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By Ronald Mah

The following e-mail arrived in my Inbox in late April 2007.

"I have a young Korean-American client who is a college graduate student in literature. He's a writer. I'll call him Jim. His initial presenting issues were dealing with a sense of isolation and his long-term resentment and anger from being misunderstood and bullied throughout his school career. This young man felt very alone and angry when he was younger. Jim wanted to work on this because he was concerned it might eventually affect his relationships and career. He is clearly exceptionally intelligent, and perhaps even brilliant in his work. He has been recognized for his writing and received awards since high school. He has been involved in an internship with one of his instructors, an editor for a literary magazine. He finds that very stimulating although he is doing somewhat menial work as a "gofer."

He talked about working on a graphic novel where the protagonist is dealing with anger over rejection, "and being invisible" with the themes of justice, compassion, violence, suffering, victimization and bullying, and redemption. It is very clear, that the novel is semi-autobiographical and that he identifies with the main character. The plot of the novel culminates with an intense massive act of vengeance upon the main character's abusers. I don't want to be simplistic, and really don't want to be stereotypical or even worse, racist, so I need to be more clear if there is potential for violence with him. The conversation was disturbing to me after the recent violence at Virginia Tech. To be more blunt, my question is, how dangerous is my client?" (Details have been altered to protect the confidentiality of the client.)

Less than two weeks earlier, at Virginia Tech on April 16, 2007, on the campus in Blacksburg, Virginia, a student, Seung-Hui Cho killed 32 people and wounded many more, before committing suicide. This was the deadliest school shooting in U.S. history. Only eight years before on April 20, 1999 at Columbine High School, two students, Eric Harris and Dylan Klebold, killed 12 students and a teacher, as well as wounding 24 others. They also committed suicide before they could be captured. Seung-Hui Cho was of Korean ancestry having moved here as a young child. Cho left behind angry and vengeful writings and videotapes chronicling a long history of mistreatment by others. His intense resentment seemed to motivate his homicidal actions. After the fact, laypeople and professionals have struggled to figure out the cause and origins of his violence, as was done after the killings at Columbine High. For some, this is to understand the tragedy. For others, it is also to understand, anticipate, and hopefully prevent similar explosions in the future. Unfortunately, examining prior episodes of violence by others such as the Columbine killers did not prevent Cho's outburst. "With his sadistic creative writing, contempt for snotty rich kids, militaristic posing, and heavily plotted revenge fantasy, Virginia Tech killer Cho Seung-Hui has eerily reminded many Americans of Columbine murderers Eric Harris and Dylan Klebold. Cho apparently saw Klebold and Harris as kindred martyrs, giving the boys two separate shout-outs in his suicide manifesto" (Cullen). None of us as therapists wish to be similarly reminded of Cho, Harris, or Klebold as we may fail to recognize a client's potential for violence.

The e-mail I received shortly after the shootings, posted a question that was not hypothetical nor academic. Television and other media analysts (the Today Show, NBC Nightly News with Larry King among others) have argued as to whether Cho was an angry depressive, a psychopath, a schizophrenic, or a psychotic among other diagnoses. Several resources, including Time (Veale) quoted family members saying that he had been diagnosed with autism when very young. This brought a quick response from AutismLink and Autism Center of Pittsburgh Director Cindy Waeltermann that it was "unfair to blame Cho's actions on autism." As mental health clinicians, it is hard not to speculate on the evolution and causes of Cho's violence. Speculation however can be beneficial if it serves us to assess other individuals, such as our clients or our clients' intimate relationships for the potential of violence. The therapist who wrote the e-mail was concerned because there were elements in her client that were similar to Cho and his history. However, there were also distinct elements once identified that allowed her to have confidence that her client was unlikely to erupt into violence. These elements also help direct the therapeutic process.

Here are fifteen criteria or elements to aid determination of the violence potential of children and teens. The concepts should also be applicable to adults. Eight of the fifteen criteria are highly compelling for an individual such as Seung-Hui Cho. These are

    •    Self-Righteousness Attitude
    •    Entitlement
    •    Ego-syntonic Perception
    •    Intense Emotional Arousal
    •    Resentment
    •    Characterlogical Nature
    •    Isolation/Avoidance Behavior
    •    Lack of Remorse

Taking into consideration, that I have not, and in all probability, you have not undertaken an intensive formal evaluation of Cho's developmental, psychological, social, academic histories, these issues are highly suggestive from the media information that has been available. He had an intensive sense of self-righteousness that fed into deep resentment from his years of being ostracized and bullied throughout his school career. The self-righteousness and resentment translated into an intense entitlement to have vengeance, which created a complete lack of remorse for actions to be taken. It is clear that he deeply believed that his victims or targets deserved to be killed. He was also living up to the powerful and vengeful persona that he believed in. There was no conflict within himself regarding who he was and his eventual violent behavior; his violence was ego-syntonic. His issues and emotional state were not transitory, but rather seemed to be deeply embedded into his personality. His perception and relationship to others and the world appears characterlogical. His inability and difficulty in social relationships led to deep isolation and a lack of relationships or community to give him any kind of feedback or reality check or testing of his perceptions. While his lack of remorse would seem to suggest being a sociopath, his writings and his videos demonstrate intense emotional arousal unlike that of sociopath. In addition, it appeared that he intended to commit suicide or go down in a blaze of glory. Sociopaths are highly manipulative and can be extremely dangerous, but they also normally fully intend to survive their behavior. In other words, they do not want to go down in a blaze of glory, but to survive and to do it again in some other form to some other people. My best guess diagnosis from afar, is that Cho had paranoid personality disorder or some other issue that results in significant paranoia. Gregory Lester, Ph.D., trainer and therapist who specializes working with personality disorders identified the Columbine killers as having paranoid personality disorders.

In my clinical experience with young children, pre-teens, and a few adults with high functioning autism or Asperger's Syndrome, I have seen a developmental progression that can lead in some cases to a paranoid personality disorder. This is by no means, the normal or only outcome. With early intervention and skillful education and care, children with Asperger's Syndrome or other high functioning autism can be highly successful in all aspects of life. Dr. Temple Grandin is one example of a very respected author with autism. She is an expert on cattle handling, and has written and spoken often from her experiences and insights as an autistic individual, including many television appearances. Unfortunately, with inadequate caregiving and/or highly negative social experiences, there can be extremely problematic outcomes for some individuals. Autism or Asperger's Syndrome does not cause violence. However, one of the major challenges for individuals within the autistic spectrum is the difficulty in reading social cues, especially nonverbal cues. Individuals within the autistic spectrum are also often more sensitive to environmental stimulation. These combine to make social interactions often extremely challenging for such a child. In communities such as classrooms or the playground, other children often identify such children as being different, and subsequently a target for teasing and victimization. The childhood history of Cho reports that he was brutally teased and bullied in school. Depending on the individual temperament or personality of the child, as well as the environmental and interventions support (or lack of) from caregivers such as teachers, children with these issues respond differently. It seems that Cho did not get the appropriate support or intervention, and with his intense personality suffered greatly and became ever more resentful. Another person with more positive support, with a similar intense personality may become a very attractive passionate individual. Because of the difficulty in understanding social cues, Cho may not have understood how he was perceived, or why others treated him so badly. This may have exacerbated his growing isolation, emotional trauma, and increasing resentment. Unable to identify why others were so abusive to him for seemingly no logical reason, a hypervigilance and hypersensitivity leading to paranoia may have resulted. Over the years, a paranoid personality disorder may have developed. Waeltermann is alluding to such destructive dynamics, when she says, "This is a wake-up call that stresses the importance of early intervention, research, and appropriate treatment strategies.... research has consistently shown that when children receive the help that they need early on they are more likely to become more adept at social and communication skills." Cho did not receive this intervention or treatment. It appears that his challenging dynamics (which I believe may have been undiagnosed Asperger's Syndrome or other autistic spectrum issue), while observed, were never accurately diagnosed and most importantly, never treated appropriately. The consequence to him was his lonely enduring deep dark world of anger and resentment that subsequently erupted to darken the lives of so many others.

Consensus may never be reached regarding Cho's diagnosis. Interestingly the paranoid personality disorder diagnosis has not been mentioned in my reading of the media literature. Whether or not, others agree with this diagnosis, does not serve Cho or the many victims at Virginia Tech. However, the criteria or elements that were compelling and led me to this diagnosis can be useful in assessing the violence or danger potential of others, hopefully before violence occurs or so that intervention can be made. If you consider the eight criteria or elements and apply them to the client, Jim that the therapist was concerned about in the e-mail, you find that there are important distinctions. In addition, if you consider other criteria or elements (the other seven I have found to be important), you can gain even greater clarity for diagnosis. Some of the criteria or elements give clear indication of a more stable and less violently prone individual. Others guide the therapist in clinical inquiry. The first major difference between Jim and the shooter at Virginia Tech is that Jim sought out therapy. Cho was a social isolate and unable to maintain social relationships. He had difficulty maintaining even formal relationships with teachers. He internalized his process and did not have any social context for reality check. Jim uses therapy for this process, and he is successful socially. He seeks out social contact and interaction. Also, Jim was not comfortable with his own anger and resentment. It was ego-dystonic for him, because he could see how it would harm his relationships. Jim is not deeply resentful, although he could have cause for resentment in being a gofer for his instructor at the internship. Instead he appreciated the opportunity to experience the work despite his menial responsibilities. The judgment regarding the other criteria and elements were not clear to the therapist for Jim, but can be pursued through the therapeutic process. The following are questions I suggested that the therapist explore to get more information and clarity. Some are specific for Jim, while others would be useful in general to examine other individuals.

