that parents can disagree and work through conflicts. The problem solving that follows occasional conflict between parents can be a healthy thing for children to witness. When parents are able to demonstrate effective problem-solving strategies collaboratively, they model supportive parenting and parental involvement at a much higher level.

The lower the level of parental conflict, the more positive parent-child relationships tend to be.

However, when conflict is chronic and parents aren’t able to come to resolution, it can become problematic from the children’s standpoint.

So what can parents do to demonstrate healthy conflict management in front of their children? Here are some suggestions to consider:

• Try to avoid arguing in front of the children.
• When discussions become intense, take a “time-out” and continue the discussion when kids are not around.
• Set aside time to have discussions when the children are not present (such as when they are in bed, at school, visiting grandparents, etc.).
• Demonstrate courteous and polite behavior with each other in front of the children.
• Take turns talking.
• Actively listen to each other.
• Validate the other parent’s feelings and perspectives, even in times of disagreement.
• Brainstorm possible solutions to the problem.
• Focus on maintaining a positive relationship with the children.
• Articulate that the children are not the issue or even part of the issue.
• Support the other parent’s relationship with the children.
• Be mindful about not sharing too much information with the children about conflict that may be present.

Finally, when trying to resolve conflict, it is important to look at family-of-origin patterns to determine how conflict was resolved in earlier generations, as patterns tend to be passed down in families from generation to generation. Then, it is important for parents to look for patterns in their relationships as well as their own behaviors and motivations.

Ideally, parents should be open to seeking help from a professional, as getting input from an objective third party who is trained to help resolve conflict can be beneficial in identifying ineffective resolution strategies that parents may be engaging in.

Every system of the body is vulnerable to physical illness. This is common sense. But did you know every system of the body is vulnerable to emotional discord as well? The nervous system, an elaborate network of cells that facilitates communication between our brains and the rest of our bodies, directly links our physical selves to our emotional life. Voluntary muscles, involuntary muscles, and our five senses can all be influenced by the emotional responses of our bodies, so we can manifest a nearly infinite variety of physical responses to stress. While these reactions can sometimes be adaptive and helpful signals (e.g., preparing for flight when in danger), they can also cause distress, leading to visits to doctors.

When our physical symptoms are caused by an injury, bacteria, or an allergen, for instance, medical treatments can work. A visit to primary care, emergency care, or a specialist will likely yield desired results, at least eventually. However, when our physical ailment is caused or worsened by emotional factors, the potential of traditional medicine is limited. At best, a placebo effect may create some relief; at worst, the frustration caused by failed medical treatments can lead our emotion-driven symptoms to worsen.

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In this article, I will identify and elaborate upon four empirically supported ideas that may be useful to all of us. No one is immune to the physical reactions caused by emotional stress, so we are all equally vulnerable to developing medically unexplained physical symptoms when emotions overwhelm our coping capacities. If we can more readily identify them and seek appropriate treatments, we may be able to significantly reduce the burden on ourselves (and our health care system) that these symptoms can cause.

1. Emotional Factors Can Contribute to or Cause a Range of Physical Conditions

Emotional centers in the brain link with many important structures of the body, including our large voluntary muscles (anything you can flex) and our involuntary muscles, such as the gastrointestinal system (Janig, 2003). As you will read below, anxiety can trigger activation in any of these muscles, triggering a huge variety of physical symptoms that can be misdiagnosed as having a purely medical origin.

• Voluntary muscles: When anxiety is channeled into the voluntary muscles of our musculoskeletal system and causes involuntary tensing, a large variety of conditions can result, including fibromyalgia, TMJ, sciatica, tension headache, hyperventilation, muscular pain, tingling hands and feet, choking sensation, cramps, and tremors.
• Involuntary muscles: When anxiety is channeled into the smooth muscles that line the gut, veins, capillaries, arteries, bronchi, and urogenital system, conditions such as hypertension, IBS (stomach acid, spasms, diarrhea, nausea), migraine, ulcerative colitis, reactive airways, bladder spasm, abdominal pain, or sudden urge to urinate or defecate can be caused or worsened.
• Thinking/perception/sensation: High levels of anxiety can disrupt our abilities to think and perceive the world. Symptoms such as dizziness, blurry or tunnel vision, sensations of physical weakness, itching, fainting, tinnitus, and difficulty thinking or speaking can all be caused by dysregulated anxiety.

Any of the symptoms described here, and many more, can be triggered by anxiety-provoking emotional experiences, and may be most effectively diagnosed and treated by the methods discussed below.

2. Emotional Factors Contribute to a Large Percentage of Costly Emergency Visits

Medically unexplained physical symptoms can have a sudden onset and can be terrifying to the person experiencing them, which can lead to visits to emergency services and referrals to specialists. It is important for all health care consumers and practitioners to be aware of the high rate of patients who present with medically unexplained symptoms—and the significant efficacy of a short course of psychotherapy for treating these symptoms.

One unpublished study cited by Abbass, et al. (2010) found that 16% of emergency department (ED) referrals leave the hospital without a medical explanation for their presenting symptoms. This included 75.8% of people who presented with chest pain. Other common health concerns that left the ED without a medical diagnosis include headaches and abdominal pain. Regarding visits to specialists, Abbass (2004) reported on studies that found:

Eighty-four percent of 567 common internal medicine complaints—such as chest pain, dizziness or weakness—yielded no new diagnosis and cost a great deal to investigate. A recent British study found that one quarter of all new specialty referrals studied resulted in no diagnosis. This included almost one-fifth of surgical referrals and over one-third of some medical specialty referrals (p. 6).

According to this data, between 10% and 20% of ED visits and between 20% and 84% of specialist referrals yield no medical explanation, and it seems the most common medically unexplained symptoms can be linked with the bodily manifestations of anxiety described above. Fortunately, advances in mental health assessment and treatment are helping to change these worrisome statistics.

