by: Rob Weiss

The late science fiction author Douglas Adams may have stated the natural reaction to new technologies better than anyone in his book, The Salmon of Doubt, when he wrote:

Anything that is in the world when you’re born is normal and ordinary and is just a natural part of the way the world works. Anything that's invented between when you’re 15 and 35 is new and exciting and revolutionary and you can probably get a career in it. Anything invented after you're 35 is against the natural order of things.

As a person over the age of 35, I completely understand Adams’ statement. The technologies available when I was a kid seemed (to me) indispensable to the world’s very survival. The technologies that arrived in my early-adult years (DVDs, CDs, websites, and Internet chats, for instance) are, in my mind, logical developments that I easily grasped and learned to use. However, the technologies of the last few years occasionally freak me out. Virtual reality, for instance.: headset that immerses me in a digital universe that feels as real as the real world is, to me, simultaneously creepy and cool.

Either way, as a social worker I know that I’d better understand how VR looks and feels and what it’s used for, because sooner or later I’m going to encounter a client who’s having a VR-centric issue. And before I know it, I’m going to have a client who would rather conduct his or her sessions using VR headsets than in-person.

If you don’t believe me, consider a 2009 study finding that kids between the ages of 8 and 18 spend 11.5 hours per day engaging with and/or through digital technology. And that was almost a decade ago, before the rise of smartphones. Moreover, the kids in that long-ago study (who were using digital devices approximately 70% of their waking hours) are now young adults. And young adults are consumers. Of everything. Including our services.

Are we ready for that?

When I was studying to become a social worker, I learned that an essential element of helping clients is understanding and feeling comfortable in their culture. I was told that if I was working with an African American client, I should have at least a basic understanding of African-American culture. The same was true with Latino clients, Jewish clients, LGBT clients, and every other ethnic and cultural group. If I don’t understand a client’s culture and belief system, I can’t adequately respond to his or her experience.

So why are so many of us ignoring this standard when it comes to technology?

In our practices today, the most commonly encountered “foreign culture” is the online world. As social workers, we need to accept this and adapt to it. We need to understand—in fact, we are obligated to understand—that many of our clients feel as much if not more at home in the digital universe as in the real world. We must further understand that the digital universe is comprised of hundreds of separate subcultures, each with a distinct purpose, code of conduct, and set of potential problems.

Of course, no therapist can or should expect to be conversant in all languages and cultures. That said, our work requires us to either become culturally competent or refer our clients to someone who is. And honestly, how many of us have even tried to fully understand the ways in which online life affects and guides our clients—especially our younger clients—in terms of romance, business, friendships, politics, socialization, entertainment, self-esteem, and other important aspects of life?

If you’re fighting the idea that it’s time to step into the digital age, think about what’s happened to the taxicab industry since Lyft and Uber showed up. Today, the idea of phoning for or hailing a cab has fallen off the proverbial cliff. And this has happened because it’s easier—and often more appealing, especially to people under a certain age—to catch a ride using an app.

Is this slow taxicab-style demise what you’d like to see in your practice? If not, then maybe it’s time to recognize that more and more people are shopping digitally these days. Countless millions are already buying groceries, watching movies, playing games, shopping for furniture, and visiting medical doctors online. If we, as social workers, hope to remain relevant, then we need to adapt to this fact.

Robert Weiss LCSW, CSAT-S specializes in infidelity and addictions—most notably sex, porn, and love addiction. He has served as an expert on human sexuality for multiple media outlets including CNN, MSNBC, The New York Times, The Los Angeles Times, and NPR, among others. His latest book is Prodependence: Moving beyond Codependency. He has also authored: Out of the Doghouse: A Step-by-Step Relationship-Saving Guide for Men Caught Cheating, Sex Addiction 101: A Basic Guide to Healing from Sex, Porn, and Love Addiction, Sex Addiction 101: The Workbook, and Cruise Control: Understanding Sex Addiction in Gay Men. Currently, he is CEO of Seeking Integrity, LLC, being developed as an online and real-world resource for recovery from infidelity and sexual addiction. For more information or to reach Mr. Weiss, please visit his website, robertweissmsw.com, or follow him on Twitter, @RobWeissMSW.

written by: Renee Burns Lonner, MSW and Michele Licht, JD | Reprinted with permission from AAMFT (Family Therapy Magazine, May/June 2018)

It’s not something that most of us would ever imagine having to deal with in our careers — a client makes or poses a threat of violence against you.

Therapists seem to be uniquely challenged in terms of knowing what to do to protect themselves, based on either their nature or education and training, or a combination of both. Therapists sometimes joke that theirs is one of the oddest professions: many spend their entire professional lives sitting in a room with clients listening to the most intimate thoughts and feelings — and pain — and their only curative tool is the spoken word. The therapy office is a most private world, and it must be so for the kind of work that is done there.

Individuals who enter the mental health field tend to be, by definition, other-oriented; people who want to improve the human condition and lessen the suffering of others. They are in the “people business” and people, not things, are their interest and field of study; they are “caretakers” of a particular sort, taking care of the hearts and minds of their clients, helping them to feel heard and understood, some for the first time in their lives.

It should not be a surprise that therapists often do not take good care of their professional selves; they are too busy taking care of the client. Usually, when supervisors tell them to pay attention to their own feelings, it is in the service of the client, or countertransference, feelings that the client often unconsciously provokes in the therapist that are a most useful kind of communication for the therapeutic process. But therapists often deny or minimize feelings of risk to themselves, anxiety or fear. The importance of observing and addressing risk to personal or professional well-being as it develops in the assessment or treatment process, in other words, the ability to identify “red flags” and intervene constructively, will be our main focus here.

In addition to direct risk posed by the client, threats to the therapist may develop from an indirect high-risk situation. The therapist may have met a legal obligation to warn a potential victim (Tarasoff) and inadvertently provoked the client’s anger, or the therapist may be viewed by the client as “taking sides” in a highly contentious divorce or custody matter. In these situations, the therapist may become one of the objects of the client’s anger.

Many therapists who have contacted the authors about a threatening client have observed, and then denied or ignored, weeks or months of warning signs and signals which are, notes Gavin de Becker, pre-incident indictors (1998). It is important to recognize, and, more importantly, pay attention to those signs and become appropriately concerned for one’s safety, a psychological position that is unfamiliar and nearly always uncomfortable for mental health professionals. Therapists need to know when to consult, when to assess and not begin treatment with a client, when to refer and when to terminate. Though we are emphasizing the need for therapists to learn they have a basic right to safety and self­-protection, the client’s needs are served here, also — no therapist who is frightened for her or his own safety can provide effective treatment and clients who present such risks usually need to be seen in environments other than a sole practitioner’s private practice office.

Red flags during assessment

There are potentially dozens of red flags that a therapist may observe in the first couple sessions with a client and many resources are devoted to that subject (see Professional Resources section). Most individuals who eventually make or pose a threat have a personality disorder (sociopathic, narcissistic) that renders them devoid of empathy, thus making it easier for them to justify harming another person physically or psychologically. However, having either a personality disorder or many of the traits thereof, in and of itself, does not make someone a risk of violence — for that, one needs to add situational factors having to do with actual loss or narcissistic injury, often combined with the abuse of alcohol or drugs. Being able to observe these red flags at any point in the assessment or treatment phases requires the therapist’s intuition, as well as paying attention to the client’s words (and behavior), and then acting quickly and appropriately to address the risk. Following are statements reflecting incidents related to a client who presented a risk of violence:

• My practice specialty is personality disorders and I take pride in helping a lot of these clients make progress; I guess the fact that she had seen several therapists before me, and did not feel helped by any of them, I took as sort of a professional challenge and I wanted to demonstrate to her that she could get help.
  
• He pushed the boundaries of the therapeutic relationship from the beginning and did not respond positively when I set limits; however, it never occurred to me that I could or should terminate him for that behavior and I just became increasingly anxious.
  
• He was extremely depressed and suicidal when I started to see him and I was so concerned that he would kill himself that I entirely missed the violent part of his suicidal thinking. I never thought he could become homicidal until he made the actual threat. Now, I recall that he told me in the first couple sessions that he collected antique guns and had a fascination with them.
  
• The father in a high-conflict divorce and custody situation admitted that he had struck his child on a couple of occasions, but he said that he did not hit him hard and considered that it was appropriate discipline, and “it worked.” He added that if I told anyone, he would “make sure I was sorry.”
  
• I was uncomfortable with the way he looked at me during the initial session and he asked a couple of very personal questions. I felt shaky by the end of the hour, but I’m an intern and I didn’t think my supervisor would react well to my not wanting to see him.
  

These situations developed over time into cases of stalking and homicidal threats, and consultation involved very sensitive and strategic interventions aimed at reducing the threat and protecting the therapist. De Becker (1998) makes the point in The Gift of Fear, while referring to workplace situations, the range of interventions narrows and the risk increases if the threat is allowed to develop and increase over time. Though not involving the context of the usual “workplace,” the authors see this phenomenon regularly in consultations. Many therapists who seek consultation after weeks or months, or in rare cases, even years, of a client’s presenting a risk of harm learn that their options are far fewer than they would have been with early intervention. This phenomenon is created, on a most basic level, because the person who is making or posing the threat has become more and more empowered by the absence of consequences. The relatively simple setting of a limit or boundary usually does not work at advanced stages of risk. That timeline is the dynamic at play in some consultation cases where the situation is so dangerous that it is advisable to terminate the client by phone or in writing, but in no circumstances in the office, in person.