• Are there any aspects of paranoid personality disorder or other paranoid thinking? This can also be from paranoid schizophrenia or stimulant drug abuse (cocaine, crack, crank, methamphetamine). It is also imperative to assess that these symptoms aren't affiliated with a medical condition, other chronic substance use, or chronic symptoms attributed to the development of physical handicaps. Is there a long held resentment and self-righteousness for past wrongs done to him? Or, is the upset or anger transitory? Intense feelings that are released through cathartic processes are less likely to erupt into violence.
• Does he/she have mechanisms to self-soothe distress or other negative emotions (other than with drugs and alcohol or other dysfunctional behavior)? Does he/she activate them effectively or readily? Individuals, who can self-soothe to any significant degree, are more likely to keep bitterness and resentment under the threshold that ignites destructive behavior.
• Is there any underlying Asperger's disorder (high functioning autism) that may be indicative of missing social cues? Does Jim give appropriate non-verbal social cues in the therapeutic interaction? Not only do many individuals in the autistic spectrum not recognize social cues, they may also not give appropriate social cues.
• Does he/she present as "odd"? Mismatch between emotional content and non-verbal cues (eye contact, facial expressions, body movements, voice tone, etc.) may indicate autistic issues, or may indicate disconnection due to intense uncomfortable emotions. In addition, any individual perceived as different is more prone to being targeted for victimization by bullies.
• Is his/her presentation that of a "normal neurotic?" "Normal neurotics" may have an intense presentation at the high or low end of the normal spectrum of emotions. However, they tend to be available to processing their emotions in therapy.
• What is the energy of the movie for Jim? The movie Jim is doing may be cathartic and serves to mollify his resentment. It may keep him from possibly exploding violently into reality.
• How does Jim feel about his recognition? Does he feel them deserved? Appreciation is the normal reaction to recognition. High fragile self-esteem or entitlement would be characteristic of narcissist individuals. Failure to get recognition can result in narcissistic rage and transitory aggression.
• Does Jim feel that despite the awards, that others still don't understand or value him? That he has got recognition and awards from others from his work would seem indicative of gaining positive social validation. Thus, he would be less likely to be dangerous. If he thought that the recognition and awards come from stupid people that he feels superior to... that getting the awards are just signs of their ignorance, stupidity, perverted values, that he's fooling them, then there should be more concern.
• Does he/she feel understood by anyone? By you? Individuals often seek validation from their therapist, after many life experiences of invalidation. They normally appreciate and respond positively to the validation. If the client cannot feel understood or appreciated, or dismisses validation, it would be of concern.
• Does he/she feel that he can be understood by anyone? Who? Cho felt he understood the Columbine killers. Determine with whom the client identifies. Who he/she understands. Are they positive models or dangerous models?
• How does he/she see his/her own anger and what does he/she do with it or in reaction to it? Even when many individuals feel their anger is justifiable, they also understand it can be dysfunctional for them. Of greater alarm, is when an individual sees the anger and the aggressive behavior that harms others, as both justifiable.
• What is the ending of the novel? Is there personal redemption or just vengeance? Does the protagonist die (is doomed) or move on to "happily ever after?" Does the character have hope? Is it a transformative process for the character? For example, from doing poorly to doing well, from being alone to having positive relationships? A transformative story is a self-prophecy of hope as opposed to a story of doom.
• What generation is Jim? Foreign-born, first American born with immigrant parents, second generation, or third generation or beyond? The less Americanized or closer to immigration generationally, the more likely an individual may have difficulty fitting in. What are his/her parents like? This is a basic psychodynamic exploration- an examination of the family of origin, attachment relationships, validation, nurturing, etc.
•  Does he/she feel rejected now? Are these feelings transitory or ongoing? Transitory feelings come and go and are not likely to cause distractive behavior, unless he/she is highly impulsive.
• Was he/she referred or mandated to therapy? Is he/she self-referred? Self-referral is an act of hope and less likely to be indicative of desperation, and thus he/she is probably less likely to be dangerous.
• Are there class issues that may also apply? Class is an often forgotten discriminatory issue.
• How does Jim identify? As American? As Korean? Internalized self-hatred can have ethnic or cultural origins. Internalized self-hatred can externalize into aggression against others.
• Does he/she identify as normal? As special? As different? Misunderstood, etc.? How does he/she identify relative to others, such as victim to bully, or superior to inferior? The role dynamics can predict behavior at or to others.
• You could ask Jim directly about the shooter at Virginia Tech. How much does he empathize versus identifies with Cho?

Empathy might be indicative of understanding Cho's pain, while identification may be indicative of seeing himself in that role.
There are lots of questions that can get greater information and insight. What do your instincts say? Versus your fears? In the short message from the therapist, there were indications that were not consistent with Jim being a danger to others. However, this therapist, just as you are, is the only one in the room to make a final judgment and to do the interventions or therapy. The therapist was able to take these questions and interact purposefully with Jim. I later received this wonderful note from the therapist,

"From the questions you prompted me with, even before seeing him again, I was able to gather that my client was most probably needing affirmation and that his attitude is more hopeful. It is clear that he was reaching out for some support and that his work most probably is cathartic. I feel empowered and will move forward in the therapy. I will use the questions to further assess him, and whether my current sense of his low or non-propensity to violence is correct." About four months later, I received an additional communication from the therapist regarding her client. "My former Korean-American client is doing a lot better. He's starting a paid post-graduate internship at the literary magazine this fall. He won an award for one of his short stories that included a financial prize. He has had a lot of support from his former instructors and myself. Although I haven't heard from him in a while, he usually contacts me for a few sessions when a crisis or he needs to work through something stressful."

The larger list of criteria or elements to use for assessment for violence or danger potential is:

    1.    Specific Triggering Event
    2.    Opportunistic Behavior
    3.    Sense of Entitlement
    4.    Self-Righteous Attitude
    5.    Ego-syntonic Perception
    6.    Self-Esteem Gain or Loss
    7.    Intense Emotional Arousal
    8.    Pleasure
    9.    Resentment
    10.    Functional Reinforcement (Positive or Negative)
    11.    Characterlogical Behavior or Perceptions
    12.    Transitory Behavior or Perceptions
    13.    Isolation/Avoidance Behavior
    14.    Social
    15.    Presence or Lack of Remorse

In addition, nine types or origins of violent or aggressive behavior may be characterized:

    1.    frustration
    2.    cultural issues
    3.    bullying
    4.    borderline behavior
    5.    narcissistic behavior
    6.    paranoid behavior
    7.    sociopathic behavior
    8.    psychotic violence
    9.    substance abuse ignited aggression

Which and how the fifteen criteria or elements manifest indicate the core etiology of the nine types of violent or aggressive behaviors. Each of the nine types of violent or aggressive behavior has a distinctive profile of the fifteen criteria or elements. Explaining how each of the fifteen criteria or elements applies to these nine types of violent or aggressive behaviors is beyond the capacity of this article. In addition, opinions may differ on the relevance of or how to apply these criteria or elements. As you examine a client for danger potential, including suicide, domestic violence, or child abuse, using this process should conceptually confirm much of your clinical instincts. I believe that clinicians often do very good work based on instincts. However, if it is good work, it also is conceptually sound work. As you understand the conceptual foundations to your instincts, you go from good to often, great work. In addition, instinctive work is largely reactive, but with conceptual clarity you can be proactive. This becomes especially important when there is a potential for violence by or to our clients. The first responsibility of a therapist is the safety of the client and the safety of others in the greater community. The threat of harm to others, suicide, child abuse, and domestic violence constitute fundamental legal and ethical requirements for all mental health professionals. The first assessment of violence or danger potential serves the choice of action to that first responsibility. The subsequent assessment serves our therapeutic responsibility to address the client's emotional and psychology process. Whether or not you operate clinically using DSM terminology and diagnoses, assessing for and addressing relevant criteria or elements from the following list can serve therapy:

    •    dealing with specific triggering events,
    •    likelihood of engaging in opportunistic behavior,
    •    sense of entitlement,
    •    origins and the consequences of a self-righteous attitude,
    •    development and consequences of ego-syntonic perception,
    •    how self-esteem is gained or lost with the behavior,
    •    dealing with intense emotional arousal that affects the behavior,
    •    pleasure versus displeasure of the negative behavior,
    •    development of and intensity of resentment,
    •    degree of functional reinforcement from the behavior (positive or negative),
    •    how established or characterlogical is the behavior or perceptions,
    •    whether the behavior or perceptions are transitory, and how to get past them successfully if they are transitory,
    •    degree of isolation/avoidance behavior,
    •    need for and success at social relationships and interactions,
    •    presence or lack of remorse

For example, the violence potential of one adolescent gangbanger versus another gangbanger can be differentiated in seeing how one individual's potential aggression may come from the cultural framework of the gang, while the other's significantly greater potential for violence and danger to individuals and society may come from a sociopathic energy within the cultural framework of the gang. Differentiating criteria or elements for the sociopath would be

    •    lack of remorse,
    •    pleasure in the violent behavior,
    •    absence of intense emotional arousal,
    •    ego-syntonic nature of the behavior,
    •    lack of resentment fueling the behavior,
    •    opportunistic nature of getting away with the behavior,
    •    disinterest in social sanctions,
    •    characterlogical nature of the behavior

Given the psychological profile of the sociopath, emphasizing or creating significant negative consequences for the violent behavior would be the most effective approach for change. Appealing to remorse would be completely ineffective, among many other approaches. For the gangbanger who may be asked to or does engage in aggressive behavior primarily because of the culture of the gang, the differentiating criteria or elements would be

    •    potential functional gain in self-esteem and social status within the gang for the high risk behavior,
    •    need to arouse intense anger in order to be violent,
    •    lack of motivating resentment against a target,
    •    displeasure in the act,
    •    ego-dystonic experience
    •    remorse for harming someone.