3. Emotional Contributors to Physical Symptoms Can Be Diagnosed Quickly

In his article about “emotion-focused interviewing” to diagnose somatization (the term for the process by which emotional factors affect physical health), psychiatrist and researcher Allan Abbass (2005) provides examples of brief conversations between doctor and patient that help reveal a clear link between emotional upsets and increases in symptoms. This interviewing technique, which has become an important part of my practice, is based on principles and techniques from a model of brief psychodynamic psychotherapy called intensive short-term dynamic psychotherapy, or ISTDP (Davanloo, 2000).

Clinicians who learn ISTDP are trained to monitor a variety of verbal and bodily signals so they can detect an increase or decrease in the physical symptoms as thoughts and feelings are explored during an interview. According to Abbass (2005):

An increase in symptoms with emotional focus suggests that emotions aggravate or directly cause the problems. A decrease in symptoms during the test also suggests a linkage to emotions. Disappearance of the symptoms by bringing emotional experiences to awareness is the best direct evidence that somatization of these emotions was causing the patients symptoms (p. 235).

Abbass suggests this diagnostic process can be accomplished in as little as 15 minutes of conversation. Considering the financial and time costs of the procedures that are often used to diagnose medically unexplained physical symptoms (e.g., fMRI), Abbass makes a compelling case for the utility and efficacy of an emotion-focused interview based on ISTDP that can help establish whether emotional factors are playing a role in physical symptoms.

4. Psychological Treatments Show Cost-Effectiveness

Seeing a psychotherapist to rule out emotional factors earlier in the diagnostic process can save money and heartache, which is especially important because the emotional upset associated with failed medical procedures and treatments can cause symptoms to worsen.

Seeing a psychotherapist to rule out emotional factors earlier in the diagnostic process can save money and heartache, which is especially important because the emotional upset associated with failed medical procedures and treatments can cause symptoms to worsen.

Abbass (2003) calculated an average health care cost reduction of $1,573 per patient by one year after a course of ISTDP. Only two of the seven studies reviewed for cost-effectiveness by Abbass (2003) were specific to medically unexplained physical symptoms (irritable bowel syndrome and chronic functional dyspepsia); however, even those who were being treated specifically for psychological concerns experienced a large reduction in their overall health care cost burden. This is strong evidence for the cost-effectiveness of ISTDP in reducing health care costs for folks with medically unexplained physical symptoms and general mental health concerns.

Another finding that supports this line of research is that the use of ISTDP therapists in the ED described above led to a 69% reduction in ED visits by those who had a very brief course of psychotherapy (3.2 sessions on average). Those who did not have the therapeutic consultation had anywhere from a 15% reduction to a 43% increase in ED use over the course of the next year (Abbass, et al., 2009). Average health care cost savings among the treated group was $910 in the follow-up year (Abbass, et al., 2010). This is strong evidence for the potential advantages of a medical system that takes emotional factors into account, both for those suffering and for the health care system overall.

Looking at the Data and Looking Forward

Thanks to the work of Davanloo, Abbass, and others, we have helpful tools for understanding the ways emotions impact the body and create medically unexplained symptoms. We know medically unexplained symptoms burden the people who experience them and the medical system with lost time, lost resources, dashed hopes, and continued suffering. Finally, we have tools and methods for diagnosing and treating somatization of emotions that have shown efficacy and cost-effectiveness. To me, as Abbass (2004) has argued, these data make the case for the importance of heightened awareness of this information among health care consumers and practitioners.

It is my hope that with greater awareness of the ways emotions can impact health, doctors and patients alike will be more open to referrals to emotion-focused assessment services like the one described by Abbass (2005) and to therapies, such as ISTDP, that have demonstrated efficacy in treating medically unexplained symptoms. However, until this becomes part of standard medical practice, we can advocate for ourselves by asking questions about whether our symptoms could possibly be linked to stress, anxiety, or other issues, and by seeking out appropriate assessments and treatments.

While we should not flip radically in the opposite direction and assume all our physical woes are psychosomatic, we may save ourselves from needless expenditures of time, money, and hope by having an emotion-focused interview early in the diagnostic process to establish whether emotional factors are contributing to our medically unexplained physical issues.

References:

1. Abbass, A. (2003). The cost-effectiveness of short-term dynamic psychotherapy. Expert Review of Pharmacoeconomics Outcomes Research, 3, 535-539.
2. Abbass, A. (2004). The case for specialty-specific core curriculum on emotions and health. Royal College Outlook, 1, 5-7.
3. Abbass, A. (2005). Somatization: Diagnosing it sooner through emotion-focused interviewing. The Journal of Family Practice, 54, 215-224.
4. Abbass, A., Campbell, S., Magee, K., & Tarzwell, R. (2009). Intensive short-term dynamic psychotherapy to reduce rates of emergency department visits for patients with medically unexplained physical symptoms: Preliminary evidence from a pre-post intervention study. Canadian Journal of Emergency Medicine, 11, 1-6.
5. Abbass, A., Campbell, S., Hann, G., Lenzer, I., Tarzwell, R., & Maxwell, D. (2010). Cost savings of treatment of medically unexplained symptoms using intensive short-term dynamic psychotherapy by a hospital emergency department. Journal of the Academy of Medical Psychology, 1, 34-43.
6. Davanloo, H. (2000). Intensive short-term dynamic psychotherapy: Selected papers of Habib Davanloo, MD. Chichester: Wiley.
7. Janig, W. (2003). The autonomic nervous system and its coordination by the brain. In Davidson, R. J., Scherer, K. R., & Goldsmith, H. H. (Eds.), Handbook of affective sciences (pp. 135-187). Oxford: Oxford University Press.