At a most basic level, the therapist’s concern about risk in general (therapist or other-directed) should be activated by clients who assume no responsibility for their behavior, have a level of anger or rage that is excessive for almost any situation, have a history of violence and/or make threatening statements (even if they are implied, conditional or indirect) and have substance abuse issues. Often in such situations, the therapist’s anxiety takes over and he or she seeks the client’s assurance or a verbal contract regarding safety. By expanding the conversation briefly at this point, the therapist can be in a position to take appropriate action, if that is indicated; such action might be to not see the client and refer him or her to a clinic or specialized practice setting. Such questions might be:

“You mentioned that you ‘got even’ on social media with your last girlfriend for breaking up with you — what did you post, how often and how do you know her response?”

“You said that you saw your last therapist for several years, but it turned out she was not helpful and you think she was not ethical on some occasions — would you be willing to sign a release so that I could speak with her?”

Generally, the authors only hear from therapists whose case situations have become very difficult, and those are the examples provided here. With that caveat, we have observed that some therapists seem averse either to not accept a client who arouses concerns during the assessment phase, or to terminate clients who are not following the key elements of the treatment plan. Often during these consultations, the view expressed by the authors that “responsibility is a two-way street” comes as a surprise to the consulting therapist, and he or she responds with 1) Isn’t that abandonment? 2) I have no colleagues to whom I can refer this client, or 3) I don’t want to reject him and repeat his early history with his parents.

Helpful forms

Informed consent. Younggren, Fisher, Foote, and Hjelt (2011) make the basic point of mutual responsibility in “A Legal and Ethical Review of Patient Responsibilities and Psychotherapist Duties”; however, this almost common-sense, legally and ethically sound position seems to be rarely communicated in education and training. Also, not emphasized before licensure is the potential depth and breadth of the informed consent process. Here, the therapist has the opportunity to discuss, among other things, the protection and limits of confidentiality, details of the treatment plan, the client’s responsibilities to cooperate and participate in order for effective treatment to be provided, and the conditions under which termination (and not always a mutually-desired termination) may be necessary.

Some therapists are uncomfortable with this process, rush through it and see it as simply the need to obtain a signature — not as a discussion of the content and an opportunity to determine if roadblocks to effective treatment posed by the client may be foreseen. An open discussion at the point of assessment may not only prevent serious issues from developing later in treatment, such a discussion also opens the door to these issues before a crisis arises. It communicates to the client that the therapist is in control of the treatment process; that is, the therapist sets and maintains the framework and boundaries for therapy. That responsibility includes ensuring that the treatment setting, for example, outpatient therapy on a regular basis, provides the correct level of care. If at any point in the treatment process outpatient treatment is not enough to ensure that treatment goals can be met, the therapist needs to initiate a discussion with the client and recommend the correct level of care. The patient’s willingness, or not, to move to that level of care should not control the therapist’s next move; that move may need to be an appropriate termination and referral.

Authorization for disclosure of confidential information

The “release of information” form is another opportunity for the therapist to communicate boundaries and scope of the therapeutic relationship. In some cases, the client requests the therapist communicate with another healthcare professional or family member; in other situations, the therapist believes it is in the client’s best interests to communicate with another person in the client’s life and the client may or may not wish such communication to occur. Alternatively, the client may not object in concept to the sharing of information with a third party, but may prohibit the therapist from discussing certain issues or facts relative to his or her situation. The therapist must assess whether any limits imposed by the client could potentially cause the client harm or interfere with the treatment process, and if so, communicate that information to the client. If the client continues to refuse (for example, that the therapist discuss current drug or alcohol use with the psychiatrist prescribing medication), the therapist needs to determine if safe and effective treatment under those circumstances can be provided. Of course, these situations can become contentious and may be viewed by the client as a “power struggle” rather than the therapist acting in the client’s best interests. The therapist should explain the reason the communication with another professional or other third party is important for the treatment process; ultimately, the therapist must be the one to make the decision as to whether treatment can move forward under those circumstances.

When the threat to others turns toward the therapist

In the execution of legal or ethical duties, therapists may become an additional, or even the main, focus of anger for the client. Some of these case situations become quite complicated, from a risk management point of view. For example, when a client makes a credible threat of violence toward a third party and the therapist warns and takes action intended to protect the intended victim (such as calling the police), the client may become infuriated with the therapist. In such cases, the client may deny intent or means, even though he or she may have communicated this clearly to the therapist in a session, and claim that the therapist misunderstood “expression of feelings.” The client may feel that the action by the police, for instance, caused embarrassment in the community or, if the threat was communicated to an employer, threatened employment standing. Clients with these feelings may threaten legal action (such as filing a complaint against the therapist) and/or harm to the therapist. Particularly risky are domestic violence situations and therapists are well advised to protect themselves with early consultation in these cases. A private practice office can be a difficult setting in which to treat either the perpetrator or the victim in a domestic violence situation; in many of these cases, a clinic setting in which there are other professionals present is a safer environment.

Also, child abuse situations may present risk if the parent client is also the suspected perpetrator of the abuse. In most of these situations, it is not appropriate for the therapist to continue to provide treatment (there are exceptions), and referrals are in order. There are similarities here to “duty to warn” situations in terms of the client’s feeling humiliated and embarrassed, as well as not in control, and the therapist may become a target of the ensuing anger or rage. In short, anytime the therapist moves to protect a third party (a child, spouse/partner, supervisor, or teacher) and gets “in between” the threatening client and third party, there may be risk in terms of physical or psychological violence. Therefore, almost at the same time as taking action to protect others, the therapist needs to assess the risk to self, and take appropriate security precautions. Consultation at this point can be very useful and can help the therapist feel, and actually be, more in control of a volatile situation.

The role of consultation

Connected with therapists’ commonly positive and expansive view of what kinds of issues may be dealt with in therapy and their occasional minimizing of their sound clinical intuition on the front-end, is their reluctance to obtain appropriate legal or clinical consultation early in the treatment process. For the reasons previously mentioned, consultation is most effective when it is obtained early in the assessment or treatment process. Therapists should not hesitate to contact an attorney who specializes in mental health law if they believe that their treatment, referral or termination of a client may raise legal concerns. The fact that the therapist may feel as if he or she has already made an “error” with the client, or records are not pristine, should not deter one from seeking a legal consult — in fact, it should hasten one. Alternatively, when seeking a clinical consult, the therapist should seek a peer consultant (expert) who has extensive experience in assessing risk and the potential for violence. A qualified consultant should be able to quickly assess the situation and make clear recommendations to protect therapist safety, as well as assisting the therapist in identifying appropriate treatment resources for the client.

Therapists are encouraged to identify red flags in the assessment and treatment process and take the initiative to gather more information to assess the level of risk and make an informed decision as to the wisdom of accepting a client into practice and/or terminating the client. Clinical and/or legal consultation is encouraged in any case situation involving risk of violence and therapists are reminded that, in these cases, they need to pay attention to their basic need for safety, at the same time they are addressing the client’s treatment needs.

Renee Bums Lonner, MSW, LCSW, maintains a private practice in Sherman Oaks, California, providing individual, marital and family psychotherapy with children, adolescents and adults. She is a consultant for mental health clinicians and organizations in general practice areas, as well as the specific area of risk assessment. She is an AAMFT Clinical Fellow.

Michele Licht, JD, is an attorney specializing in the representation of mental health practitioners on a wide range of issues. Over the past 35 years, she has represented over 2,500 psychotherapists in legal and ethical consultations, before licensing boards, in disputes regarding hospital and medical staff privileges, and general practice issues. She represented psychology before the California Supreme Court in CAPP v Rank, setting a precedent for psychologists’ scope of practice in hospital settings.

References

de Becker, G. (1998). The Gift of Fear. New York: Dell Publishing.

Younggren, J. N., Fisher, M. A., Foote, W, E., & Hjelt, S. E. (2011). A legal and ethical review of patient responsibilities and psychotherapist duties. Professional Psychology. Research and Practice, 42(2),160–168.

Professional Resources

Babiak, P., & Hare, R. D. (2007). Snakes in suits. New York: Harper Business.

Gross, L. (1994). To Have or to Harm. New York: Grand Central Publishing.

Madden, A. (2009). Treating violence: A guide to risk management in mental health. Oxford, UK: Oxford University Press.

Mah, R. (2013). How dangerous is this person? Assessing danger & violence potential before tragedy strikes. Saarbrucken, Germany: Scholars’ Press.

Meloy, R. (2000). Violence risk and threat assessment. San Diego, CA: Specialized Training Services.

Meloy, R. (2001). The psychology of stalking. Cambridge, MA: Academic Press.

Monahan, J., & Steadman, H. J. (Eds.) (1994). Violence and mental disorder. Chicago, IL: University of Chicago Press.

Robert, S., & Tardiff, K. (Eds.) (2008). Textbook of violence assessment and management. Washington, DC: APA.

The Online Clinical Toolbox is a new feature for the CSCSW community to share useful online resources for clients and clinicians. Please send descriptions of your favorite applications, websites, podcasts, or blogs along with a short explanation of how you or your clients have used/benefited from them to Rizzotti.alessandra@gmail.com.