For this gangbanger, challenging the cruelty of the act, the dystonic identity of being a violent person, the gangbanger's remorse from harming someone, while also addressing and offering alternatives to gain self-esteem and status would be more effective therapeutically. This approach would have little or no effect on the sociopathic gangbanger. Can we absolutely be sure about a client's potential for violence? Probably not, but we are nevertheless responsible to do the best that we can. Applying these criteria or elements to other clients could provide diagnoses, assessment for violence potential, and direct treatment differentially. And, give us greater confidence for our clinical judgments.
I have been contemplating, developing, using, and sharing this conceptualization with other therapists and human services professionals for the past three years. It has developed and grown with input from others, and has proved to be a useful tool in clinical work. I invite you to participate in the conceptualization and use of this process. Your feedback, commentary, and ideas would be very welcome. You can contact me by e-mail at Ronald@RonaldMah.com or through my website www.RonaldMah.com.

References:

AutismLink Reacts to Diagnosis of Autism in Virginia Tech Shooter, AutismLink, PR Newswire Association LLC, www.prnewswire.com/cgi-bin/stories.pl.

Professor: Shooter's writing dripped with anger, 2007 Cable News Network, CNN.usnews/2007/US/04/17/vetch.shhting/index.html.

"The Ones Who Make You Mad and Drive You Crazy: Personality Disorders For The Marriage and Family Therapist," presentation by Gregory Lester, Ph.D. at the 2004 CAMFT 40th Annual Conference in Los Angeles, May 2, 2004.

Psychopath? Depressive? Schizophrenic? Was Cho Seung-Hui really like the Columbine killers?, Dave Cullen, April 20, 2007, Slate Medical Examiner, Washingtonpost.Newsweek Interactive Co. LLC, www.slate.com/id/2164757.

A Family's Shame in Korea, Jennifer Veale/Seoul, Time in Partnership with CNN, www.time.com/time/worls/article/0,8599,1613417,00.html.

http://www.templegrandin.com, website of Temple Grandin, Ph.D.

Ronald Mah, M.A., L.M.F.T. has a private practice in San Leandro, CA. He consults and trains for many human services agencies, therapists, and educators. He's on the Board of Directors of the California Kindergarten Association, and also on the Board of the California Association of Marriage & Family Therapists (CAMFT). He's the author of "Difficult Children in Early Childhood, Positive Discipline for Pre-K Classrooms and Beyond," Corwin Press, 2006, and "The One-Minute Temper Tantrum Solution," Corwin Press, 2008, and has another book in development for Corwin Press on social emotional issues including victimization for children with Asperger's Syndrome, Learning Disabilities, or ADHD, and gifted children; has dvds on child behavior, discipline, and development with FixedEarthFilms.com. He's written online courses for the National Association of Social Workers- California Chapter. He also teaches MFT trainees at the Western Institute for Social Research in Berkeley. He also is a credentialed elementary and secondary school teacher; and has owned and directed his own child development center. His website is www.RonaldMah.com which includes articles and resources for parents, educators, and therapists. E-mail is Ronald@RonaldMah.com.

By Steven Herrmann

In my 2010 book Walt Whitman: Shamanism, Spiritual Democracy, and the World Soul, I examined in-depth the poetry and prose of Walt Whitman. From a contemporary, analytical psychological point of view, I demonstrated how Whitman speaks to age-old sociopolitical and religious questions that are highly relevant to our world today. My book discusses topics including:


1) Whitman's emergence as a world-liberating figure;
2) Three stages of American democracy: the political, economic, and spiritual;
3) The awakening across the globe of the archetype of bi-erotic marriage;
4) Whitman's religious vision; and
5) Spiritual Democracy: the oneness of all religions.

I showed in my book how Whitman tapped into the archetype of Spiritual Democracy, which has indigenous roots in North America, and I attempt to clarify how he tried to universalize it, by announcing a new religious attitude that is nondiscriminatory, feminist, and LGBT affirming. I feel moved to share ideas from my book with East Bay CAMFT members because the notion of marriage equality is pivotal today, particularly with the focus in the world being centered right now on democracy. The breakdown of organized religions and need for new unifying myths to give coherence to changes that are taking place in the world presents us with an urgent psychological task.

Whitman not only tapped into the archetype of same-sex marriage, he may have predicted its emergence in a prospective way as an institution in the American polis and the world; he places images of same-sex marriage at the foundation of his democracy along with the rights of the well-married man and wife; his democratic visions appear to anticipate the movement currently afoot commemorating the political and legal recognition of same-sex marriage, now ratified in seven States across the US (Connecticut, Iowa, Massachusetts, New Hampshire, Vermont, New York, Washington, plus Washington D. C., and the Coquille, Suquamish Indian Tribe in Oregon). All seven of these States have legalized same-sex marriage. Why CAMFT has lagged behind these States and remained "neutral" by not taking a position on the issue of marriage, when all other national mental heath organizations (the American Psychological Association or APA, the California Psychological Association or CPA, the American Psychiatric Association or APA, the National Association of Social Workers or NASW, and the California Association of Social Workers or CASW) are all in support of marriage equality, is puzzling to me.

My hope is that my workshop will be of particular interest to MFT's today in light of current debates at the State and local chapter levels regarding marriage equality/inequality. In my view it is important to raise not only practical and clinical issues of how to effectively treat LGBT patients, following Proposition 8, but to question where we stand as an organization, and examine the impact of our various positions on clinical treatment and the ethics of our profession. I am not taking a personal position on what CAMFT's position has been or should be, but I do want to question it. In this workshop we will also take a brief look at what is happening globally, to widen our knowledge base.

Workshop Description

My workshop will cover a notion brought forth in my 2010 book Walt Whitman: Shamanism, Spiritual Democracy, and the World Soul, namely the archetype of bi-etoric marriage as a new guiding myth for our times. I am delighted to share this Workshop with EBCAMFT members because I feel the notion of marriage equality is pivotal in our work today, particularly with focus in the world being centered right now on democracy on all three levels, which Whitman identified for us in 1871: 1) political, 2) economic, and 3) spiritual. The breakdown of organized religions in many parts of the world, the reactionary trend towards fundamentalism in Islam and the West including America's religious right, and the need for new unifying myths, to give coherence to political, economic, and spiritual changes taking place across our diverse world, presents us with an urgent psychological task as Marriage and Family Therapist's or MFT's: a call to vocation. We are each called today to take a stand on an important issue of either enlightening our public about the need for same-sex equality for all people, on all three levels--political, economic, and spiritual--or not. Personally, I am in support of same-sex marriage. What the California Association for Marriage and Family Therapy's or CAMFT's position on marriage equality/inequality is or is not is up to CAMFT. I will address the controversial religious dimensions of this sacred domain by presenting a new myth. My workshop will address therefore the controversial religious dimension of the sacred institution of marriage and will present a new myth that provides a foundation in the collectivity to lend support for the movement afoot towards the institutionalization of same-sex marriage. This again is my personal view I will be sharing, so I have no intention of converting anyone to adopt either Whitman's, or my point of view. That is a matter of personal conscience and we each must decide for ourselves, or remain neutral about it. With some of my friends and colleagues at EBCAMFT, I feel a professional duty to speak out about this matter. I hope you will join this important discussion.

A Brief Biography of the Author

Steven B. Herrmann, PhD, MFT received his Bachelor's Degree in "Depth-Psychology and Religion" from the University of California at Santa Cruz in 1982, where he worked as a Teaching Assistant for the poet William Everson. He received his Master's and Doctoral Degree in clinical psychology and has over twenty five years of clinical experience working with children, adolescents, adults and couples. He has taught at John F. Kennedy University and has published numerous essays, lectured nationally and internationally, and written two books, including Walt Whitman: Shamanism, Spiritual Democracy, and the World Soul (2010) Published by Eloquent Books: Durham, Connecticut. ISBN: 978-1-60911-699-6. Steven is in private practice with offices in Montclair, Oakland and San Francisco. Steven is especially interested in the interface of analytical psychology, world religion, and American poetry.