Think of the stories you tell about the endings in your life. Line these stories one against the other. What do they tell you about your relationship with endings in general? For many of us, goodbyes have a bad rap, associated with some of our worst memories. At best, we consider them gratifying conclusions to periods of prolonged misery. At worst, we construct them as traumatic punchlines to stories where we felt powerless and victimized, perhaps by the person who left us or by a harsh world which has taken a loved one. Conversely, as we see ourselves through the eyes of those we have left, we can experience complicated spirals of guilt, as unresolved today as the day we decided to depart. Whether voluntary or forced, the impressions left upon us are fraught with misgivings.

When therapy is successful, we are faced with the prospect of a new kind of ending. By the time it has come to say goodbye, a genuine mutual attachment between two presumed strangers has taken place. This kind of relationship, rare as it is in this world, certainly seems worth keeping. At the same time, it remains a professional relationship designed to conclude naturally as treatment goals are achieved. As therapy concludes, both therapists and the people they serve struggle with some of the same feelings prompted by other losses. We are faced, perhaps for the first time, with an opportunity to construct a mutual and intentional ending to a caring relationship.

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Carrying out an honest and healthy farewell reverberates on many levels. Within the safe field of therapy, there is a full spectrum of meaning we might put to the experience of saying goodbye. I offer the following brief scenarios of therapeutic closure with the expectation that we can see in each some basic elements of the human condition and of our own wish to find peace with the act of parting.

Saying Goodbye in an Incomplete World

Timothy’s goals in therapy had grown less specific over time. As he gained footing with the initial bouts of social anxiety that prompted his first visit to my office, he chose new goals for himself every few months. Overall, it had become a year of great personal growth for Tim. Moving into our second year of weekly sessions, he and I spent less time examining particular life challenges and more time exploring previously unexpressed aspects of his personality. “Expanding self-awareness” was a very appropriate goal for our time together yet brought with it a sense of endless expanse. A few months later, we agreed our work had plateaued. It was coming time to say goodbye.

The ease and companionship afforded by our extended time together gave Tim a broad view of himself. He had grown to expect the unexpected to surface. Thus, as the time of our departure arrived, there was no sense he had reached any set destination. Unlike graduating from school, he had no final test to measure mastery of a predesigned curriculum. Instead, similar to how it is to end relationships outside the office door, our ending point was inconclusive. “I feel like there is so much left uncovered, so many parts of me that have barely broken through,” he told me. “That hurts a little. Still, it just feels right to put this chapter of my life behind me. I’m grateful for it.”

Leaving therapy, for Tim, called upon a newfound experience of self-acceptance. We said our goodbyes with a bittersweet appreciation for what had transpired—both purposefully and unexpectedly—between us. As we shook hands at the door for the last time, we shared a final moment of accord: “This was enough.”

Saying Goodbye in a Solitary World

Julie felt trapped in her relationships and looked to therapy for help in setting better boundaries. “I am sick of being so afraid to make my own decisions when they inconvenience those who care about me,” she said. We spent three months together as she focused on establishing more independence as a daughter, wife, and mother. Julie was practical about her goals and diligent in applying new coping skills when confronted with others’ unease. I played what seemed a supplementary role in her personal transformation as I encouraged her latent sense of power, praised her intelligence, and offered assurance to the legitimacy of her quest. Over the course of these 12 sessions, she achieved a more outspoken and balanced role with her family members and felt “almost ready” to terminate therapy.

I was propelled into my career by a high regard for building deep connections. It wasn’t clear to me during my training as a therapist that I would become a master at relinquishing them as well.

“Maybe I should plan on seeing you monthly,” she said. “You’ve become a bit of a father figure to me and I just don’t want to give this up.” This statement, shared at our “final” session, was uncharacteristic for Julie. She seemed surprised, though not embarrassed, by her tears as she spoke. I felt touched by the depth of her affection but also recognized that her tears were not about her and me. There was the ghost of another father in the room with us, one whom she had never had the chance to show those tears. “He left me way before I was ready to let him go. I’m still so afraid to be on my own.”

Julie and I settled on a four-week extension of therapy to look a little deeper at the fears associated with the early loss of her father. It was a volatile and vulnerable set of sessions. In one, Julie gave herself brief permission to rage and sob over being abandoned in a lonely world; a side of herself so rarely expressed but situated at the center of her long-held habits of dependency. Then, just as quickly as they surfaced, the intense feelings subsided. The following week, we took another try at having a final session. Julie’s voice was steady and her hands lay still at her side as she thanked me for our work together. Our goodbye was that of two grown-up adults—solitary, intact, prepared.

Saying Goodbye in an Impermanent World

Death and dying had become a preoccupation for Matthew. He had good reasons to fear death—as do we all—but for Matthew these fears tended to permeate his every waking hour. His apartment had begun to reflect his inner state (“Why bother washing dishes if I might die tomorrow?”), making it a difficult place for casual entertaining or dating. In therapy, he sought the space to expound on the bleak thoughts he knew his friends would find too morose.

With time, as we formed our own retreat for his darker visions (both real and imagined), Matthew learned to compartmentalize his fears and address them more fully with me. As our sessions focused on giving air to his compulsive morbid thoughts, the rest of his life opened up. He took more interest in others and incidentally began to adopt more of their interests as his own. His apartment began to express more of a genuine investment in life.

Anticipating his eventual departure from treatment, Matthew grew nervous. He had no intention of painting the end of therapy as a point of progress or new possibility. Endings, for him, would always carry an air of intense calamity. Ending his relationship to me meant also ending his relationship to the history of thoughts expressed between us. “Without you as my witness, it’s like all those parts of me will be taken from me as well,” he said. I immediately understood the truth of his words.

When we end relationships, we are forced to say goodbye to parts of ourselves as well. Terminating therapy brought a conclusion not only to Matthew’s past dysfunction, but also to the kindness, integrity, and intelligence we showed each other along the way. We decided to treat this closure much like a funeral. We took turns honoring the sadness entailed in letting go of this significant yet transitory connection. Our bonds with others on this planet are always tinged with melancholy for their brevity. Each goodbye is a small death to those grand pieces of ourselves that we can only find in one another.