The suggestions made here are for you to check out and determine their usefulness for you or your clients.

A wealth of research supports the benefits of meditation for both clients and therapists. The following free or low-priced apps provide mindfulness tools that both clients and clinicians can use that may facilitate change in how they relate to cognitions and emotions.

Stop, Breathe, and Think App: This app recommends guided meditations, video sessions of yoga, gratitude practices, and grounding techniques based on how one is feeling physically, mentally, and emotionally. Starting with 10 seconds of closing the eyes, the app will then ask how the client is doing physically, mentally, and emotionally. It will then provide a meditation or yoga routine of 5-9 minutes and if the client purchases a membership, other tools such as mindful eating and breathing techniques can be unlocked. After the mindfulness practice is used, the app checks in with the clients’ physical, mental, and emotional wellness and creates a visual graph of the progress of the client daily. With a gaming feature that aims to encourage a daily mindfulness practice through “badges” and “trophies,” this tool is fairly easy to use and has the potential to change clients’ relationship to mindfulness if hesitancy is expressed initially. Find it at stopbreathethink.com.

Insight Timer: This app provides music, interval bells, ambient sound, as well as guided meditations and movement exercises that may help clients increase self-compassion, gratitude, and improve mood. By typing in key words such as anxiety, depression, focus, or mood, clients can find meditations that may help them with current issues they’re facing. Although it is not as customizable as Stop, Breathe, and Think, it provides 11,000+ meditations of varying lengths from 2 minutes to an hour from many meditation teachers and has a feature in which clients can journal their feelings and thoughts after the meditation is over. In addition, there is a community feature in which clients can see other people who are meditating with them at the same time. While some clients may find it overwhelming due to the amount of choices provided, exposure to the app during a session can be helpful. In addition, there are some Spanish meditations provided on the app. Find it at insighttimer.com.

Headspace: For those who find meditation “too feel good” or “cheesy,” a more irreverent humorous approach may be found in the app Headspace. Guided by a UK meditation teacher, it has a playful upbeat approach to meditation that may resonate with some clients who doubt the benefits of meditation. Find it at headspace.com.

Relax Meditation: For the clients who are struggling to fall asleep, are creative, and have a desire to customize their meditations, the app Relax Meditation provides an opportunity to create a looped soundtrack with soothing nature sounds, instrumentation, white noise, and more. The app also provides meditations specific for sleep, dreaming, recharging, and reducing anxiety, but this is for an extra membership charge. Overall, this app’s free features may be more useful for clients who resonate more with sound versus guided meditations. Find it at the iTunes store.

Whether clients and clinicians use meditation in or out of session, it can provide benefits to some. Try one of these apps and let us know what you think, or comment with an app you don’t see listed.

Alessandra Rizzotti (ACSW 83520, MSW, RYT-200) is a Psychiatric Social Worker 1 who will be based at DMH’s American Indian Counseling Center this fall. She has experience with a variety of modalities including DBT, CBT, ACT, PE, grief support, and yoga. As a current volunteer at The Trevor Project, she has provided suicide prevention and crisis intervention, and was formerly the full-time Communications Manager there. She has a 10-year career in media working for the social impact media company GOOD, as well as various TV and film studios. You can contact her at Rizzotti.alessandra@gmail.com and alessandrarizzotti.com.

by: Elaine Leader, Ph.D.

The Challenge of Multiculturalim and the Rise of Intolerance:

In his inaugural speech of 1997, President Clinton questioned, “Are we coming together or coming apart?” Previous concepts that defined American society as a melting pot have long been discarded in favor of multiculturalism. Instead of defining oneself with pride as being an American, one is expected to precede this with a hyphened acknowledgment to one’s origins or forebears, no matter how distantly they emigrated to these shores. But following the tragic events of September 11th despite an apparent unity amongst Americans in face of a common enemy – terrorism, a wave of intolerance has again arisen. This has been continually accelerated by our current President, Donald Trump. Those with Islamic names, even those not known to be associated with acts of terror, are being targeted with epithets and acts of hate. People of color, and particularly immigrants of color, are demeaned. This intolerance, although arising from fear, cannot be allowed to flourish.

The idealism and hopes of the civil rights movement of the 1960s to combat racism, prejudice and bigotry have almost been forgotten. True, many of the legal impediments to equal rights have been eliminated, but our concern now is that these may be threatened by our current administration in Washington. Also, what our young people are facing today is, for the most part, a subtler form of stereotyping and prejudice.

California’s Complex Racial and Ethnic Diversity

In Los Angeles and throughout Southern California, the sheer number and variety of racial and ethnic groups is remarkable. There are Samoans, Iranians, Armenians, Cambodians, Lithuanians, Ethiopians, Romanians, Ukrainians, Peruvians and countless other Spanish-speaking groups. The gradations of color on the faces of the people here undercut the traditional black-white dichotomy so prevalent in other parts of the country. UC Santa Barbara sociology professor Reginald Daniel, a scholar of racial identities, says, “the visual factor in racism is so critical. What you see is going to affect how you treat a person, and as it becomes more difficult to code what you see, your behavior is going to be influenced by the fact that you’re not absolutely certain of whom you’re dealing with at any given time.”

The racial and ethnic intermarriage rate in Los Angeles County is five times higher than the national average. In fact, 15% of babies being born in the state are of mixed race or mixed ethnicity, according to an analysis of birth records by the Public Policy Institute of California. Of course, the blurring of racial and ethnic lines does not automatically eliminate social and economic hierarchies based on skin tone.

Resources

As helping professionals I believe we have the responsibility to assist people in dealing with the fears and prejudices that arise from this ever changing diversity. Resources are available. For instance, The Southern Poverty Law Center provides free teaching materials, posters and videos for use with elementary and secondary school students. Other organizations such as the Anti-Defamation League have excellent programs, videotapes and speakers.

Peer mediation or conflict resolution strategies are examples of approaches to resolve difficulties that occur between diverse and divisive sectors of a school population. Schools that include these approaches in their curriculum are to be applauded. Another avenue to understanding has been the teen Drug Courts that use peers to address misdemeanor drug infractions. However, one phenomenon that must be explored if a program is to succeed, is the ways that cross-cultural differences affect communication. It is necessary for mediators to deal with their own prejudices and biases so that these do not adversely affect the mediation process.

Teen Line*

Much has been written about the need for social programs to reflect the multiculturalism of their community by including staff who are representative of their target population. The goal is to incorporate principles of cultural and ethnic diversity to enrich the quality of service to the community. Teen Line, a well-established teen hotline in Los Angeles, deals with these issues of diversity with their front-line staff who are teenagers. Issues faced include appropriate training that encompasses cultural sensitivity, recognition of prejudice and stereotyping (both conscious and unconscious) and the development of suitable outreach strategies. Mandatory training includes experiential exercises to further insight into prejudicial thinking and stereotyping and all volunteers are required to visit the Museum of Tolerance. Many of our teen volunteers complain that at school students tend to congregate and socialize according to ethnicity. For most of them, the Teen Line training is the first experience they have of dealing with these issues in an open and frank manner. And for some it is the first time that they have formed relationships across the usual boundaries.

We all need to feel that sense of belonging that comes with identification with others like ourselves. We strive at Teen Line to promote equality, justice and humanness in a society where prejudice and discrimination are still evident. The challenge is to help our teen volunteers to recognize, understand, and confront the many types of prejudice and discrimination present in their world at the same time as we encourage cultural pluralism as an opportunity for growth.

Dr. Elaine Leader co-founded Teen Line in 1981 and was the Executive Director until 2015. She is now entitled Founder and is establishing a Legacy Line for supporters to contribute to Teen Line long term. She received her MSW from UCLA in 1970 and Ph.D. from the Sanville Institute in 1981. She has been in private practice since 1970. She can be reached at drleader3@gmail.com.

*Teen Line is staffed by trained teen volunteers and is accessed by teens worldwide through calls, texts and emails. In 2017 73% heard about it as a resource via the internet site www.teenlineonline.org. In addition to the hotline Teen Line has an extensive community outreach service that includes the Youth Yellow Pages which is also now available on an App, presentations at schools and adolescent serving agencies as well as an educational component for parents, training in suicide prevention for law enforcement and consultation to the media.

I write these words without judgment, as I too am a South Bay parent and struggle to do my daily best by my own family. Parenting adolescents is not for the faint of heart, but it can be done with awareness, acceptance, empathy, and a sense of teamwork. I witness in my office how meaningful these shifts are and how life-saving they can be for struggling teenagers.

My hardest days at work are the ones where I am sitting with a suicidal teenager. Unfortunately, it is far more common in the South Bay than many people would guess. Sometimes teens have a biological depression that is extremely difficult to shake…and sometimes teens have been through a trauma of some sort -- abuse, harassment, bullying, divorce, a parent’s alcoholism or addiction, sudden loss, academic failure, or social isolation. Their despair is understandable to me. Due to my training and experience, I understand how to work with these types of challenges and how to help the adolescent stay safe and stable. We make a plan, enlist more support from home and school, identify new coping tools, and keep reminding them that the black cloud of depression will eventually lift if we all work hard enough. Usually the cloud does lift, the teen navigates the rough patch with extra support, and we work toward prevention and increased coping.