Walt Whitman: Shamanism, Spiritual Democracy, and the World Soul (2010) Published by Eloquent Books: Durham, Connecticut. $28.95 ISBN: 978-1-60911-699-6 Available at Amazon.com By Steven B. Herrmann. PhD, MFT (EBCAMFT Member).

By Sandy McQuillin, LMFT

I was innocently sitting in an East Bay CAMFT Board meeting about a year and a half ago, when the question of "who would take over the CEU Coordinator position arose?" Since I loved going to the presentations I thought "Why not me?" That's when my life became so interesting and chaotic.

First of all I had no idea what the position did, so I had some quick learning by attending a presentation with the outgoing coordinator. That was it! I did a fast learning of the paperwork, how to make coffee (I don't drink it so big problem for attendees) and how to line up great speakers. Then I was off and running to do the job.

Over this past year and half I've learned that the fun part is getting to know all the talented members in our chapter. One of the secret benefits is I have been able to gain so many CEU's. I have also enjoyed the advantage of learning from all these presentations and to be able it use this it in my work with clients. The knowledge and experience from all the wonderful talent we have in this Chapter is truly a benefit I see, from being involved.

Last October of 2011 our coordinator for the intimate Wednesday presentation in Orinda had to step aside and guess who said she would take it on for awhile? Yes I can't help myself and just stepped right up. I love this cozy comfortable group of seasoned, pre- and newly-licensed members that, meet on the first Wednesday of every month. What a great opportunity for this close knit group to support me and all the presenters.

But I am fast realizing that it is such a great big job I need some members to take advantage of having an involvement opportunity to help me. I love telling you how these first rate presentations work, so maybe some of you will see an opportunity for your involvement.

On the second Saturday of each month the presentations are two hours and one can receive two CEU's. The meeting starts at 9:30 for bagels, coffee, tea and an opportunity to mingle and get to know other members. The presenter starts at 10:00 and ends at 11:55 so that we can do a quick introduction and fill out the evaluations. These meetings are alternated between Epworth Methodist Church in Berkeley and St. Mark's Methodist Church in Orinda. There are no presentations in the months of July and December.

As mentioned above we have a presentation on the first Wednesday of the month worth one CEU and lasts one hour. This meeting starts at 10:00 for coffee, tea, bagels and mingling. The speaker starts at 10:30 and stops at 11:30. At this time we all introduce ourselves and pass out business cards or workshop information. After the evaluations are collected and certifications are passed out we finish at noon. We do not meet in AUGUST OR DECEMBER.

These are a great opportunities to really get to know other therapist in the area for consultation or referrals. I realized after attending the CAMFT leadership Conference last week-end how much I would like to have one meeting a month for the lower ( Hayward, Castro Valley, San Leandro, ) East Bay members. I am open for any suggestions on how to go about having presentations in that area. I will leave this involvement opportunity to all therapists who relish getting to know all our Chapter members.

By Don Mack

A hallmark of owning a Private Psychotherapy Practice is isolation. Regardless of how many years we've been doing this work as Therapists, or even how well we're doing professionally, it can be tough to navigate the legal, ethical or personal questions that arise in each of us. When we connect with our clients about their concerns and questions, sometimes we're left feeling drained and uncertain about things we hear. We might also be unclear how to proceed with difficult therapy challenges. This is when a group consultation meeting can provide guidance and clarity.

I've been involved with a monthly Therapist consultation group for about eight years and it has consistently been a great source of clarity, knowledge, connection and validation for my clinical work. I began the group by inviting a few colleagues and posting an online invitation. Each participant came with their own clinical experiences, concerns and expectations for the group. Some Therapists that responded were a natural fit, others weren't.

As one might imagine with the varying personalities of Therapists and our differing clinical orientations, assembling a new work group met with some small challenges.

Since it was the first group I had organized, I was unsure what to look for when interviewing potential members. While most participants had an open approach regarding how the group would evolve over the first few months, others had a clear, commanding presence early on. One participant seemed to overshadow the collaborative intent that I had envisioned for the group, and eventually opted out. One thing that became clear for me was that bringing together a group of unique professionals with an intention of forming a strong, creative, trusted bond required commitment, patience and time.

During the first few meetings of the group we primarily discussed the desired structure and goals to be met. Our group agreed on a fairly loose structure, but there would be several key components that would take place in every session. We decided a two hour meeting was a good amount of time to tackle issues without being cumbersome in its longevity. The meeting begins with each member briefly "checking in", both personally and with psychotherapy practice concerns. While every session is unique, ongoing themes have emerged in each of our meetings. Common topics include insurance and paperwork questions, efficient marketing ideas, case presentation and designing our private practices to best match the clinician's ideal goals.

As time has gone on the group has evolved into a trusted entity which functions both as a professional network and has led to trusted friendships. Not surprisingly, as we learn about each member's therapeutic specialties, the relationships also have evolved into a consistent referral source. Being a member of a monthly therapy consultation group has had an immeasurably positive affect on both my therapy practice and my life. While admittedly I occasionally have had reservations about attending one of our meetings because of a full schedule or other obligations, I've never left one of our sessions feeling disappointed. I always end our meeting with some clearer insight, new clinical information or more focused motivation for my practice.

So if you're looking to add focus and inspiration to your therapy practice, consider joining a consultation group. You might also think about starting your own, with any specific focus you'd like. When I posted that invitation 8 years ago I knew that I wouldn't regret it.

Don Mack, LMFT is a licensed Marriage and Family Therapist and a Clinical Hypnotherapist. He specializes in working with people struggling with addictive behaviors, as well as assisting others in finding the motivation to express themselves creatively. With offices in both San Francisco & Berkeley he can be reached for consultation at contact@donmack.net or phone 415.820.9620.

A Dan Hughes attachment and intersubjective model for working with foster, adoptive children and families

Whether an intern or therapist, you have all been presented at sometime or another with a child or teen that has been exposed to intrafamilial abuse, neglect, inadequate or unpredictable parenting, separation or loss of a primary caregiver. Many of these young people exhibit oppositional-defiant behaviors, have difficulty trusting adults, have problems controlling their emotions, and frequently try to control people and events in their lives. Most children that demonstrate this profile will not meet the criteria for Reactive Attachment Disorder (RAD). They demonstrate what Dan Hughes, PhD and founder of Dyadic Developmental Psychology (DDP) calls an "attachment disturbance". Whether RAD or not at the core of these children's sense of self is shame. Their belief is that they are "bad" and "unlovable".

Probably most of you, like me, were trained to work with these young people by providing individual therapy. Play therapy with a child and talk therapy with a teen, with the occasional family or parenting session thrown in just for good measure. Utilizing this approach I struggled with children who cleverly controlled our therapy sessions. The impetus for them to do so was perfectly understandable. They were trying to avoid any contact with their personal histories that would get them in touch with their pain and suffering, lack of self worth, and of course shame. I felt frustrated, ineffective and believed that I rarely made a lasting connection with them. Unfortunately for those young people I hadn't yet happened upon a model that would help to provide them with a "safe harbor" to explore themselves.

DDP is a model of treatment that is consistent with the theories of attachment and intersubjectivity which creates a safe setting to explore, resolve, and integrate a wide range of memories and emotions. Through non-verbal and verbal attunement, reflective nonjudgmental dialogue, empathy, and plenty of reassurance the child/young person can join with the therapist and caretakers (that are in session) to co-regulate affect, as well as co-construct meaning to their lives. Through this work the child's level of trust grows, their level of attachment with their caregivers expands; their shame diminishes as do their behavioral problems. Parents/caregivers feel more connected and effective.

Mervin Maier, MA, MFT has been training with Dan Hughes since 2004 and is a "Certified Dyadic Developmental Psychotherapy ® Therapist". In his practice Mervin serves children, teens, adults, and couples. He is currently working on certification in EFT for couples. In addition to attachment issues Mervin has specific expertise in trauma, anxiety, depression, ADHD, learning difficulties, anger management and spectrum disorders. Contact Mervin at mmaiermft@att.net.

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However, none of this relieves us of the ethical and professional obligation to carefully assess factors that may undermine treatment. Sometimes we collude with our clients' denial systems, deliver services that are misdirected or even harmful, and allow problems to get worse, under the guise of providing treatment. Meanwhile, our clients continue to believe they are getting help, and we continue to collect our fees. Whether the undiagnosed problem is addiction, bipolar illness, domestic violence, or some other weighty issue, part of our job is to make educated guesses and follow up on them.

The purpose of this article is to address one specific error I encounter with troubling frequency: the failure of couples therapists to assess adequately for partner abuse. By partner abuse, I mean the use of force, intimidation, or manipulation--or the threat to use any of those methods--to control, hurt, or frighten an intimate partner. Note that the definition can be met even if no physical violence is involved. Verbal and psychological tactics are more common; frequently they are also more effective, and they can be more emotionally damaging in the long run.