I was propelled into my career by a high regard for building deep connections. It wasn’t clear to me during my training as a therapist that I would become a master at relinquishing them as well. Of course, the door to those connections never fully closes. Most people are invited to return as the need arises or to schedule additional sessions to revisit their long-term goals. But the act of ending therapy is always a crucial piece of the process and a strong reflection on the nature of the person seeking help. Financial limits, scheduling conflicts, and abrupt changes at home usually provide the pragmatic reasons for sudden terminations. These are genuine, but they often also mask an underlying distrust that a meaningful ending is possible in a fragmented and fragile world.

I’ve learned to hold out that an intentional goodbye is the most instructive. A true companion deserves nothing less.

Note: To protect privacy, names in the preceding article have been changed and the dialogues described are a composite.

What does wellness look like to you? When you envision someone who is “well” and “healthy,” what comes to mind? What factors do you think influence wellness?

The Substance Abuse and Mental Health Services Administration (SAMHSA) has identified eight dimensions of wellness to focus on to optimize health. The eight dimensions include: emotional, spiritual, intellectual, physical, environmental, financial, occupational, and social. Wellness can be compromised by lack of support, trauma, unhelpful thinking styles, chronic illness/disability, and substance use. The eight dimensions are described below and are accompanied by examples and ideas for improving each area.

1. Emotional

SAMHSA identifies emotional wellness as an ability to cope effectively with life and build satisfying relationships with others. People with healthy emotional wellness feel confident, in control of their feelings and behaviors, and are able to handle life challenges. Working through life challenges can build resiliency as we learn that setbacks can be overcome. Emotional health can be maintained or improved by engaging in regular leisure and recreational activities. Do activities that involve each of your senses: smell, taste, touch, sight, and sound. Listen to music, eat your favorite food, light your favorite candle, play with your pet, and watch your favorite movie or the sunset.

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2. Spiritual

Spiritual wellness is related to your values and beliefs that help you find meaning and purpose in your life. Spiritual wellness may come from activities such as volunteering, self-reflection, meditation, prayer, or spending time in nature. Signs of strong spiritual health include having clear values, a sense of self-confidence, and a feeling of inner peace. To improve your spiritual health, it can help to create a quiet space for solitude and contemplation or a place of curiosity and playfulness. Maintaining a playful, curious attitude can help you find experiences that offer hope, purpose, and meaning.

3. Intellectual

Intellectual wellness is when you recognize your unique talents to be creative and you seek out ways to use your knowledge and skills. When you foster your intellectual wellness, you participate in activities that cultivate mental growth. Reading, doing challenging puzzles such as crosswords or Sudoku, debating issues with others who have opposing viewpoints, learning a new language or musical instrument, trying a new hobby, or teaching and tutoring others are all ways to maintain or improve your intellectual wellness. When you challenge yourself to learn a new skill, you are building your intellectual health. People who pay attention to their intellectual wellness often find that they have better concentration, improved memory, and better critical thinking skills.

4. Physical

Physical wellness is affected by physical activity, healthy nutrition, and adequate sleep. There are many examples of physical activity that range in levels of intensity from light to vigorous. Maintaining your physical health can include yoga, bike riding, jumping rope, engaging in sports, running, walking, jogging, skiing, dancing, tennis, and gardening. Many people use smoking as a coping tool. Unfortunately, this method of coping can lead to a number of physical health problems, including heart disease and cancer, and can increase one’s chances of premature death. SAMHSA states that smoking-related illnesses are related to half of all deaths for people diagnosed with a behavioral health condition.

Environmental wellness is related to the surroundings you occupy. This dimension of health connects your overall well-being to the health of your environment. Your environment, both your social and natural surroundings, can greatly impact how you feel.

5. Environmental

Environmental wellness is related to the surroundings you occupy. This dimension of health connects your overall well-being to the health of your environment. Your environment, both your social and natural surroundings, can greatly impact how you feel. It can be hard to feel good if you are surrounded by clutter and disorganization, or if you feel unsafe in your environment. Pollution, violence, garbage buildup, and water conservation are some of the factors affecting environmental wellness. Ways to manage environmental wellness include creating neighborhood watches, recycling, planting a personal or community garden, purchasing products with minimal packaging, avoiding littering, and conserving energy and water by turning off lights and water when not in use.

6. Financial

Financial wellness is a feeling of satisfaction about your financial situation. Finances are a common stressor for people, so being able to minimize worry about this aspect of your life can enhance your overall wellness. Options for managing financial wellness include having a household budget, starting a savings account and adding to it every month even if it is just a small amount, saving some of your income in an emergency account, cutting back or limiting unnecessary expenses, avoiding credit card debt, donating to a meaningful charity, shopping at thrift stores, utilizing the library for free books and DVDs, and cooking your own meals instead of dining out. Try tracking your spending for a month to see where your money is going and set goals based on what you find.

7. Occupational

Occupational wellness is a sense of satisfaction with your choice of work. Occupational wellness involves balancing work and leisure time, building relationships with coworkers, and managing workplace stress. An occupational wellness goal might include finding work that is meaningful and financially rewarding. Finding work that fits with your values, interests, and skills can help maintain occupational wellness. Consider your office culture and determine how supported you feel; if you discover you feel a lack of support, seek out support from others close to you and be sure to engage in recreational activities that can help balance out work stress.

8. Social

Social wellness is a sense of connectedness and belonging. The social dimension of health involves creating and maintaining a healthy support network. Building a healthy social dimension might involve asking a colleague or acquaintance out for lunch, joining a club or organization, setting healthy boundaries, using good communication skills that are assertive rather than passive or aggressive, being genuine and authentic with others, and treating others in a respectful way.