There are other situations where adolescents are highly anxious, depressed, overwhelmed, and suicidal without a clear reason that we can identify. In general, there is a feeling that these adolescents feel misunderstood, isolated, and that no one “gets them.” They are lonely, overwhelmed, and highly stressed by school and parental expectations. They feel as if they don’t belong—at school with their peers…and, even worse, at home in their families. Their suffering feels as real to them as for the kids that have experienced a trauma, though it is harder for them to articulate their suffering or gather much empathy in the community (as often their suffering is silent and unnoticed). This type of kid ends up in my office far too often—for reasons that are entirely preventable. If you have a sensitive child like this or know someone that does, I am going to give you a generalized glimpse into their thinking…in the hopes that this will promote healing.

In general, these teens are working hard at school and home and rarely get into trouble. These teenagers desperately want their parents to accept them for who they are—not just lip service, but actual unconditional love. They want to feel heard and acknowledged. They want less criticism. They want their parents to help them manage their school and extra-curriculars in a balanced way and help them to say “no” to commitments that no longer serve them. They want their parents to understand that harsh words hurt their hearts because they actually do want to please them. They want their parents to pay attention to them, smile, and give them far more hugs than they are getting. They want their parents to be less invested in their successes and failures—it puts tremendous pressure on them. They want their parents to take away their devices so that they can get a break and some sleep—and they have trouble self-regulating this themselves. They want less comparison with their siblings. They want their parents to care less about them being popular and be less critical of their physical appearance. They want to feel understood and not judged—no matter their sexual identity or whether they are college bound or not. They want their parents to understand that it’s difficult to be a teenager today—no matter how privileged their lives are. They want their parents to trust them. They want their parents to slow down and spend time with them. Often the adolescent’s perception is accurate and there is room for improvement within the family system.

Of course, I have ideas about how our schools, communities, and society at large can do better by our adolescents. I also think that teenagers need to own their feelings and actions—and despite hurts from family, peers, and schools—they have to make a conscious choice to prioritize their own health and make good decisions. This is all important work. However, this article is written for parents. As parents, you have an incredible role in the shaping of a young person’s life—don’t underestimate your power in their lives. Use the power as a good influence and an example of the kind of parent they may want to emulate someday.

Leah M. Niehaus, LCSW is a psychotherapist in private practice in Hermosa Beach. She specializes in working with adolescents and their families, individually and as families. She also runs a High School Girls’ Group and a Middle School Girls’ Group for typical teens that are struggling with anxiety, depression, stress, and friendship difficulties. Leah can be reached at (310) 546-4111 or leahniehaus@me.com. Check out her website at www.leahmniehaus.com.

This article is reprinted from the blog Smartliving360.com By Ryan Frederick

Finding Purpose for the Long Haul

Charlotte Seigel is a tour de force. She is passionate about social work, psychiatric work in particular. She also believes in actively collaborating with colleagues to improve the field.

In fact, she has been passionate about this work for over seventy years! Charlotte is 97 years old.

Last year, Charlotte was the recipient of an award for honorary recognition for contributions in the field of clinical social work from the California Society of Clinical Social Work. For years, she worked at Stanford before starting her own practice in midlife. She continued to see patients until just a few years ago, well into her 90s. Patients would come to her retirement community for her services. She remained active in the Mid-Peninsula district California Society for Clinical Social Work and had been instrumental in bringing high-profile speakers, including Dr. Carol Dweck who has gained attention for articulating the value of the growth mindset as compared to the fixed mindset. Charlotte is a lifelong case study of the growth mindset.

In Charlotte’s words, “My social work self, my clinical self, my total being self, they are all wrapped together. There isn’t a separate clinician and separate Charlotte Siegel. It’s all a part of the definition and a part of what I am able to give to clients who come to see me – a sense of life moving for me and for them.”

Charlotte has had an integrated sense of purpose for a long time and it turns out that purpose matters a lot. It’s not happenchance that she has lived such a long and vital life.

Choosing Happiness with Purpose

Our culture is obsessed with happiness. Nearly 50% of people in the US set New Year’s resolutions, many with the aim of leading a happier life. In surveys, most people list happiness as their top value, and self-help books and life coaches are part of a multibillion-dollar industry of happiness. It seems to work well with book titles, too: The Happiness Curve is one of the latest examples. Part of the challenge is that we often don’t understand or fully appreciate the different definitions of happiness or life satisfaction. Going back to the days of Greek philosophers, much thought has been directed in this important area. There are two forms of well-being — hedonia, or the ancient Greek word for what behavioral scientists often call happiness, and eudaimonia, or what they call meaningfulness. The happy life is defined by seeking pleasure and enjoyment, whereas the meaningful life is bigger.

In her TED talk and recent book, The Power of Meaning, Emily Esfahani Smith presents the case for choosing happiness with meaning. She points to the research that shows that the pursuit of happiness – hedonia — negatively affects our well-being and such pursuits tend to have only a brief boost in mood that soon fades. One of the most powerful examples comes from research around lottery winners. Six months after you hit the lottery the average lottery winner has permanent baseline levels that are slightly lower than they were the day before they bought the ticket. In contrast, while life with meaning can be associated with stress, effort and struggle, it can also be more deeply satisfying and sustaining. As one example, in a recent study, researchers from the University of Ottawa followed college students and found that they behaved very differently depending on whether they emphasized meaning or self-focused happiness. Those that focused on meaning, such as helping friends, did not feel as happy right after the experiment but, over a longer period of time, reported fewer negative moods and expressed a prolonged sense of inspiration and enrichment than those focused on self-oriented happiness.

It turns out that happiness with meaning is a mindset – a choice we make – that is more valuable and sustainable than hedonistic happiness.

A Movement for Choosing Happiness with Meaning and Purpose in the Age of Longevity

Of course, living a life of satisfaction has been important since the beginning of man. What’s different now is that we are living a lot longer; thirty years longer than our contemporaries from a century ago. Charlotte Seigel is a living example of purpose sustained over the long haul.

Marc Freedman and his colleagues at Encore.org are helping create a movement of purpose. Marc is the founder and CEO of Encore.org, a not-for-profit with global influence that serves as an innovation hub tapping the talent of older people as a force for good, and one of the leading voices embracing the opportunities for greater purpose in the age of longevity.

Earlier this year, Encore.org and Stanford, led by William Damon, Director of the Stanford Center on Adolescence and author of The Path to Purpose, released a research report on purpose sponsored by the John Templeton Foundation. This report, “Purpose in the Encore Years: Shaping Lives of Meaning and Contribution,” defined purpose as “sustained commitment to goals that are meaningful to the self and that also contribute in some way to the common good, to something larger than or beyond the self.”

In this report, they found that approximately one third of older adults they surveyed currently exhibit such purpose, representing approximately 34 million people if extrapolated to the population at large. Among other findings, they also learned that purpose was not a zero-sum game. People who place a high priority on beyond-the-self goals simultaneously endorse views of later life that embrace self-oriented activities such as continued learning and leisure, even more so than people who aren’t engaged with purpose.

Where You Live Matters with Purpose

We can’t expect where we live to automatically give our lives purpose. However, it can make a difference. As a previous Smart Living 360 blog (“On Personal Connection”) pointed out, our networks influence our well-being. If our friends’ friends are happy, we are more likely to be happy. Being around others that value purpose will naturally impact our priority on purpose.

Also, our living environments can help us up to focus on things that matter most. Living spaces that free us up from home maintenance – things that can take time and resources – allows us to allocate more time and energy towards purpose. Further, built environments that minimize risks of falls and make it easier to be physically active can help us stay healthy longer to actively pursue our passions.

Finding Your Purpose at Any Age

Finding your purpose is not easy but it’s vitally important. In the context of a long life, our purpose may change and our “encore” chapter of life may create new opportunities to choose happiness with meaning. Or, for the lucky among us like Charlotte Seigel, our extra years may create additional avenues to amplify and extend our lifelong purpose and inspire younger generations along the way.

Ryan Frederick is the founder of Smart Living 360, a platform to help people and institutions thrive in the Age of Longevity. Smart Living 360 publishes a monthly blog on health & well-being in the context of longevity. Interested parties can sign up for the blog at www.smartliving360.com. Ryan is currently working on his first book, tentatively titled Thriving in the Age of Longevity: A Practical Guide to Smart Living over the Long Term. Ryan is a graduate of Princeton University and Stanford Business School. He can be reached at ryan@smartliving360.com.

Janet Anderson Yang, PhD, ABPP, Krista McGlynn, MA and Breanna Wilhelmi, MS

Later life can be a time of troubling concerns, such as physical and cognitive decline, pain, loss, awareness of life ending, and approaching death.  Standard approaches to mental health treatment often require physical and cognitive abilities, focus, and energy.  Clinicians working with older adults may struggle in helping clients find satisfaction in the face of these declines and losses. 

A number of clinical approaches can help aging adults enhance meaning in their lives.  These approaches include interventions related to existential meaning, life review and reminiscence, leaving a legacy, transcendence, mindfulness, wisdom, spirituality and religion, grappling with the end of life, creativity, and enhancing relationships.  Clinical methods for helping aging clients enhance meaning and achieve the goals of later life within the context of co-existing challenges will be discussed within this article.

Existential Meaning
One approach to help aging clients is assisting them in developing altered perspectives and increasing existential meaning, wisdom, and integrity.  Renowned psychiatrist Victor Frankl (1986) considered three avenues of meaning, including creating a work or doing a deed, experiencing something or encountering someone, and changing one’s attitudes about situations.  Other authors also emphasize the importance of helping clients develop new forms of meaning after losses and trauma (Neimeyer, 2011; Horowitz, 1986).