I have met with couples in treatment for several years with seasoned therapists who missed the extent and severity of the physical and emotional abuse taking place at home. While it is true that clients bear some responsibility for staying silent on the issue (whether out of fear, or outright denial), the obligation to assess rests firmly on our shoulders. For example, an abused partner may feel unsafe to bring up abuse in the presence of the other because of likely retaliation, yet many therapists have a policy of never meeting with separately with one member of a couple they are treating jointly.

Regardless of the reason for the assessment failure, the tragic result can be months or years of continued abuse. "Suffering" is a pallid word to describe the soul-damaging, spirit-deadening impact of ongoing abuse on the abused partner and the children who live with it. The corrosive nature of some abuse leads to an erosion of the self that can be extremely difficult to reverse. The effects are cumulative and must stop before healing can begin. Additionally, abuse generally grows worse without intervention. Meanwhile clients incur a sizeable expenditure of time and money, and the therapist (and, by extension, our profession) loses credibility.

COMMON MISCONCEPTIONS

Several common misconceptions hamper or prevent an adequate assessment of partner abuse.

"The couple reports that they yell at each other, so they both contribute to the problem." Loud arguments should always suggest the possibility of partner abuse. Most abusive relationships involve some angry behavior by both parties; some involve mutually abusive behavior as well, although the degree of fear is generally much greater for one partner than the other. While both partners are responsible for their own behavior, they probably contribute disproportionately to the abuse.

"I spoke to them about partner abuse and they deny it is going on." As therapists, we know better than to accept a client's analysis of their difficulties and to probe more deeply. If an angry client reports that he believes in firm discipline but would never abuse his children, do we simply take his word for it?

"It is my policy never to meet individually with clients I see in couples therapy." Adequate assessment cannot be accomplished with both partners in the room. Asking directly about abuse in a couples session puts the abused partner in a no-win position: to disclose and risk reprisal, or to deny and thereby avoid getting needed assistance.

"I have a 'no secrets' policy, so clients know that anything they share with me individually will be brought into the couples session." In my view, such a policy is designed to relieve the therapist's anxiety and hinders rather than helps the client. As therapists, we often learn things we cannot or choose not to divulge. Holding some information in confidence is a small price to pay if it allows us to leverage our clients into the right form of treatment.

"Even if there is undiagnosed partner abuse, I'm helping them resolve the underlying relationship dynamic." By its very nature, abusive behavior prevents the resolution of other issues. Abuse skews the relationship dynamic and leaves most of the power and control in one partner's hands.

"I can teach them better communication skills until they trust me enough to disclose the issues they are withholding." Communication skills are easily subverted at home by abusive partners. "I statements" are meaningless if the intent is to hurt, control, or manipulate.

"I'm not taking a stand on the issue because I'm afraid the abusive partner will bolt from treatment." Again, the delusion here is that some treatment is better than none. What is needed is a referral to appropriate treatment, rather than maintaining the fiction that the couple is getting help while the abuse continues.

INDICATORS OF PARTNER ABUSE

Clients in abusive relationships present with typical complaints: "We don't know how to communicate with each other." "We've been arguing a lot." "We're both under a lot of stress." "We've needed counseling for a long time and he/she finally agreed." "We disagree about disciplining the children." Their level of intimacy usually has declined.

More telling indicators are embedded in the relational dynamic that emerges in the consulting room. There may be unexplained tension in the room; certain topics appear to be off limits. There may be a marked difference in the way and the degree to which each partner participates in the session. The abusive partner may always start the session or alternatively always make the abused partner begin. One partner may be highly critical and judgmental, or exercise control through silence, intimidation, and manipulation. The other may speak hesitantly and haltingly--or, alternatively, may be hostile, resentful, and angry, seemingly out of proportion to the subject under discussion.

They may disagree on basic facts and have widely divergent views of the same events. Frequently both partners are highly defensive and misconstrue what the other says, as though looking for an opportunity to act angry or hurt. They report or exhibit destructive communication patterns, such as escalation, invalidation, or a demanding/withdrawing dynamic. Impulse control may be poor. Problem-solving and conflict resolution skills are lacking.

Any of these symptoms are sufficient to raise suspicions of partner abuse. Alternatively, many abusive relationships present as typical relationships with occasional heated arguments that both parties have come to see as the necessary though undesirable price of an intimate partnership.

ASSESSMENT PROTOCOL

When a couple comes to see me specifically because of my expertise in treating partner abuse, I typically employ a four-session protocol. I meet once with the couple, once separately with each partner, and then once more with the couple (or twice, if I need to gather further information or test hypotheses) to deliver my recommendations.

Alternatively, a couple may come to see me because they're having difficulties and have decided to try therapy. I might not begin to suspect partner abuse until they have seen me a few times. At that point, I might say something like:

"During the last several sessions, I've been able to observe how you interact with each other. As part of my work and to get to know you a little better, I'd like to schedule an individual appointment with each of you. That will give me a chance to get to know you better, find out more about you, your childhood, family history--that sort of thing."

I wait until the individual session to address the issue of confidentiality and "secrets." I typically begin that session with:

"This is kind of a rare opportunity to get together with you, and I'm wondering if there's anything you'd like me to know that you're not comfortable saying with your partner in the room? If it's something you want to tell me in confidence, I can keep it to myself. If it's something I think would be helpful to discuss in a joint session, I'll let you know that today, but I won't disclose anything you don't want me to."

I also tell the client that I would like to ask a series of questions about the kinds of behaviors that happen in relationships. I use an Abuse Behavior Inventory I developed after several years of working in the domestic violence field. (A slightly abridged version is included at the end of this article.) These specific questions can be supplemented by inquiring about the first, last, and worst conflicts that have occurred.

The individual interview allows me to uncover whether a pattern of abusive or controlling behaviors exists. This is accomplished best in the context of a clinical interview, for two principal reasons. First, clients provide much more information--factual, psychological, and emotional--than they would with a self-administered questionnaire. Second, clients may be so disturbed by their answers that they need an opportunity to process their reactions.

Comparing their answers side by side is an exceptionally useful diagnostic tool. Couples who corroborate each other's answers generally exhibit greater awareness of problems in their relationship and are more often motivated to do something about them.

RECOMMENDATIONS FOR TREATMENT

If the individual sessions reveal a pattern of partner abuse, my recommendations to the couple might go something like this:

"I have some thoughts about your therapy and where we go from here. We've discussed the issues and difficulties you experience together (name them), and I think it's clear to all of us that the two of you need couples therapy. But I think it's premature at this point. It's really just a matter of timing. You're going to be spinning your wheels until you both have a chance to address your own issues. Then you'll be able to take advantage of what couples therapy has to offer."

In the typical abusive heterosexual relationship, I generally refer the man to one of my men's groups with a focus on partner abuse; I refer the woman to a colleague who offers groups for women in abusive relationships. Other options include individual therapy with a therapist who has experience treating partner abuse and group therapy for abusive women. I generally refer men who are being abused to individual therapy, since groups for this population are rare.

In recommending separate treatment, there is a risk that the abusive partner will accuse the abused partner of having disclosed sensitive or confidential information that led to the recommendation. To minimize that risk, I base my recommendation primarily or solely on what the abusive partner told me and what I observed in meeting with the two of them together.

There is not sufficient room here to address the arguments for and against conjoint treatment in cases of partner abuse. Before I will consider treating an abusive couple together, they must meet several conditions.

1. Their answers to the Abusive Behavior Inventory match closely.
2. Past abuse was moderate to mild; currently, abuse is mild or absent.
3. The couple can adhere to a contract of no further abuse.
4. The abused partner is safe, unafraid, and able to mobilize resources if needed.
5. Both partners are motivated for treatment out of a sincere desire to grow and change.
6. Both partners are willing to be accountable for their behavior, without blaming the other.
7. The couple can use basic communication skills in a non-manipulative manner.

In short, couples therapy is appropriate when the dynamics of the relationship, not the abuse, is the proper focus of treatment.

RESOURCES

Treating partner abuse is a specialized field. Trainings in recognizing and treating partner abuse are helpful, but the only way to develop expertise is through direct experience. Practice administering the Abusive Behavior Inventory with colleagues. The next time you suspect partner abuse, assess for it. Consult with colleagues, a supervisor, or an expert. If you discover your suspicions are groundless, you can breathe a sigh of relief. If your suspicions are confirmed, refer the couple immediately for further assessment, if necessary, and appropriate treatment. The hazard of proving your suspicions incorrect is small compared to leaving partner abuse undiagnosed and untreated.

Abusive Behavior Inventory.  Click here to download this form in PDF format (85Kb).

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Albert J. Dytch, Licensed Marriage and Family Therapist, has been treating partner abuse and domestic violence since 1984. He has worked at Men Overcoming Violence and STAND! Against Domestic Violence and was co-founder of The Center for NonAbusive Relationships. He currently leads four men's anger management/partner abuse groups in his private practice in Oakland, where he also sees individuals, couples, and families. Albert has been a frequent presenter on the topic of partner abuse and consults with other therapists on their difficult or dangerous cases. He can be reached at 510-452-6243 or on the web at www.mensangermanagement.com.