What dimensions do you feel are your strongest? What areas would you like to work on? If you have areas you would like to improve, seeking out support can be helpful, whether it’s from a friend, family member, or counselor. What would life be like if you optimized all eight dimensions? Setting goals for yourself in each area can help you feel more fulfilled and optimize your health.

Reference:

Substance Abuse and Mental Health Services Administration (SAMHSA). (2016, April 28). The Eight Dimensions of Wellness. Retrieved from http://www.samhsa.gov/wellness-initiative/eight-dimensions-wellness

For as long as society has been aware of mental health concerns, it has also harbored stigma toward those experiencing such concerns. With limited knowledge of the varied factors influencing the development of mental health conditions, people historically believed these issues to be divine punishment, demonic possession, the effects of immoral behavior, or some combination of the above. People who developed mental health concerns were often shunned, exiled, locked away, abused, or subject to other cruel treatment.

Today, mental health issues such as depression, anxiety, and posttraumatic stress tend to be better understood by society than they were in the past, especially as more research shows just how common these conditions are. People who experience these concerns today may feel more comfortable discussing them with friends, family, or others experiencing similar conditions in their own lives than people may have even 50 years ago. A number of celebrities and other public figures even speak openly about their own mental health challenges in an effort to reduce stigma and increase awareness and support for those facing similar issues.

Stigma does still exist, however. Not everyone who wishes to seek treatment is able to do so, and some barriers to treatment result from the stigma attached to certain mental health concerns. Some may believe, for example, that challenges such as addiction result solely from an individual’s choices, and they may fail to recognize the range of contributing factors. Many conditions such as schizophrenia and bipolar are falsely associated with violence, which may heighten feelings of shame or discrimination and lead those experiencing them to avoid seeking treatment. People diagnosed with borderline personality, one of the most stigmatized mental health conditions, often experience stigma even from mental health care practitioners and may be more likely to withdraw from treatment early as a result.

At GoodTherapy.org, we are committed to normalizing mental health concerns and eliminating mental health stigma. We believe all people should be able to seek care without fearing judgment or discrimination, and this Mental Health Awareness Month we would like to highlight 11 like-minded organizations working to increase mental health awareness and reduce stigma.

• Helpguide, a nonprofit, was founded by Jeanne and Robert Segal in 1999 after their daughter died by suicide. They started the website to provide people seeking help with access to professional research, presented in a non-biased and supportive format. The goal of the site is to offer hope and empower people to achieve greater mental well-being through knowledge and self-help, as well as treatment. Helpguide, which collaborates with Harvard Health Publications, provides extensive information about mental health concerns and emotional issues, an emotional intelligence toolkit, and a free monthly newsletter.
• Time to Change, a U.K.-based campaign run by the mental health charity organizations Mind and Rethink Mental Illness, works with adults, children, and youth to end discriminatory attitudes and behavior toward those with mental health concerns across England. Their work, which aims to challenge stigma in the workplace, in health care, and in all other areas of life, has already achieved some measure of success: The last annual survey conducted reported an 8.3% improvement in public attitude toward those with mental health concerns since the movement began in 2007. Visitors to the site can learn about mental health and the impact of stigma, access tips on discussing their own mental health conditions, pledge to end mental health stigma themselves, and find out how to get involved.
• mindyourmind is a Canadian nonprofit designed to offer supportive,  relevant resources to youth, young adults, and adult professionals working with these populations. The site, which asks for and incorporates the input of the young people it serves, offers crisis and informational resources to those who need immediate help, information on wellness strategies and mental health concerns, interactive educational tools, and shared stories–which include art, videos, zines, and poetry.
• See Me, Scotland’s response to the stigmatization of mental health concerns, is a national program dedicated to ending the discrimination affecting outcomes for those facing mental and emotional challenges. The program also works to help people, especially young people, realize mental well-being is essential to good health and empower them to seek help and support when necessary. See Me’s website provides visitors with information on talking to employers and health care professionals, supporting staff members or coworkers, and advice on what to do when experiencing discrimination.
• Teenmentalhealth.org, a nonprofit dedicated to providing youth, their families, and educators with reliable, evidence-based mental health information, works to combat stigma through accurate information and greater mental health literacy. The site offers several “First Person Experience” videos, each of which features a unique individual’s story, information about mental health and behavioral concerns as well as general wellness, a toolbox containing an informational app and resources, and “Care” resources specifically directed toward friends, educators, parents, and educators of those facing mental health challenges.
• CenterLink works to develop and support LGBT community centers throughout the United States and other parts of the world, promoting diversity and equality and celebrating LGBT culture. Nonprofit LGBT centers may, in some areas, be the only places LGBT individuals can seek information, health care, or other services of benefit to their well-being, but many locations lack resources, staff, and face other difficulties. CenterLink works to increase the capacity of these centers in order to allow them to reach and support a greater number of individuals. Visitors to the website can see center locations, access resources on CenterLink’s programs, view a list of LGBT-related job listings across the United States, and learn how to get involved.
• Families for Depression Awareness is a nonprofit organization working to promote depression awareness by uniquely focusing on the friends, family, and caregivers of those experiencing depression and/or bipolar. The website highlights their “Family Profiles,” a collection of interviews with individuals who have depression, which spread the message that anyone can experience depression in an effort to reduce stigma associated with the condition. Families can email these profiles to those they feel may be at risk. The site offers wellness analyzer tools, links to videos and resources for adults and youth, free webinars, and Depression Wellness Guides in English and Spanish.
• Freedom From Fear, a nonprofit organization advocating for those with mental health concerns such as anxiety and depression, offers content in both English and Spanish. Based in Staten Island, Freedom From Fear has a local treatment center and also offers information on alternatives to traditional counseling. Visitors to the site can watch informational videos about anxiety and depression, access treatment resources, subscribe to a free newsletter, and read weekly informational posts from experts and mental health professionals on a variety of topics related to wellness. The website also provides an extensive collection of links to other sites providing mental health care or crisis information and counseling resources.
• The NoStigmas Network is an organization seeking to unite individuals with a common goal: the elimination of stigma toward mental health concerns. Their website offers free membership to anyone who agrees to uphold core values of respect, community support and advocacy for others, personal responsibility, and the elimination of stigma. Membership includes tools for awareness; informational content; and access to peer groups, events, and e-learning courses. Site visitors can also view the NoStigmas project, which are member-contributed stories in various media formats about the journey toward healing and wellness. Visitors in need of support can connect online with peers, obtain information about free or low-cost counseling resources and services, and access wellness information and treatment tools.
• The National Network to Eliminate Disparities in Behavioral Health seeks to promote equal behavioral health care resources for all. The organization strives to connect minority communities through shared values and wellness goals to foster the growth of community-based knowledge, eliminate stigma, and achieve equity in behavioral and wellness resources. Each year in July, which is National Minority Mental Health Awareness Month, NNED partners with the National Alliance on Mental Illness (NAMI) to offer Twitter chats and Mental Health Awareness webinars to celebrate and increase mental health awareness across diverse communities nationwide.
• MentalHealthChannel is a web-based platform for mental health and wellness programming. The channel’s programming includes several original series on a variety of topics, such as personal stories and information about wellness, treatment, and care access. Thorough their programming, MHC hopes to encourage people to have positive conversations about mental health and wellness, increase understanding of mental health challenges, and support those who are facing them. All of their content, some of which appears on PBS and other television channels, is completely free to view and share by individuals or organizations. MHC also offers filmmakers the option to submit short films raising awareness about mental health concerns with an annual Online Film Festival.