Life Review and Reminiscence
Erik Erikson (1982) proposed that the developmental task of older adulthood is to resolve conflict between integrity and despair.  The approach of death stimulates review of life to prepare for death. This involves  consolidating an understanding of one's life, to be achieved through the “mourning for time forfeited and space depleted, autonomy weakened, initiative lost, generativity neglected, identity potentials bypassed, and too limiting an identity lived" (Erikson, 1982).

Robert Butler and James Birren also discussed the importance of life review.  Butler (1963) suggested that later life is a time for people to review their lives, allowing a return to consciousness of past experiences, especially unresolved conflicts.  By reviewing one’s life, one can expiate guilt, resolve internal conflicts, reconcile relationships, and renew ideals, thereby experiencing new peace and gaining wisdom (Butler, 1963).  Birren (2001) suggested that the purpose of life review is to develop an acceptable image of one's life and leave behind an acceptable legacy; that an awareness of coming death can stimulate a person to review one’s life to integrate the actuality of one’s life with what might have been and to reorganize attitudes toward one’s life in a more positive way.

The developmental process of life review has been adapted to become a form of psychotherapy, sometimes referred to as reminiscence therapy.  Life review or reminiscence therapy is a structured activity to access and process thoughts about past experiences.  It often involves marking down a timeline and writing in dates and major life events, then analyzing and discussing the meaning of the events.  Integrative reminiscence generally refers to reappraising losses and difficulties, reviewing values and personal meaning, and working toward a renewed understanding of the life lived.  Instrumental reminiscence refers to recalling past successes, achievements, and positive adaptations, in order to reactivate a positive self-concept.

Within life review or reminiscence therapy, techniques that can be used include marking the years and ages of the client, asking the client to recall important personal events (e.g., education, family events, work successes, loves, losses, hopes, regrets, and memorable experiences), using important world events as markers, using aids to evoke memories (e.g., photos, picture books, letters, diaries, music, and foods), encouraging the client to take a pilgrimage (e.g., to an old home or neighborhood), and writing an autobiography.  These activities then evoke therapeutic conversation.

Leaving a Legacy
Another aspect of understanding the meaning of one’s life is to consider what legacy the person has left.  Irvin Yalom (2008) stated that one may find meaning in life and come to terms with death through understanding “rippling,” or the ways in which the person has influenced others, which, in turn, consequently influence other people’s lives and can impact generations to come.  James Birren (Birren & Deutchman, 1991) discussed the importance of reviewing a person’s legacy, which might include acts of helping others, raising children, creating art, writing, professional successes, political achievement, influencing others, and contributing to science, among other things.  To this end, clinicians can help clients consider their legacies, including what they have done in their lives, these actions’ impact on others, and potential effects on the future.

Transcendence
Gerotranscendence represents the ability to move beyond the immediate circumstances to form connections beyond the self, transcending the gulf between people, between person and the universe, or between person and the creator of the universe (Brennan, 2009; McFaddon, 2009).  Within aging, there may be an increased emphasis on internal processes that facilitate expanded consciousness.  Older adults may have more time to meditate, contemplate, and reflect (Newman, 1987).  Life satisfaction may increase as a person shifts toward increased focus on the cosmic world rather than on the material world (Tornstam, 1994).  Clinicians may suggest contemplative practices to older adult clients and explore the idea of transcendence with them to improve their sense of meaning in life.

Mindfulness
Developing a mindfulness or meditation practice is another avenue to help older adults gain meaning and satisfaction in their lives (Hayes, Strosahl, & Wilson, 1999).  Mindfulness is the act of concentrating one’s attention on moment-to-moment experience with a nonjudgmental attitude.  Mindfulness is successful in treating anxiety and stress, as well as other disorders (Kabot-Zinn, 2003).  Acceptance and commitment therapy (Hayes et al., 1999) and Mindfulness-Based Stress Reduction (Kabot-Zinn, 2003), among other evidence-based practices, can be useful interventions to help clients experience their lives in meaningful new ways.  Mindfulness may also include encouraging the client to learn new breathing techniques, to listen to recorded meditation lessons, and/or to set up a space to meditate or connect with nature, among other possibilities.  Since mindfulness can be practiced anywhere, it may be a helpful intervention for those experiencing a lack of mobility and consequent boredom or depression. 

Wisdom
Due to their long lives and consequent extent of experience, older adults have undoubtedly developed substantial wisdom (Baltes & Staudinger, 1993).  They have used knowledge, experience, and understanding in many different ways to confront circumstances, tolerate difficulties, and make decisions.  Clients can be encouraged to discern, honor, appreciate, and share with others the significant wisdom they have developed from life experiences. 

Spirituality and Religion
Older adult clients may find meaning in their lives through developing or rediscovering spirituality and/or religion.  Spirituality includes a set of beliefs that may include love; compassion; and a respect for life, existence, and relationships with ourselves, others, the universe, and/or the sacred.  Spirituality can extend beyond the physical and material to transcendence and can be secular in nature.

Religion includes the practical expression of spirituality in the organization, ritual, and practice of one’s beliefs.  Many older adults indicate interest in religion and/or spirituality; addressing these issues may benefit the client’s mental health. 

Clinicians need to use careful clinical judgment as to if, when, and how to talk about spirituality or religion in order not to assert their own values or proselytize clients toward their own beliefs.   Encouraging a client’s positive spiritual and/or religious coping activities and exploring previous negative experiences may be good places to start.  Specific instruments, such as the HOPE Questionnaire (Anandarajah & Hight, 2001) or structured guidelines (“Parameter 4.15”, County of LA Department of Mental Health, 2012) may be used.

Grappling with the End of Life
Many older adults are troubled about being closer to death.  Discussing this topic may be difficult.  While health care providers have been encouraged to talk with patients about end-of-life wishes (Steinhauser et al., 2001), clients’ fears and concerns about dying and death are often not addressed.  Older adults may have concerns or fears related to pain and suffering during the dying process, what happens at the moment they die, whether they will be alone when it happens, what happens after death, and who all they will leave behind.  A related case example follows:

Carol was a 69-year-old client seen in therapy by the first author at Heritage Clinic in Pasadena, California.  Carol had had a stroke, was bed-bound, and fought with her husband considerably.  With some help, she moved out of Heritage Clinic to an assisted living facility.  Carol then began having conflict with the staff.  The therapist helped the client talk about her anger and then wondered if her anger might be related to underlying fear.  With enough trust established, the therapist asked the client if she was afraid of what was happening to her body.  The client identified that she was frightened of having another stroke and intolerable pain.  With consultation with her physician, Carol was reassured that if she were in pain, she would be offered enough medication to relieve her pain.  Carol then identified that she was afraid of dying and going to hell, which surprised her to realize, as she was a staunch atheist.  Her fear of going to hell was traced back to childhood messages at home and within early church lessons.  The therapist helped the client challenge and resolve her belief that she was bad and would go to hell.  Her fear, anxiety, and interpersonal conflict decreased, and her satisfaction in her life improved.

Clinicians may gently initiate discussions about these concerns through asking clients questions about their parents’ age at and cause of death, in what way the conditions of their parents’ death affect their thoughts of their own death, how they feel about being their current age, what they think about their end of life, and what they think will happen after they die.  Clinicians may then assess the client’s answers and link them to their mental health concerns.  In addition, clinicians may complete an advanced health care directive or a Five Wishes document (Aging with Dignity, 2011) to obtain more clinically-relevant information.

Creativity
Encouraging creativity can bring new or renewed meaning in later life.  Activities may include listening to music, playing music, singing, writing, dancing, drawing, coloring, painting, or viewing art or art books.  Clinicians may use a Pleasant Events Schedule to stimulate a structured discussion of creative or pleasant activities within clients’ lives (Lewinsohn, 1971).

Enhancing Relationships
Later life can be a time of losses of relationships, leading to isolation and loneliness.  Coping with these losses  may include developing new relationships, seeking to reconnect with prior relationships, and/or working to reconcile conflicted or estranged relationships.  Hargrave and Anderson (1992) describe a combination of life review therapy and family therapy in a way that can help promote healing in family relationships.  Volunteering, giving to others, caring for grandchildren, and mentoring younger persons may bring considerable meaning from an interpersonal approach for aging patients.
 
Later life can bring about frailties that cause dependence on others for personal needs. While the increased dependency can be troubling, it may be an opportunity for enhanced relationships.  Lustbader (1999) presents a beautiful example of the latter:

“A physical therapist tells how a stroke led to the reconciliation of a father and son who had not spoken in years: My patient was a large man, and the dead weight of his stroke made it impossible for his tiny wife to move him at all.  His son agreed to come over and learn how to do a wheelchair transfer, but he came in looking so hostile I wanted to call off the whole thing.  He didn’t even say hello.  I explained that he had to grip his father in a bear hug and then use a rocking motion to pivot him from the bed to the wheelchair.  The son went over to the bed where his father was sitting and put his arms around him, just like I said.  He got the rocking motion going, but then all of a sudden I realized that both of them were crying.  It was the most amazing thing.  They stayed like that for a long time, rocking and crying.  This son was moved to linger in his father’s arms for the first time since boyhood.  Unexpected embraces, uncharacteristic expressions of feeling, these are only some of the ways that relationships grow through frailty’s demands” (p.23).