By Jessica Sorci, MA

I remember nursing my newborn daughter and feeling an overwhelming physical thirst of emergency intensity nearly every nursing session. It felt as if I would die from not having liquid and my entire being was clamoring for more, more, more. I could drink 32 ounces and my thirst was still unquenched; I kept a large bottle of liquid at my side everywhere I went and I became anxious when it was more than half gone.

The sensation of that thirst brought up a keen awareness of NEED in me, mixed with panic that I wasn't going to be able to get the need met. It was as though the infant part of me that hadn't gotten "enough" was reawakened every time I attempted to meet that particular need of my daughter's. I experienced the need and the panic behind it as an indication that I was lacking something vital in myself.

I think now that I was glimpsing the psychological world of my own internal infant self, and that she had been left very thirsty, or the emotional equivalent of very thirsty in a way that had been terrifying and all consuming.

For most new mothers, the days, weeks and months following the birth of a baby are challenging and exhausting. And for some new moms the postpartum experience actually results in a crisis and a total or near complete collapse of self. I believe this subsection of new mothers who suffer so intensely in the postpartum period might be more deeply understood and more successfully treated if we consider them through the lens of character style, and in this case, specifically the oral character style. (Johnson, 1994).

During the symbiotic phase of development, "there is no conscious differentiation between oneself and one's caretaker" (Johnson, 1994). The infant experiences the mother as its self, and the mother too, has a sense of sharing her infant's experience. This symbiosis is critical to survival in that it forces the mother's attention to be always on her newborn in a way that helps ensure proximity and acute awareness of the newborn's needs. If we accept the idea that mothers are in a sort of psychological lockstep with their babies, we can imagine that parents continue to experience the part of their self that is developmentally congruent with their child, simultaneous to the child experiencing that particular stage. Mothers of newborns are then thrust back into re-experiencing their own newborn infant self that has essentially been dormant in the unconscious prior to the birth of this new baby.

Our earliest psychological developmental task is embodying the capacity for attachment and bonding (Johnson, 1994); failures in this period result in schizoid and oral adaptations in the fundamental structure of the infant and later the adult. For mothers who suffer greatly in the months following birth, I believe it is often the case that their own early infancy was fraught with either harsh, aversive parenting (leading to a schizoid character style, typified by withdrawal) or deprivation and unreliability (leading to an oral character style typified by premature, exaggerated independence). It's almost as though the birth of the baby forces the mother back in time to when she herself was an infant. If the mother was well cared for by an attuned, consistent, responsive other, that newborn part of her will likely be well resourced and able to draw from her own full tank to meet the needs of her young infant. But a mother who did not herself receive the kind of warm, attuned and empathic responses that a newborn requires for optimal development will find herself overdrawn and out of gas as she tries to nurture her own new baby. The meaning that she makes of her struggle and the way in which she responds to the crisis also tend to fall in line with her established character style. Mothers who encountered developmental blocks after their early infancy will be challenged in other predictable ways as their children's development progresses and pulls forth those characterological facets. Here I am focusing on the oral character style, as I have noticed the prevalence of "oral" traits in the new mothers I've worked with whose struggle to adjust to their new role is particularly painful. My hypothesis is that as clinicians working with PPD, we can be of immense help to our clients by supporting them in making the difficult leap into owning their own "neediness" and allowing their dependence to move to center stage.

The central theme of the oral character's life is denial of her own needs. "Orality will develop where the infant is essentially wanted and an attachment is initially or weakly formed but where nurturing becomes erratic, producing repeated emotional abandonment, or where the primary attachment figure is literally lost and never replaced" (Johnson, 1994). "Essentially the oral character develops when the longing for the mother is denied before the oral needs are satisfied" (Johnson, 1994) and the child in effect has to grow up too soon. As an adult, the oral character suffers from "the inability to identify needs, the inability to express them, disapproval of one's own neediness, inability to reach out to others, ask for help or indulge the self. The individual tends to meet the needs of others at the expense of the self, to overextend and to identify with other dependent people" (Johnson, 1994), effectively denying and projecting her own needs onto others. Her false self appears to be nurturing and helpful, but in truth she is desperate (perhaps unconsciously) for the kind of sustained care and love she did not receive. This false self is her "compensated" self -- that part of her self that has learned how best to function in a world where her own needs could not be met, by being helpful to others and not acknowledging her own immense needs. She also has a "collapsed" self that emerges when the compensation fails, such as in the postpartum period. There is an ongoing fluctuation between compensated (sometimes grandiose and even manic) and collapsed (depressed) states that can appear cyclothymic (Johnson, 1994) in oral characters.

New mothers who fall into this oral category tend to describe themselves as having been "Type A", controlling, and/or particularly independent, having identified with this compensated part of their selves. Sometimes it is the case that these women have histories of appearing to be highly functional, and prior to their postpartum period were superficially quite well adjusted, though they often report having lived with low grade depression throughout their lives. Metaphorically, it's as though they've built a reasonably solid looking house on a very weak, incomplete foundation. Having a baby is the crisis that shakes the house so hard it completely collapses and reveals the jury-rigged structure beneath.

The postpartum period is a time when mother and infant need an extraordinary amount of external support. Oral characters tend to find themselves in family and social contexts that are consistent with their own style, meaning there generally aren't supportive systems in place nor is there access to many helping hands, either because the mother is unable to relinquish control, reach out and trust others to help and/or because there actually aren't helpful others available. Consequently, as the new mother is coming into a psychological reexperiencing of her old injuries from her early infancy (namely her sense of lack and of being a burden), mixed with absolute need for support in the present time, she is simultaneously re-injured in the same manner that caused her orality. Feelings of helplessness, terror and futile longing set in, all while she is "burdened" with the task of caring for another similarly helpless, terrified little being who continually echoes and reminds her of her own unmet need for soothing.

The therapeutic aim in working with new mothers who have PPD (or the like) and have had developmental arrests in their own infancies is to assist them in identifying resources and mobilizing adequate support as quickly as possible. This can be quite challenging when working with women who fundamentally don't know how to ask for what they need and don't feel entitled to receive what is offered. In my experience, helping a new mother to get over the initial hump of asking for and receiving, regardless of the discomfort she will feel, can make a profound difference in the emotional health of the entire family and in the outcome of PPD. The fact that she appears for treatment is a promising sign, indicative of receptivity. The window for attachment and bonding with a baby is finite (though generous), and I see it as imperative that mom begins to accept nurturance and sustenance for her self in the postpartum period so that she can genuinely nurture and sustain her baby. Without adequate sustenance for herself, she will undoubtedly though not deliberately, perpetuate the oral style in her child.

In her collapsed state, mom must be encouraged to go ahead and need, to go ahead and ask for and take in some of what she has always longed for and what she has secretly been enraged about never having received. It's as though she has to transform her entire internal world and operating system to be one where it's permissible to have needs, to speak up, to take in, all while learning to feed and care for and understand a newborn -- and quite probably with little sleep! In therapeutic terms, what might be a prolonged, gentle and gradual approach in a non-postpartum period is by necessity a crash course in self-care in the wake of PPD. Although it flies in the face of my psychodynamic/analytic training, I find it necessary to bluntly state and firmly repeat a sort of mantra to these new mothers attesting to the naturalness of their immense needs in the postpartum period, the idea that mom is of little use to baby when mom is undernourished on any level, along with an ongoing, exhaustive review of all of her potential resources. As the crisis eases, we have the luxury of slowing the process down and understanding and exploring the nuances and particulars of her personal story.

In the postpartum period, many mothers with an oral character style have access to incredible feelings of need and longing in a way that is unfamiliar and overwhelming to them. Allowing those feelings to emerge, to be named, felt and then grieved is the beginning of a transformative healing process whereby they can begin to restructure their very character. We are gifted as mothers with an opportunity to readdress our early attachment wounds through the process of bonding with our own babies. But as adults we now have the power to bring words and consciousness to the experience, so that we can affect the outcome in ways that are consistent with our deepest values. A mother's experience of postpartum suffering can be the undoing of her oral character style and also an opening for incredible developmental and characterological growth.

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Jessica Sorci is a Marriage and Family Therapist Intern who received Master of Arts Degree from Antioch University in 2009. She is in private practice in Campbell and Los Gatos, CA, specializing in postpartum and parenthood transitions as well as relational and attachment challenges. She facilitates a Postpartum Adjustment Group for new mothers and draws from her training in psychodynamic, somatic, attachment and mindfulness-based theories.

References
Johnson, Stephen M. (1994). Character styles. W. W. Norton & Company.

There are many types of traumas that effect children and adolescents, and there is a great deal of variation in what different people find upsetting. What is a trauma for one might not upset another person at all. Traumas can range from the dramatic (such as witnessing violent death, or being sexually assaulted) to the subtle (experiencing an incident of emotional abuse, or being bullied) and everything in between. I find it is important not to judge whether or not a child "should" be upset by an experience. If a memory is disturbing him or her, trauma treatment may help.