If you know of an organization working to end mental health stigma, please recommend it here.

References:

1. Deans C., Meocevic E. (2006). Attitudes of registered psychiatric nurses towards patients diagnosed with borderline personality disorder. Contemporary Nurse, 21 pp. 43–9.
2. Foerschner, A. M. (2010). The history of mental illness: From skull drills to happy pills. Student Pulse, 2(09), 1-4. Retrieved from http://www.studentpulse.com/articles/283/the-history-of-mental-illness-from-skull-drills-to-happy-pills
3. Szabo, L. (2014, June 25). The cost of not caring. USA Today. Retrieved from http://www.usatoday.com/story/news/nation/2014/06/25/stigma-of-mental-illness/9875351
4. Yasgur, B. S. (2015, April 03). Stigmatizing patients with borderline personality disorder. Retrieved from http://www.psychiatryadvisor.com/practice-management/stigmatizing-patients-with-borderline-personality-disorder/article/407316

Part of GoodTherapy’s mission and vision is encouraging people everywhere to learn more about mental health issues and treatment. We believe this is helpful in changing stigmatizing language and beliefs about mental health issues, in developing mental health care policies, and in promoting a system in which better, more compassionate outcomes are the norm.

Mental Health Awareness Month, established in 1949 and recognized each May, is a great opportunity for us to talk about stigma, share statistics, and demystify psychotherapy and other healthy treatment options. It’s also a chance to celebrate the important work mental health professionals are doing every day. This Mental Health Awareness Month, we reached out to our members and asked them to share, in their own words, what motivated or influenced them to work in mental health care. They responded:

Jessica Wade, LPCC

As long as I can remember, I have been a student of people. I remember asking questions about why some people did well in life and others seemed struggle. While I think this is a question researchers are still studying, I did notice patterns in the lives surrounding mine. I noticed that people who believed they could overcome their problems seemed to fare better than those who believed their problems were too big. I watched people who believed they could overcome problems truly rise to the occasion and overcome serious addiction, rise out of poverty, choose healthy relationships, and find mental and behavioral stability. As a therapist, my goal has been to enrich and fortify people’s self-knowledge that they can overcome difficulty. They have the potential for personal greatness within them, and I help them rally their resources to create the lives they desire. I firmly believe that they can create the kind of lives and relationships they desire, only when they firmly believe they can. I have made it my mission to help my people see their own potential and believe in the power of themselves to make it happen. I see greatness come alive in the small steps my clients take each day.

Benjamin Meyer, LCSW

As I think about the tears that dripped down the face of one of the mothers who had lost her son in the 1970s in the clandestine and infamous German colony known as Colonia Dignidad, located in Southern Chile, I distinctly remember the words of one of my college advisers: “And to think, Benjamin, that after all these years, she still remembers it as if it was yesterday.” My interest in becoming a mental health professional stems from my experiences working with individuals and families who had been violently persecuted under Chile’s Pinochet dictatorship and during the Salvadoran Civil War.

[fat_widget_right]I witnessed the ongoing impact of having lost a loved one, having experienced torture or knowing someone who was, and being forcibly uprooted from one’s community. I felt limited in my ability to help the persecuted and their family members to process the complex feelings associated with political violence. My motivation for becoming a therapist stemmed from my desire to do more. Therefore, I pursued a master’s in social work and began to work with children and families, many of whom have faced forced immigration, domestic violence, racism, and school-related concerns. I make a difference every day.

Davida D. Price, MS, EdS

For them; that’s why I did it, at first. I wanted them to understand that they didn’t ruin me. That I had become full—exceptionally strong, self-empowered, capable—despite them. I completed my undergraduate degree in psychology, seeking to understand them and myself. I wanted to understand how I had become an adolescent poetess, drinker, smoker, partying, feeling-all-the-time-not-wanting-to-feel-at-all type of person. I learned during that time in my life that I was none of those things, but rather an empty, love-desperate child pretending to be an adult who was complete. Then, I entered graduate school. Now older, rubbed raw from military experience and weary from rumination and “self-help,” I wanted it for me this time. Not them. The program I entered was strategically designed to cultivate integrity, strength, and wholeness.  The student-therapist I became developed a strong self-concept, a secure locus of control, and (most important of all) faith. That faith led me to where I am today. Today, I want to serve others. Motivate others. Help other people on their journey from emotional poverty to wholeness, security, and their truest self.