Cultural Considerations
Clinicians may help older clients find meaning in their lives through collaborative exploration of clients’ cultural identities.  The intersectionality theory framework provides one such way to navigate this task.

Introduced by civil rights advocate Kimberlé Crenshaw (1991), intersectionality theory emphasizes the multidimensionality of cultural identities with specific attention to the roles of power, privilege, oppression, and marginalization.  From this perspective, clients find meaning in life through the sociocultural lenses through which they experience the world (Yang et al., 2016).  In clinical practice, this means working with clients to unravel the complexity, diversity, and connectedness of their co-existing identities.

Some identities tend to garner privilege and power, (e.g., being white, cisgender, heterosexual, educated, male, or wealthy) while others tend to yield oppression and marginalization (e.g., being of color, transgender, homosexual, bisexual, uneducated, female, or impoverished).  Due to the prevalence of ageism, old age may be associated with greater feelings of powerlessness and marginalization (Laws, 1995).  Younger adults often experience greater social capital while older adults may struggle with feeling “past their prime” and “put out to pasture” (North & Fiske, 2012).

The process of exploring one’s various identities may be challenging.  Clinicians can help aging clients explore questions concerning the importance of these identities; when, where, and how they experienced the most and least privilege and power in life; and which of the client’s identities are the most and least dominant and important to them. 

A patient's various identities can give clinicians an idea of themes to explore within the therapeutic setting, but the clinician should also be careful not to make assumptions.  Many people within certain groups do not subscribe to beliefs that may be associated with that group.  Therefore, it is important for clinicians to let the client lead these conversations and to be aware of their own biases. 

With that said, there may be certain issues that are more relevant and helpful to explore for members of specific groups of aging clients.  For example, family relationships may be particularly important for clients of certain ethnic or racial groups, so meaning may be derived from reconnecting or improving communication with family members or from mourning unmet expectations.  For others, spiritual or religious beliefs may be of particular significance, so it may be helpful for these clients to explore their spiritual understanding, read religious texts, listen to religious programs, visit a place of worship, or explore the meaning of death in the context of their spiritual or religious beliefs.

In conclusion, therapists working with older adults may benefit from considering ways to help their clients enhance satisfaction and a sense of meaning in their lives.  While some clients may directly indicate they want to work on developing meaning, others may not suggest that developing meaning could help them.  The therapeutic work may benefit from gently approaching one or more of these avenues toward increasing meaning in life, including reminiscing and reviewing the client’s life, considering what legacy the client has left, enhancing the client’s sense of spirituality, exploring transcendence, utilizing mindfulness, honoring the client’s developed wisdom, coming to terms with the end of life, enhancing existing relationships, and increasing creative endeavors.

Dr. Janet Anderson Yang, PhD, ABPP is a licensed clinical psychologist, board certified in geropsychology.  She has been working with older adults for over 35 years.  She is the Clinical Director and the Training Director at Heritage Clinic, a division of the Center for Aging Resources, a mental health clinic and adult day care center.  She provides services to older adults, supervises clinical staff, and trains mental health professionals.  This includes directing Heritage Clinic’s doctoral internship accredited by the American Psychological Association.  Dr. Yang has published articles and conducted trainings on psychotherapy with older adults, mental health outreach, reminiscence, and other topics related to mental health and older adults.
 
Breanna L. Wilhelmi, MS is a PhD Candidate at the Pacific Graduate School of Psychology at Palo Alto University (expected graduation 2016).  She specializes in trauma, geropsychology, and culturally-sensitive clinical practice and advocacy.  Her doctoral internship is with Heritage Clinic in Pasadena, California and her postdoctoral fellowship is with Wise and Healthy Aging in Santa Monica, California.  She currently provides in-home psychological services to community-dwelling older adults with serious mental illness.

Krista McGlynn, MA is currently a clinical psychology intern at Heritage Clinic, a community-based mental health clinic serving the older adult population.  Previously, Krista worked as a Registered Nurse in the areas of critical care and hospice.  Her future career goals include continuing her work with the older adult population and expanding her training in the area of palliative care psychology.  Krista recently began a fellowship position specializing in palliative care at the Audie L. Murphy Veterans Administration Hospital in San Antonio, Texas.

References
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Butler, R. N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26(1), 65-76.
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Hargrave, T. D., & Anderson, W. T. (1992). Finishing well: Aging and reparation in the intergenerational family. New York, NY: Brunner/Mazel Inc.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy. New York, NY: Guilford Press.
Horowitz, M. J. (1986). Stress-response syndromes: A review of posttraumatic and adjustment disorders. Psychiatric Services, 37(3), 241-249.
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Laws, G. (1995). Understanding ageism: Lessons from feminism and postmodernism. The Gerontologist, 35(1), 112-118.
Lustbader, W. (1999).  Generations: 23(4), Winter, 1999-2000.
Neimeyer, R. A., Harris, D. L., Winokuer, H. R., & Thornton, G. F. (Eds.). (2011). Grief and bereavement in contemporary society: Bridging research and practice. New York, NY: Routledge.
Rainer, T. (1978) The new diary: How to use a journal for self-guidance and expanded creativity. New York, NY: St. Martin’s Press.
Rainer, T. (1997). Your life as story: Writing the new autobiography. New York, NY: TarcherPerigree. 
Swensen, C. H. (1993). Review of Finishing well: Aging and reparation in the intergenerational family. Psychotherapy: Theory, Research, Practice, Training, 30(3), 541.
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Ariel Schneider, LCSW

“For the meaning of life differs from man to man,
from day to day, from hour to hour. What matters, therefore, is not the meaning of life in general but rather the specific meaning of a person’s life at a given moment” (Frankl, 1959, p. 108).

Reconnecting people with the outdoors and their food sources is gaining popularity after a long period of mainstream cultural disconnection. The local food movement phenomena popularized by such authors as Michael Pollan, Barbara Kingsolver, and Eric Scholsser, urges us to support sustainable agriculture by eating fresh foods produced by nearby farms (Alkon & Agyeman, 2011).  From the White House initiative to end obesity through fresh food education to a free substance abuse treatment center in Italy that utilizes farm-based work (Pianigiani, 2013), the healing effects of the outdoors are increasingly recognized across disciplines. 

Research tells us that connecting with or being surrounded by the natural world has numerous positive effects.  It produces an increase in the subjective experience of vitality (Ryan, Weinstein, Bernstein, Brown, Mistretta, & Gagné, 2010), a restoration to mental clarity, and a physical healing to the body (Clay, 2001).  Relatedly and perhaps unsurprisingly, these healing qualities of nature have been shown to improve functioning for vulnerable populations, including people with depression (Gonzalez, Hartig, Patil, Martinsen, & Kirkevold, 2010), dementia and Alzheimer’s (Jarrott, Kwack, & Relf, 2002), cognitive delays (Berman, Jonides, & Kaplan, 2008), post-traumatic stress disorder (Lorber, 2011), major mental illness (Simpson & Straus, 1998), and sensory integration issues (Wagenfeld, 2009), as well as for individuals involved with the criminal justice system (Hale, Marlowe, Mattson, Nicholson, & Dempsey, 2005) and living in low-income communities (Hale, Knapp, Bardwell, Buchenau, Marshall, Sancar, & Litt, 2011).

Long before the relatively recent popularization of the positive effects of being in and caring for nature and eating a diet rich in fresh plant foods, the idea existed that people with mental illness might benefit from working outside in a farm-like environment.  About 200 years ago, America’s first Surgeon General, Benjamin Rush, MD, wrote prolifically about the use of farms for the treatment of the mentally ill (Lewis, 1987) and started the first hospital-based garden program in 1817 at Friends Hospital in Philadelphia, Pennsylvania (Taylor, 2009).  Years later, this approach evolved into a more institutionally-based treatment modality routinely implemented by state psychiatric hospitals.  In 1936, the Camarillo State Mental Hospital in Southern California (which closed in 1997) was founded as one of many state hospitals designed to treat patients for months to years to entire lifetimes (Noxon, 1997).  The hospital housed 100 “working patients” to maintain farming operations on its 1200 acres, including 304 acres of alfalfa, 227 acres of vegetables, 178 acres of grain crops, and 80 acres of orchards. 

Hospitals around the country operated similar programs within the context of Moral Treatment, a period of U.S. American psychiatry during much of the 19th century that saw a shift toward more humane treatment of patients.  Under this model, providers developed close personal relationships with their clients, rewarded patients’ positive behavior, and created daily opportunities for purposeful activity (Dunkel, 1983).  Some cite this model as hugely successful for being the first practical effort to provide systematic and responsible care for the mentally ill in the U.S. and abroad (Bockoven, 1963).  Camarillo’s program was drastically reduced in 1969, when new legislation eliminated indefinite commitments of persons defined as “mentally disabled” (Camarillo State Hospital, 1993), though it continued to house patients into the early 1990s.  This time in history marked a significant shift in attitudes and public policies in the treatment of mental illness.