Children who are suffering from disturbing memories or a full diagnosis of PTSD may exhibit different symptoms than adults. These symptoms may be confusing to the parents or caregiver, and might include:

• Post-traumatic play. Children use pretend play or toys to recreate and act out their upsetting memories. They play looks very serious or frightening to the child, and may scare other children.
• Post-traumatic reenactment. A child may do to others what has been done to them, or encourage others to do the upsetting thing again. For example when a sexually abused child initiates sex acts with others, or a child who has been frightened by a fire plays with matches or engages in arson.
• Frequent frightening nightmares, or difficulty sleeping. May begin trying to sleep in parent's bed.
• Appear to "zone out" or freeze up suddenly.
• The child may do well (or even improve) at school and when busy, but act disturbed at home or when given free or quiet time.
• Sudden clinginess.
• New anxiety or fears.
• Sudden jumpiness or exaggerated startle response.
• Refusal to participate in previously enjoyed activities, including a sudden hatred for school.
• Phobias.
• Make negative statements about one's self ("It was my fault", "I'm bad", "I'm not safe", "I am ugly/stupid/worthless").

EMDR stands for Eye Movement Desensitization and Reprocessing. It is a scientifically proven treatment that cures problems caused by trauma quickly and effectively. EMDR is particularly efficient at treating trauma in children and teenagers. The young brain is constantly growing and changing which enables children to use EMDR extremely successfully and unbelievably quickly. Whereas an adult will usually take 2 hours to process a traumatic incident, a child will process in 5-15 minutes, and a teen 30-40 minutes. I often see dramatic symptom reduction immediately after the first EMDR processing session.

Children (ages 18 months-12 years) follow a special EMDR protocol that looks quite different from the adult procedures, but covers the same basic elements of desensitization and reprocessing. The therapist makes a game out of the bi-lateral stimulation and tells the child the story of the trauma beginning with the child being safe, and ending safe having learned something. An individualized story is used because children do not desensitize or reprocess on their own as adults usually do. When the child's trauma story is known to the parent/guardian/caretaker, the adult(s) are seen alone for 1-3 sessions for the therapist to gather history and information, and explain the procedures. Then the child and parents are seen together for one session of introduction and preparation. One or 2 EMDR treatment sessions per trauma are needed, usually with the parent present, followed by one follow-up/goodbye session. This direct EMDR method works well for both adjunct therapy work and short term treatment.

When the adult(s) do not know the trauma story, are extremely low functioning, perpetrated the trauma, or are new to the child (i.e. foster parent) the therapist may find play therapy to be safer and more effective for the child in building rapport and determining the trauma story(ies). EMDR techniques can then be incorporated into the play. The play therapy/EMDR hybrid approach takes significantly longer, but has been equally effective in my experience. The hybrid approach is possible as an adjunct therapy, but can be more complicated and difficult. I have found that it works best when the long term therapist has witnessed extensive post-traumatic play or the child has told the therapist the trauma story, and the long-term therapist can describe the trauma story to the EMDR therapist. In these instances the long-term therapist fulfills the role of the parent and the EMDR treatment progresses more similarly to the direct EMDR method.

In some cases the parent or caretaker has been traumatized as well. It may be a multigenerational type trauma, such as abuse, or an incident that impacted multiple family members, such as a robbery. In these circumstances I have found that when the parent completes EMDR treatment first, they are more able and willing to provide the necessary safe-base and an accurate and clear EMDR story for the child. The old metaphor applies of putting on one's own oxygen mask before helping a child.

Adolescents (ages 13-21) follow the same protocol as adults, moving through 8 phases of treatment, and are typically seen without the parents. However, while teens desensitize very rapidly, they do not usually reprocess on their own. The therapist can assist the teen in logically thinking about the event, and preparing for the future. Teens can expect a minimum of 3 preparation sessions and approximately one session per trauma, plus one follow-up/goodbye session.

What parents have said about their children:

• "She is sleeping in her own bed now, with no nightmares. It's a miracle!"
• "He doesn't talk about the bad man anymore. He is happy--normal, he can play again."
• "She has not gotten in trouble at school since the EMDR session. I didn't think she was paying attention, but it worked, she has stopped all of those behaviors" (from the parent of a child who had been sexually acting out at school).

For more information about EMDR, check out the EMDR International Association website www.emdria.org. There are many excellent books on using EMDR with children. I most enjoyed reading Small Wonders: Healing Childhood Trauma with EMDR by Joan Lovett, M.D.

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About the Author

Alexandra Phillippe, MFT has 18 years of experience caring for and working with children. She has 7 years experience as an art and play therapist and has been practicing EMDR with children for 5 years. Alexandra is fully trained in EMDR and child EMDR and is working toward her EMDRIA certification. Alexandra has a private practice in Oakland and is currently accepting clients with approved Victim Compensation claims, Blue Shield insurance, or private pay. Alexandra is also experienced at providing adjunct EMDR treatment for children, adolescents and adults who are in long term therapy or groups elsewhere.

By Steven Kessler

Any journey is easier if you have a map that shows you where you are and how to get to your destination. This is especially true on the journey of psychological healing, since some of the territory you must navigate is buried in the unconscious. Whether you are healing yourself or guiding someone else, having a good map is often essential to your success.

For complete psychological healing, we must heal not only the original core wounds, but also all the defense mechanisms that the person has created to protect themselves from feeling those core wounds. The defense mechanisms can be quite complicated. They are often organized in layers, with each layer imperfectly solving the problems created by the layer just beneath it and leaving problems to be solved by the layer above it, or not solved at all.

It is those remaining problems, the ones not solved at all, that show at the surface. Those are what people are typically aware of when they come to therapy or buy a self help book. They think that all they need to do is solve the surface problem. When that doesn't work, they often feel disappointed. But if you have a map, you can tell by looking at the surface problem where to dig for the core wounds and what types of defense layers you may encounter along the way.

I have created a simple map that shows how the various layers of defense mechanisms are laid down, each one on top of the layer before it. Starting with the simplest at the bottom and building up to the most complex, the layering looks like this:

4. trauma + self-negation --> self-defeating behavior

3. trauma + numbing habit --> addiction

2. big or repeated hurts --> defense is ego syntonic --> trauma

1. an isolated hurt --> defense is ego dystonic --> phobia

I hasten to point out that in real life the different layers are not always so distinct, and one level may blur into another. The map is simplified so that what's important stands out, but real life is rarely so simple. The map is useful, but the map is not the territory. Keeping that in mind, let's go through the layers one at a time and unpack each one.
The 1st Level -- Phobias

The simplest kind of wound is a single, isolated hurt. Up to that time, the person's life has been basically okay, at least in the area of this latest hurt. So the problem that the client presents is relatively small and simple, within the context of an otherwise functional life.

For instance, suppose the client is an adult who used to do all the usual adult things, including driving her car on bridges. But then something happened. Since then, she becomes anxious every time she drives over a bridge. She begins to sweat; her hands shake. She tells herself there is no reason to feel this way, this is childish, it's 'not me'. But it continues. To avoid feeling this way, she now avoids bridges.

She has developed a phobia, a fear of a particular situation. She can feel the fear and name the situation that arouses it. She knows what she does to avoid the feeling, and she considers the feeling to be uncharacteristic of her. In psychological jargon, the feeling is 'ego dystonic'. She has not identified with this feeling or the avoidance behavior and they have not become part of her personality or identity. She will say things like "I know I shouldn't feel this way" or "This just isn't me."

This is the simplest kind of wounding. The hurt and the attempts to avoid it are close to the surface. The person experiences little or no secondary gain from the feelings or behaviors, so ending them brings uncomplicated relief.

Because phobias are structurally so simple, they can be fairly easy to heal, if you have a tool such as EFT (emotional freedom technique) to dissolve the trauma. It was in healing phobias that EFT got it's reputation for "one minute wonders". Using EFT, all you need to do is find the core incident that created the phobia and collapse it, testing your work thoroughly to make sure you've cleared all of its aspects. When there is only one core incident, this is usually easy to do.
The 2nd Level -- Trauma

The next, more complicated level is what we typically call trauma. Here the wounding incidents are so big and/or repeated that they have re-organized the person's relationship with the world. The person's whole life may now be organized around making sure 'that' never happens again. And they feel justified in feeling the way they do; the feeling is 'ego syntonic'. If they have been coping with this wound for a long time, it usually has become an identity structure, so that now they identify themselves by referring to it, as in "I'm an incest survivor" or "I'm an adult child of an alcoholic."

A deep healing of the core wounding incidents will usually dissolve that identity structure, leading to a spontaneous shift in how the person identifies them self. For instance, a client who had been repeatedly molested by her father and who had believed since childhood that she must have been bad to have deserved such treatment, paused during an EFT session to reflect on it all and then stated, "You know, this had nothing to do with me. I was a wonderful little girl. He was a sick man." Her whole psyche had just spontaneously re-organized itself.

What differentiates this second level from the first level is the relative size of the trauma and it's defense and the extent of identification with it. In the first level, the trauma and defense are smaller than the rest of the person's life, which is free of this feeling and behavior. In most of their life, they are okay, but in certain situations, they "have a feeling." In the second level, the feeling has them. The feeling and defense are so large that they color and organize the person's entire life, becoming part of their identity and causing them to say things like "That's just who I am."
The 3rd Level -- Addiction

At the third level, the level of addiction, we have all the trauma and defenses of the second level, but they are now buried under an additional layer of defense, an habitual behavior that serves to numb the person to the pain and anxiety of the core trauma. Here, the person's solution to the underlying problem has itself become a problem. Usually, people come for help with stopping the addictive behavior, completely unaware that it is their medicine for a deeper wound, and that we must heal that deeper wound to really cure the addiction.