Gena Golden MSW, LCSW, CHt

As a child, my outlook was filled with pessimism and negativity mainly as a means to protect myself from hurt and disappointment. I convinced myself that if I had low expectations about outcomes, I would be shielded when the other shoe dropped. My mother, a case worker at a Philadelphia psychiatric hospital, would always refer to a concept called mind over matter. She would try to convince me that what we believe to conceive, we can achieve. Clinging to my “Negative Nancy” outlook on life, I couldn’t understand my mother’s notion about the mind having power over my experience. However, it all changed one day when I had the most horrific headache I ever experienced in my young life. I was so miserable and debilitated by this strange pain in my head that I declared at 9 years old that I would never have another headache again. That day, I put my mother’s teachings into action and declared and imagined every day that I was free of headaches. I maintained a 35-year headache-free life all due to how I changed my thinking, words, and actions as a tool to manifest my desired outcomes for my life. I decided as a young girl that I wanted to support others through challenges in their life by helping them to heal through the use of their own inner power. As a counselor and hypnotherapist, I help people relax their bodies and minds through the use of hypnosis. Together, we explore positive ways to recondition limited thinking patterns, belief systems, and behaviors to uncover the results desired for their lives, business, and relationships. I am passionate about people I treat and their transformation from self-sabotage, unhealthy beliefs, self-doubt, and pessimism, to a space of clarity, self-esteem, confidence, and optimism with our work together. I find joy in helping others live a more fulfilled life.

Meri Levy, LMFT

I imagined growing up to be a therapist when I was a teenager, because my mother worked as a psychotherapy office manager and the therapists seemed like interesting people. But when I got to college, the psychology department was all about lab rats and psychological experiments, and I really had no interest in that. I discovered I was good at economics and ended up getting a master’s degree and working as an economist in state government for over a decade. Then, after having my second child, I suffered from postpartum depression and anxiety. It took months of suffering to get a diagnosis and the proper treatment. After I recovered, I was fired up about supporting other moms in getting help. After several years of running support groups, I decided the best way I could help was to become a therapist and specialize in the treatment of new moms. It’s been so satisfying to be able to help light the way for those suffering through a traumatic journey that I have personally experienced.

Marni Amsellem, PhD

Mental Health Awareness Month is a meaningful time to reflect on why I wanted to become a psychologist and how that still rings true today. As someone who has devoted my career to the promotion of mental health, I am grateful for the opportunities I have been granted through my work. As a therapist, I have been allowed access into the inner worlds of others. I have been entrusted with thoughts and feelings that are often not shared with others in their daily lives. It is a giant responsibility and something that I thoroughly enjoy.

I became a therapist so that I could help others understand themselves better so they learn how to help themselves feel better. I help others recognize insights and make connections in their own world that lead to a shift in their understanding of themselves. My goal is to help teach skills that bring meaningful and positive change into the lives of others. The changes that happen in therapy will both lead to immediate relief and, ideally, to sustained improvement and growth over time. Having the opportunity to have an influential role in this process is exactly why I provide therapy.

Tammi Young, LMFT-S

I became a therapist because of the sexual abuse and domestic violence that I experienced as a child. I could not understand why I could not get over the anger and other overwhelming feelings I had until I went into counseling. The feeling of being understood and validated was so healing that it didn’t matter to me anymore if my family didn’t understand me because I knew that God understood me as well as my therapist. I became a therapist to walk that “scary road” with people and to let them know that I do understand! Understanding is what I received, and understanding is what I want to give back!

Reference:

Mental health month. (2016). Retrieved from http://www.mentalhealthamerica.net/may

The therapeutic relationship can be a very powerful relationship. In fact, power in this relationship is vital, and something ethical therapists should think carefully about. Ideally, the therapist uses the position of authority inherent to the role to empower people in therapy and encourage them toward wellness and autonomy. Unfortunately, this does not always happen. In some cases, therapists have been known to abuse the imbalance of power in the therapeutic relationship. This can of course be harmful to the people they are entrusted to help, who may not know exactly what is happening or what to do about it.

As a person in therapy, trusting your own experience and communicating about it are both essential to the outcome of therapy. If you have fears or doubts about something that happened or how you are being treated, in most cases you should speak with your therapist about these concerns. In turn, any such concerns should be taken seriously and addressed immediately by the therapist.

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Some ways therapists may go astray in the therapeutic relationship include behaviors related to boundaries, to fostering dependence, to their duty of care to you, and to acting in hostile ways. A number of specific things would be red flags. While I will discuss some of them, please know this list is by no means exhaustive, nor can it possibly be. It is important to trust your instincts about how you are being treated.

Boundaries are extremely important in the therapeutic relationship, and many are outlined in the ethical codes mental health practitioners are bound by. It is incumbent upon your therapist to maintain appropriate and professional boundaries; this is one of the ways the therapist fosters trust in the relationship and in the therapeutic process. Maintaining boundaries means your therapist should neither cross boundaries nor allow you to cross them as part of the relationship. The therapeutic relationship should empower you and enrich your life.