Following the deinstitutionalization of mental health care, therapeutic horticulture has emerged in communities around the world, but lacks any systematic backing from the mental health community.  One such example is the Grow Native Nursery in the Westwood neighborhood in Los Angeles, California that partners with the VA Greater Los Angeles Healthcare System to “maximize veterans’ opportunities in the sustainable horticulture industry” (Rancho Santa Ana Botanic Garden, 2012).  Located within the Veteran’s Garden, capable VA patients are invited to spend a few hours per week at the nursery, engaging in all aspects of nursery business and building skills, that they can then apply in a job once discharged from hospital care.  Similar programs can be found at VA hospitals around the country (Taylor, 2009), but unfortunately they are neither representative of national VA policy nor psychiatric hospital policy in general.

One of the more exciting therapeutic horticultural projects currently underway is the first-of-its-kind sensory garden at the UCLA Resnick Neuropsychiatric Hospital where I work.  Once weekly, adult patients are invited to interact with the garden to the best of their ability whether that means turning the soil, pruning the plants, smelling the herbs, watering, or simply watching other people complete these tasks.  By patient self-report, there is an improvement in patients’ mood and evidence that gardening has reduced the amount of physical and chemical restraints needed on the unit.  We hope to be able to show that our integration of horticulture therapy into our regular milieu program has contributed to a significant reduction in patient heart rate and blood pressure, as well as to an overall positive experience in the inpatient unit.

Logotherapy offers a theoretical lens by which to understand the impact of meaningful horticultural therapies.  Developed by Austrian neurologist and psychiatrist Viktor E. Frankl, logotherapy offers a psychological framework from which to understand how humans can persist through extreme hardship.  Frankl is considered one of the founders of the Third Viennese School of Psychotherapy following Freud, who proposed a “will to pleasure” and Adler, who proposed a “will to power” (Frankl, 1969). Instead, Frankl offers a “will to meaning” based partly on his experiences as a survivor of a concentration camp during the European Holocaust in World War II (Ameli & Dattilio, 2013).

Frankl’s concepts are based on three major tenets, including freedom of will, the will to meaning, and the meaning of life—all of which rest on the core assumption that humans are capable of surviving even the most horrific of experiences if they have an attitudinal belief in a higher meaning (Frankl, 1969).  Similar to the phenomena around vocational horticulture, these three major concepts focus on an individual’s future and the meanings to be fulfilled (Frankl, 1959).  Following diagnosis of a mental illness, individuals have been reported to feel a loss of self, power, meaning, and hope for the future (Slade, 2009), or what Frankl would call the “existential vacuum,” which explains why rehabilitation efforts not addressing these feelings fail (Julom & de Guzmán, 2013). Furthermore, individuals can experience a sense of isolation, rejection, and objectification following a diagnosis.  Horticultural activities provide individuals with meaning via responsibility to plants, animals, and other community members, as well as through a newfound sense of purpose.

There are a number of community-based programs, as well as a growing body of research, that address the increasing desire among individuals with psychiatric disability or mental illness to acquire vocational skills that aim to help people find meaning in their lives.  In fact, Supported Employment is now considered an evidence-based practice with widely-researched outcomes and models for implementing programs in mental health agencies (Becker & Drake, 2003; SAMHSA, 2009).  However, there is an underutilization of this model in mental health treatment in part due to different perspectives between practitioners and consumers about the importance of the consumers’ desire to work (Casper & Carloni, 2007).  In the United States, only two percent of people with serious mental illness receive any form of Supported Employment (Marshall et al., 2013). 

Vocational horticulture is a form of Supported Employment that comes out of the larger field of horticulture therapy.  Vocational horticulture focuses on training individuals to work in the horticulture industry, either independently or semi-independently (Messer Diehl, 2007), as a way to provide rehabilitation for individuals who historically would have been institutionalized for treatment.
There is great need for recovery-oriented alternatives, such as horticulure therapy, within the current landscape of mental health care in this country.  One out of four U.S. American families experience mental illness.  Unlike other ailments, mental illness does not discriminate across race, age, income, religion, or education (NAMI, 2013).  For the nearly 57.7 million adults living with a mental illness in this country (NAMI, 2013), the hopes for recovery are largely dependent on an individual’s access to both pharmacological and psychosocial interventions, an opportunity that may be hard to come by for those without good insurance or access to treatment (NAMI, 2013).  For acute crises, psychiatric hospitals serve as places for stabilization and connection to longer-term options, which often include partial hospitalization programs, board and care facilities, or residential treatment centers, depending on an individual’s diagnosis.  Certainly, these options provide support to individuals who can participate meaningfully, but this is not the case for many psychiatric patients for whom symptoms or social situations are barriers to participation or follow-through. 

For those who can even access these services, treatment can be isolative and prevent an individual from engaging in “real-world” pursuits.  Less than 15 percent of people receiving public mental health treatment hold competitive jobs despite the 60 to 70 percent of people who would like to do so.  This is in part due to a lack of vocationally-focused rehabilitative services (SAMHSA, 2009).

As a psychiatric social worker, I have often felt a sense of dissatisfaction upon discharging a patient who I believed might return to the hospital because the discharge plan failed to include sufficient recovery-oriented services.  My toolbox of interventions is limited and frequently dictated by insurance policies.  I often find myself wondering what alternatives exist for people to work toward recovery following discharge.  I strongly believe that horticulture therapies could be one such alternative for many patients.

The current healthcare system is poised to contribute to a shift toward recovery-based mental-health interventions, including horticulture therapy, due to its monetary resources, regular access to the public, and the recent shift in the medical community toward recovery-oriented practices (Barber, 2012).  People look to their doctors and mental health care providers as experts, who therefore have a lot of power when it comes to shaping their patients’ perceptions.  Reaching people within their chosen communities and offering interventions to meet people at the level of engagement in which they are open will further reduce the barriers to receiving care and ultimately help people feel better and live more meaningful lives.

Clinical social work’s whole-person approach to care implies that we must look at complementary and alternative treatment options, such as horticulture therapy, as we work to connect people with the services they need.  Given our ethical standard to “promote wellbeing” and to make “client’s interests primary” (NASW, 2008), social workers are a key link to rehabilitative services.  We are not only able to provide a therapeutic experience while interacting with our clients, but also to offer options about where to receive treatment and where and how the most healing might occur.  The intentional and attuned relationships we build with our clients, similar to the mentorship model employed in horticulture therapy, is core to how social workers are instructed to approach treatment.

Ariel Schneider is a licensed clinical social worker in Santa Barbara, California. She facilitates therapeutic gardening activities with adults on an inpatient psychiatric unit and at an intensive outpatient program (IOP). She studied social work at Smith College in Northampton, MA where she had the opportunity to see horticultural therapy in action through a mentor and completed her masters thesis on the topic entitled, Finding Personal Meaning: Vocational Horticulture Therapy for Individuals with Severe and Persistent Mental Illness. Since graduate school she has had the opportunity to facilitate groups at the UCLA Resnick Neuropsychiatric Hospital as well as Santa Barbara Cottage Hospital where she currently practices. She is currently working towards her certificate in Horticultural Therapy through the Horticultural Therapy Institute. Ariel loves hiking with her dog, skiing, and taking care of her small container garden of succulents and herbs at home. Please feel free to reach out with questions, comments, or to share how you use gardening in your practice! You can reach Ariel by email at: a2schnei@sbch.org

References
Alkon, A., & Agyeman, J. (Eds.) (2011). Cultivating food justice: race, class, and sustainability. Cambridge, MA: MIT Press.
Ameli, M., & Dattilio, F. M. (2013). Enhancing cognitive behavior therapy with logotherapy: Techniques for clinical practice. Psychotherapy, 50(3), 387-391.
Barber, M. (2012). Recovery as the New Medical Model for Psychiatry. Psychiatric Services, 63(3), 277-279.
Becker, D. R., & Drake, R. E. (2003). A working life for people with severe mental illness [electronic resource]. New York, NY: Oxford University Press.
Berman, M. G., Jonides, J., & Kaplan, S. (2008). The cognitive benefits of interacting with nature. Psychological Science (Wiley-Blackwell), 19(12), 1207-1212.
Bockoven, J. (1963). Moral treatment—Forgotten success in the history of psychiatry. In, Moral treatment in American psychiatry (pp. 10-19). New York, NY: Springer Publishing Co.
Camarillo State Hospital. (1993). History. Retrieved from http://repository.library. csuci.edu/bitstream/handle/10139/6151/CSH0006$.pdf?sequence=1
Casper, E. S., & Carloni, C. (2007). Assessing the underutilization of supported employment services. Psychiatric Rehabilitation Journal, 30(3), 182-188.
Clay, Rebecca A. (2001). Green is Good for You. American Psychological Association 32(4). Retrieved from http://www.apa.org/monitor/apr01/greengood.aspx

Roxanne Rae, LCSW, BCD

Many social workers engage deeply with people who have experienced trauma.  The inherent nature of this work exposes us to compassion fatigue or vicarious traumatization because we use our own lives as a safe container for healing our clients.  Psychology professor Daniel Stern aptly explained that “our nervous systems are constructed to be captured by the nervous systems of others, so that we can experience others as if from within their skin, as well as from within our own” (Stern, 2004). 

It is in this empathetic life-to-life connection to people with trauma that a therapist’s own implicit personal resources and deficits may be revealed.  At times, the effort of maintaining affective synchrony with a trauma victim will pull out the best in us.  As one educator and philosopher put it, “our hearts change others’ hearts” (Ikeda, 2008).  Unfortunately, while supporting our clients, we may also become hopeless, anxious, depressed, or exhibit a myriad of trauma-related symptoms ourselves. 