The numbing agent may be anything. Some of the favorites are alcohol, drugs, food, sex, work, money, success, and popularity, but any substance or activity can be used, as long as it works well enough to dull the feelings from the trauma. However, all addictive behavior is ultimately unsuccessful because "You can never get enough of what you don't really want." If what you really want is to feel loved, there is no substitute that will give you that feeling. If what you really want is healing for the original hurt, there is no amount of anesthesia that will work. Sooner or later, the numbness wears off and the hurt returns.

This extra layer of defenses makes the healing process that much more complicated. In addition to healing the original core wound and the feelings, beliefs and identity arising from it, the addictive behavior itself must be addressed. Typically the addictive behavior has several components, including the craving for the drug of choice, the situations that trigger the craving, the habit of self-medication for the craving, and chronic psychological reversal (this is a term from energy psychology, referring to a situation in which the healthy flow of energy in the body is so disrupted that perception gets confused. In this state, what is bad for the body can actually feel good.) All of these parts of the addiction are interwoven and mutually re-enforcing, which makes them that much harder to untangle and dissolve.
The 4th Level -- Self-Defeating Behavior

The 4th level is the deepest and most difficult to change, because here a deeper and more effective numbing process has been added to the usual layers of trauma defenses (and there may be active addiction, as well.) This additional layer of defense is an unconscious, automatic habit of self-negation.

Self-negation is a much deeper and more damaging habit than addiction, because while addiction tries to bury the pain, self-negation tries to bury the self. It does this by stifling all the expressions of the self and assertions of personal will, such as initiating actions and having preferences and desires.

Why would anyone adopt a habit of negating their own impulses, of preventing their own self-expression? Like all defense mechanisms, it was the best solution the child could find for the problems it faced. In this case, the problem was a parent who could not tolerate the child's developing sense of separateness, autonomy and will. To prevent this development, the parent set out to break the child's will by actively punishing the child's expressions of his own separateness, autonomy and will.

Today, such actions may seem unusual or even bizarre, but during the 1800's and early 1900's, this practice was the norm. Most books on child-rearing from that era state that a child is a wild animal and it is the parents' duty to break the child's will in order to civilize it. Although the instructions in child-rearing manuals have changed, there are still many parents who were brought up this way or who, for some reason, were not able to psychologically separate themselves and therefore cannot tolerate the development of a separate self in their child.

The core wounding usually happens something like this: around the age of two, the child naturally becomes aware of it's separateness and begins to express its will as different from the parent's. Instead of supporting the child's budding autonomy, the parent opposes it, using guilt, shame, manipulation, over-control, or outright violence. At first the child fights back, asserting his own will in opposition to the parent's. But the parent is bigger and stronger and willing to escalate the punishments as far as it takes to force the child's compliance. Time after time, the child loses the fight. Eventually, he concludes that "I can never win, and any assertion of my own will only brings more punishment."

So the child does the only thing that will stop the pain -- he turns its own will against himself and stops himself from feeling or expressing his own impulses and desires and autonomy. He learns to automatically defeat himself before the parent can defeat him. This is the habit of self-negation. This habit organizes the child's psyche so deeply that the behavior persists long after he has grown up and left home. Even as an adult, impulses and desires are derailed before they reach the surface and find expression. Projects are begun, but somehow never completed. Situations that would draw attention or praise are avoided, since those were the moments that brought humiliation. Little is desired or accomplished.

These are the clients who have a reputation for defeating their therapists by refusing to change, even though they want to change. Being successful can be terrifying, since any act of self-assertion re-awakens the old fears of punishment and humiliation. They have never gotten what they wanted before, so why expect to get it now? For them, the only way to avoid losing big is to continue losing small. And underneath the self-negation there is an ocean of pain and rage at the way they were treated. But the act of self-negation protects them from experiencing all those overwhelming feelings. It is their medicine, their drug of choice.

How, then, do we help someone who is stuck at this level? First, we need to recognize early on that self-negation is present so that we don't play into the try-and-fail pattern and end up re-enforcing it. Instead, we need to recognize the need to refuse to change and give it a voice. Within EFT, Carol Look has beautifully laid out one way to do this in her Refusal Technique. This technique is very effective, both to break the logjam and to confirm that self-negation is the issue. When it is, doing the Refusal Technique will cause the client to become more animated. In fact, they often break into peals of laughter at this permission to finally say out loud what they have felt in silence for so long. This release can continue for a long time as they vent the pressure they've been carrying inside for years. And you may need to return to the Refusal Technique repeatedly, each time the logjam re-appears.

Since these clients are profoundly psychologically reversed, I suggest also applying the EFT un-reversal technique early and often. Their system is accustomed to being reversed, and you must help it gradually re-orient to being in alignment.

As you penetrate the layer of self-negation (even temporarily), you can begin to address the underlying specific incidents (traumas) that led them to resort to self-negation in the first place. Their identification with being the loser must also be named and dissolved. If addictions are present, you will have to address them at some point as well, although this will be much easier if you can collapse the underlying traumas first.

It will likely be a long and twisting road, but if you understand the function of self-negation in their psychic economy, you will make real progress.

Looking back over these four levels of trauma defenses, we can see how they are laid down, each one on top of the one below, each layer trying to solve the problems left by the previous layer. With this map in mind, I hope you will find it much easier to understand and heal the various traumas you encounter.

Steven Kessler , LMFT has been a licensed psychotherapist for over 20 years and is the Director of the EFT Therapy Center. He has studied many different healing modalities, including Character Structure, the Enneagram, NLP, energy work, and Thought Field Therapy, the precursor of EFT. He is now credentialed as an EFT Expert practitioner.

by Isadora Alman, MFT

Most of the clients I see in my counseling and psychotherapy practice meet with me only a few times, sometimes only once or twice. The work I do generally and in sex therapy follows the PLISSIT Model developed by Jack Annon and his colleagues in the 1970's. Specifically, I normalize my clients feelings and behavior (give Permission), offer Limited Information, make Specific Suggestions, and finally, if warranted, do Intensive Therapy. Seldom is the latter what people want when they consult me.

If a woman comes in because she has difficulty reaching orgasm, a man because he is afraid to ask for what he wants, or a couple hoping to get along better without as many quarrels I see no need to do family of origin investigation or spend several sessions taking a detailed sexual history. They come with a specific problem. It is our job, working together, to arrive at a specific solution, or a selection of possibilities. Should the presenting issue be more complicated than the client or I originally thought, that can be explained and explored as well.

I work in 90 minute sessions. I begin the first session with "housekeeping rules" such as the bathroom location, assurances of privacy with legal exceptions, that I will give a 20 minute announcement when we near the end so that we can wrap up gracefully, the rules of discourse ("Feel free to speak directly to each other rather than through me" and "If I ask a question you do not wish to answer please say so and I will back off") and I end this with "Now, how can I be of help?".

The reason I begin with my two minute or so housekeeping spiel is only partly to convey the information. It is also for the client to become a bit more comfortable with the surroundings and with me personally -- what I look and sound like and, I hope, the warmth and lack of judgment I project. It's difficult enough for some to decide and locate a therapist, make an appointment, enlist any partners to accompany them, and to get themselves finally to my office. How much more so to launch into their most intimate concerns with a stranger.

When my daughter was little and first learning the facts of sex she would ask wide-eyed and horrified "Do you and Daddy do that?' My answer then was always "What Daddy and I do is private but most adults do it and enjoy it."

My clients are all adults, not innocent six year olds. While I am certainly entitled to keep my private life private and psychotherapists are, in fact, enjoined to do so, judicious disclosure on my part goes a long way to both normalize clients' thoughts and feelings and establish our rapport. Often I will present stories of anonymous other clients for the same effect, but I find that sharing some of the misconceptions I personally also had about female anatomy for example does just that more effectively and allows us to laugh together.

I have clients that come in periodically with new life challenges over the years. While I am flattered that many quote something I said years ago, or say when stuck they try to imagine what I might tell them, several have recalled some personal sharing of mine to be what was most helpful.

Because I encourage clients to record our sessions for their use later, I am aware that bits and pieces of my own history are out there all over the place. Yet in more than 26 years of counseling, I have yet to have this come back to haunt me in any way. To the contrary, I have been told many times how meaningful my personal disclosures have been to them. They have served not only as illustrations of coping strategies but as models of how to take risks and the value of being open with others.

Isadora Alman, MFT has a private practice in Alameda. She has authored multiple books and currently writes a blog for Psychology Today titled "Sex and Sociability" http://www.psychologytoday.com/blog/sex-sociability . Isadora will be presenting at this month's Berkeley CEU workshop titled "Honey, Let's Talk," on Sept 10th. Visit Isadora at www.askisadora.com.

This article first appeared in Psychology Today.com.