Examples of boundaries being crossed include:

• Violating confidentiality: Sharing your information with others, or others’ information with you.
• Attending sessions while compromised: This includes being inebriated, or conducting sessions if the person in therapy is too inebriated to meaningfully engage the therapeutic process.
• Conducting sessions while distracted: This means doing other things, such as running errands, having meals, or answering phone calls.
• Not adhering to expected lengths of sessions: Sessions sometimes run a bit late, but consistently going long or cutting short, or if you don’t know how long sessions are supposed to be, is not respecting boundaries.
• Expecting, asking for, or accepting favors or gifts: Small gestures such as thank-you cards are okay if offered, but should never be expected, and the person in therapy should never feel pressured to give anything.
• Extending invitations or accepting invitations to social events: Your relationship is professional and should be conducted within the confines of professional contexts; while we, as therapists, do sometimes receive invitations to important social events involving people in therapy and generally are very touched and honored by this, we should decline them gracefully to preserve the integrity and safety of the professional relationship, which is our first priority.
• Requesting support for their business: Therapists should not ask for donations, contributions of time or money, or any other support of their business outside of what you owe them directly for your therapy. This includes soliciting reviews for use in their marketing or websites.
• Maintaining multiple relationships: Therapists generally should not be in a therapist role for people with whom they have other significant relationships, or for people with close ties to others the therapist is working with. In small communities with very limited numbers of therapists, this can be difficult, but therapists should work hard to find the best ethical balance they can while preserving the safety of the therapeutic space.
• Any sexual innuendo, requests, pressure, or behavior: Licensed therapists are prohibited from sexual contact with the people they work with in therapy. If your therapist makes sexual overtures to you or encourages them from you, this is a serious violation of trust.

Fostering Dependence

Therapists are ethically obligated to support people in therapy in living full, independent lives to the extent this is possible for them. In some (hopefully few!) cases, therapists have intentionally fostered dependence. As a therapist, my goal is always, as I say, to “work myself out of a job,” because this means the person in therapy has achieved the goals established at the outset and moved into a better space.

Some clues that your therapist may be fostering dependence in the relationship include:

• Pressuring you to cut off ties with important people in your life who support you.
• Encouraging frequent out-of-session contacts with no reasonable clinical justification.
• Responding negatively or dismissively to positive changes you make.
• Having excessive influence over your personal choices—leisure activities, relationships, clothing choices, career choices, etc.
• Pressuring you not to disclose your therapy work to others, or seeking to isolate you from other important people in your life.
• Offering or encouraging you to use illegal or potentially addictive substances outside the boundaries of appropriate prescriptions by a qualified physician or psychiatrist.

For what it’s worth, some of the signs above are hallmarks of emotional abuse. You don’t deserve such abuse from anyone, let alone your therapist.

Deviations from Duty of Care

Therapists have a specific duty of care to you. This includes a legal and ethical duty to work actively toward your welfare and to be responsive to your needs.

Therapists have a specific duty of care to you. This includes a legal and ethical duty to work actively toward your welfare and to be responsive to your needs.

Some specific deviations from a therapist’s duty of care to you might include:

• Failing to respond to suicidal or homicidal ideas you express during sessions, or encouraging such thinking or planning.
• Not listening to your concerns about your well-being or your priorities in this regard, or failing to respond when you voice such concerns.
• Being dishonest or deceptive in regards to the goals, process, or prognosis of your therapy.
• Abandoning you—suddenly terminating therapy without explanation or referrals to other qualified providers, or failing to respond to reasonable needs or requests for support.

Hostile or Abusive Behaviors

Therapists may sometimes need to confront problematic behaviors or hold reasonable expectations regarding behavior of the person in therapy. However, this boundary should never take the shape of openly hostile or abusive behaviors.

Some indications your therapist is engaging in hostile behavior include:

• Expressing excessive anger at you or your behaviors.
• Using language with you or about you that is insulting, demeaning, or inappropriate—using profanity in the therapy room is not particularly uncommon, but this language should never be directed at you in an insulting way or used in ways that are frightening or offensive to you. My rule of thumb is to follow the lead of the person in therapy; if the person chooses to use profanity to express strong feelings, that is fine with me, but I do not use such language outside the context of the person’s own use of it. Strong language, whether profane or not, should not be directed at you in insulting or abusive ways.
• Yelling at you—again, raised voices sometimes accompany the discharge of strong emotions, and this can be fine and even healing at times. However, your therapist should not be yelling at you in demeaning or belittling ways, or ways that feel frightening or upsetting.
• Violating your boundaries—if you set a clear boundary about something you don’t want to discuss, your physical space or touching, or language you find upsetting, this should be respected. It may reasonably happen that your therapist might express an opinion about the clinical benefit of talking about something that feels uncomfortable to you; however, this should be a calm expression that helps you understand and feel supported rather than an angry or confrontational demand.
• Threats—you should not feel threatened by your therapist. Threatening to disclose sensitive information to others, to use it against you inside or outside of therapy, or to terminate therapy if you don’t “toe the line” are red flags. A therapist may need to terminate therapy with you if they believe it is not benefitting you or for other reasons, but this should be handled in a sensitive way that helps you to understand the reasons for it and offers other options.

The scenarios above provide a broad overview of some behaviors that may be indicators of a problematic or abusive therapeutic relationship. In some of these cases, it is conceivable that there might be reasonable clinical justification for certain behaviors. However, if you feel uncomfortable about your therapeutic relationship, you should address that discomfort—it is real, valid, and deserves attention.

If You Have Concerns Regarding Therapy or Your Therapist

If you have concerns about the safety or appropriateness of your therapy relationship, in most cases the best first step is to bring these to the attention of your therapist. In many cases, there may have been a miscommunication of some sort and your therapist will be grateful to you for bringing this to their attention so it can be addressed. (Good therapists want to help you feel better!)

If this does not seem possible or reasonable in your circumstances, you are always free to seek a second opinion from another therapist. Although it’s rarely advisable to have multiple concurrent therapists, one session to consult with a different therapist about how your therapy is going and explore the possibility of changing to a therapist who may be a better fit for you is always a reasonable step.

If you have serious concerns about how you have been treated in therapy, you can contact the licensing board for the type of professional you are working with in your state and ask what your options are. A simple web search should help you find this body. For example, searching for “counselor board state of Indiana” should help you navigate to the relevant authority that can help you with your specific questions or concerns.