Trauma work is intimate and requires a network of support for healers to minimize the negative impact of this trauma work on their own lives.  For those of us using expressive arts therapies, we are exposed to our clients’ traumas not only through stories, but through images as well.

Healing arts practitioners can use the very techniques that they employ with their clients to help process the traumas that we experience through our empathetic resonance.  We can also use these methods to explore and heal issues that arise from our own past experiences that may be evoked through trauma work. 

Out of the various expressive arts therapeutic modalities, I most often work with the sandtray due to its multisensory qualities that allow access to the implicit aspect of the mind.  Associated techniques within the sandtray modality enhance neuroplasticity through focused attention, novelty, and exploring emotional arousal.  Sara’s story shows us one way in which this identification and processing of trauma may occur.
A busy mental health professional, Sara requested a sandtray session because she was feeling a bit overwhelmed by her work.  Normally, she felt a rich satisfaction from her trauma work with teens.  When Sara noticed consistently less eagerness as she prepared for work, she accurately considered it a red flag.  She had a history of successfully using expressive arts methodologies to facilitate her own clarity and growth.

Sara began by making a circular sand form, like a hill, in the center of the tray.  On top of it, she placed people holding hands in a circle around a candle.  She then stated, “The world is so crazy, it needs some harmony.”  Quickly she lit the candle (Figure 1).  Then, she brought in images of abuse, torture, evil, and war.  She spoke of the poor state of humanity in today’s world.  Sara specifically referred to “evil atrocities in our world,” such as “rape in the Congo, the training of child soldiers, devastating natural disasters, and the existence of warlords in many regions.”  She was intermittently verbally descriptive as she created her world.

Later in the session, she focused on the small, black, and hunched-over devil as it crept toward the circle of people holding hands around their light.  Sara described this devil as the “creeping…seeping of evil” toward her central figures of “harmony and peace.”  She placed a red broken heart figure as a barrier between the two, saying that the heart was “so tattered the evil is likely to get through” (Figure 2).  Sara made this statement immediately after pushing the heart into the sand.

Through my considered inquiry and our reflection together as she processed the experiences portrayed in her sand world, Sara became able to recognize the connections between her globally-focused observations and her personal stressors.  She also realized that she had become increasingly more sensitive about and less modulated in her response to her trauma clients.

Just like the miniature group of people in the center of her sandtray, Sara felt bombarded by evil and negativity.  She expressed feeling overwhelmed by the intense and graphic images of child abuse that she dealt with in her psychotherapy practice.  Her heart was feeling “ragged and torn” in her attempts to hold onto her own “safe place,” while being present with her clients’ suffering.  Eventually, she acknowledged not only feeling assaulted by her everyday work world and the “big world,” but also by some personal family issues.  Once this realization was acknowledged between us, the focus turned to how she could strengthen and nurture herself.

During the dialogue that followed, Sara placed the “Do Not Enter” and “Stop” signs in the tray.  She moved the “Do Not Enter” sign toward the “devil’s path” and “other evils,” as a way to protect her “harmony and peace.” In the end, her peaceful circle conquered all (Figure 3).  Sara expressed a deeper commitment to strengthen herself to deal with her family difficulties more effectively and created a specific plan to do so. 

As this story demonstrates, a therapist may facilitate a client’s active, conscious engagement with previously implicit features of a client’s life, making what is implicit more accessible.  In this case, Sara was able to see and reflect on the connections between her subtle dissatisfaction with her work and her previously unacknowledged conflicts at home.

The sandtray process provides the opportunity to tap into our own inner wisdom and explore life’s alternatives.  Sandtray teaches and supports awareness of our own processes and how they impact the choices we make within our environment.  In this case example, Sara was able to use sandtray therapy to identify her need to work on strengthening her spiritual and social supports, on forming more effective boundaries, and on taking actions to resolve her immediate family matters. 

For therapists who treat trauma, maintaining an awareness of our work’s inherent interpersonal stressors may aid us in engaging in preemptive as well as reparative self-care activities.  The sandtray offers a unique and deeply personal way for us to explore issues that both stem from, and influence, our capacity to engage with and help our clients transform their sufferings.Roxanne Rae, LCSW, BCD is the author of Sandtray: Playing to Heal, Recover, and Grow (Jason Aronson, 2013, 2015).  She has more than 43 years of social work experience and is licensed in both California and Oregon.  For more photographs, information about Sandtray, and to download the author’s articles free of charge, please visit www.roxannerae.com.

References
Ikeda, D. (2008). My dear friends in America: Collected U.S. addresses 1990-1996. Santa Monica: World Tribune Press.
Stern, D. (2004). The present moment in psychotherapy and everyday life. New York: Norton.

Laura Sherwood Higgins, MPH, ASW, PPSC

When I was an MSW student, I spent a summer in Bolivia volunteering in a pediatric health program.  My plan was to shadow social workers in a medical setting, but I was invited to shadow and even assist physicians as well.  A particular incident highlighted the challenge of fusing conflicting healthcare priorities and policies with cultural mores — a challenge social workers regularly encounter domestically and abroad.

When I asked if I could put the baby on its mother, the doctor looked at me as if I had just requested a dozen oysters on the half shell.  Had I?  Having arrived in La Paz just four weeks earlier, my communication skills were limited, and I wondered if I had been misunderstood. 

I repeated my question, and the doctor shook her head brusquely and said, “Claro que no.”  She needed to oversee the delivery of the placenta and stitch up her patient who had undergone a routine episiotomy; a baby did not belong in the middle of all of that.  I was to wipe the baby down, dress him, swaddle him in his blanket, and set him down next to that other newborn baby, who was bundled up and squirming on a metal countertop next to the sink.  I could not argue; I did not have the vocabulary or medical expertise to do so, nor was there time for a discussion.  It was the dead of winter, and the unheated clinic sat at about 13,000 feet above sea level.  The baby needed to stay warm.  So, I held the baby as the nurse gave him a Vitamin K injection, and then I cleaned, dressed, and swaddled him as instructed. 

However, I did not put the baby down on the countertop.  Instead, I held him close to me, waited by the mother’s bedside as the placenta was delivered, watched the doctor finish her last stitches, and then, without asking any questions, I placed the newborn on his mother’s chest.

There were two loud and conflicting voices in my head: one called for cultural sensitivity and respect for the clinic and its policies (put the baby on the counter) and the other was talking about skin-to-skin contact, oxytocin levels, maternal-infant bonding, and breastfeeding (put the baby on his mama).  The latter voice moved me to do something that could have been interpreted as disrespectful and paternalistic.  Yet, despite being a foreigner both to Bolivian culture and the field of medicine, I wondered whether my instincts regarding infant and maternal care were somehow more valid than the standard care provided in that clinic.
 
After all, though the facility had been built to serve an indigenous population in El Alto, it seemed to me that little regard for the predominant culture’s mores existed.  The medical providers spoke in Spanish, though the primary language of their patients was Ayamara.  The women in labor were isolated from their support networks, as family members were not permitted access to the labor ward.  The clinic walls were painted white, a color that the Aymara associate with death and the burial of babies. 

In this severely under-resourced clinic in a country with some of the highest maternal and infant mortality rates, used needles were haphazardly thrown in cardboard boxes, body fluids were splattered on floors and countertops, and there was a dearth of plastic gloves.  Myriad issues needed attention, intervention, and resources.  Suggesting that this clinic reevaluate where a healthy baby was placed postpartum was, no doubt, a low priority.

Still, there are empirically-based physiological and psychological benefits associated with keeping healthy mothers and infants together immediately following birth.  Despite the doctor’s instructions, my scant medical ken, and my visitor status in Bolivia and in the labor room, I felt compelled to do whatever I could — whatever I knew how to do — to promote the health of the infant in his first moments out of the womb.

What I did felt justified on a visceral level, and it was supported by recent studies.  Yet, I had meddled in a system more complex than a newly-arrived gringa could comprehend.  The relationship of the clinic to the Ayamara community, the expectations of the mother and her family, and the priorities and responsibilities of the health providers were all unknown to me.  My actions may have been culturally insensitive, and I definitely overstepped boundaries.  Even so, I think I would do it again.

Attempting to demonstrate cultural humility in a complex, culturally-diverse field elucidates a sometimes-grey area where ethics can become convoluted.  When we work with disenfranchised groups within disenfranchised groups, how do we advocate for the most vulnerable group?  How do we reconcile our own knowledge, expertise, and personal experience when it is contrary to the prevailing culture in which we are working?  To what degree do we set aside our own expertise to adapt to policies and cultural mores?  How do we make positive change while practicing cultural humility?  While the answers to these questions seem abstruse and, at times, impossible to reach, continually asking such questions with curiosity and openness seems foundational to social service work.Laura Sherwood Higgins, MPH, ASW, PPSC has worked with children and their families as a School Social Worker in the San Francisco Unified School District since 2011.  Originally from Santa Cruz, California, she received her MSW with a concentration in Health from UC Berkeley's School of Social Welfare and her MPH with a concentration in Maternal and Child Health from UC Berkeley's School of Public Health.  Laura has worked in a series of positions — voluntary and paid — in the social services and health sectors, in diverse communities, and on a variety of issues, from food insecurity to mental health.  Outside of work, she likes spending time in redwood forests, fly fishing, and traveling the world over.