Trauma

The Limits of Talk: Bessel Van der Kolk Wants to Transform the Treatment of Trauma
By Mary Sykes Wylie
January/February 2004

The Politics of PTSD: How a Diagnosis Battled Its Way into the DSM
By Mary Sykes Wylie
January 2004

Bringing the War Home: The Challenge of Helping Iraqi War Vets
By Cecilia Capuzzi Simon
January/February 2007

Creating a Culture of Healing: Recovering from Trauma in War-Ravaged Gaza
By James Gordon
January/February 2007

Applying the Brakes: In Trauma Treatment, Safety Is Essential
By Babette Rothschild
January/February 2004

The End of Innocence: Reconsidering Our Concepts of Victimhood
By Dusty Miller
July/August 2003

Content Search Overview: Therapists, social workers, counselors and others found these articles helpful in learning more about the effects of trauma. People searching for information on the following terms and concepts found these articles helpful:

Trauma
Post Traumatic Stress Disorder (PTSD)
EMDR
Cognitive Therapy
Exposure Therapy
Antidepressants
Combat PTSD
Vicarious Trauma
Compassion Fatigue
Abuse Survivors
Mind/Body Techniques
Somatic Therapies
Somatic Experiencing
Mindfulness

Sample from: The Limits of Talk, by Mary Sykes Wylie

And what was the treatment that he felt was not really helping his patients to move on? It was standard talk therapy 101--helping them explore their thoughts and feelings--supplemented with group therapy and medications. During individual sessions with clients, he often focused intensely on patients' past traumas, in the interest of getting them to process and integrate their memories. "I very quickly went to people's trauma, and many of my patients actually got worse rather than better," he says. "There was an increase in suicide attempts. Some of my colleagues even told me that they didn't trust me as a therapist."

The fundamental conundrum of how trauma affects the mind and body that still plays out in treating trauma survivors was already crystallizing in van der Kolk's mind 20 years ago. "When people get close to reexperiencing their trauma, they get so upset that they can no longer speak," he says. "It seemed to me then that we needed to find some way to access their trauma, but help them stay physiologically quiet enough to tolerate it, so they didn't freak out or shut down in treatment. It was pretty obvious that as long as people just sat and moved their tongues around, there wasn't enough real change."

From Psychotherapy Networker, January/February 2004

Sample from: Creating a Culture of Healing, by James Gordon

Afterward, we share our drawings. Ali, a surgeon, quick-moving and humorous, begins. In his first drawing, he's alone and looks confused. In the second, his four children stand in front of an Israeli soldier, who's pointing his gun at them. "I live near an Israeli settlement," he says, "and, every day, when I leave the house, I worry that something will happen to my children before I come home. Two years ago," he adds matter-of-factly, "my house was bombed." In the final picture, the one that shows the "problem solved," he's joyfully playing with his children. The occupation is over and the Israeli soldiers have gone home. "I'm thankful to God," he concludes.

Several others hold up their own pictures of endangered children, assuring me that they didn't have to copy from each other. "This is our biggest concern," Mahmoud says. "Everyone worries about their children, every single morning when we leave for the hospital or clinic." They share memories of homes vacated on Israeli orders and destroyed, of bombs shaking their houses, of children bleeding in hospital emergency rooms. Later I think of the recent training we led in Israel, where health professionals drew their own pictures of vulnerable children traveling on buses or sitting in malls that might be attacked.

From Psychotherapy Networker, January/February 2007

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Confronting the New Anxiety

How Therapists can Help Today's Fearful Kids

Johnny says I'm a faggot. I'll rip his arms out--then we'll see who's gay! "Bitch!" How did Jenny get that tattoo? I'm going to throw up. "Just do it!" A lot of kids are going to crash that party. "Parents, the antidrug." Mom will kill me--wait I'm at Dad's this week. "Get the stuff!" I want Game Boy, Play Station 2 . . . . "You've got mail!" "Wazzup! Hey, everybody does not think I'm bipolar!" "New standardized tests . . . ." Shit, I don't get this math. The test's tomorrow, but first, I have to check my e-mails and then listen to the CD I just burned and . . . .  "Twelve more killed in . . . . " I'm so tired, but what's that noise outside? "Order in the next 30 minutes and . . . ." "Mom, I am not too young for a thong!" "New unemployment figures . . . ." Valerie's father died and Betsy's parents just split up and Bobby's family is moving away. "You're a teenager now, deal!" I just can't take it anymore!

Listen to enough kids and it often sounds like they're coming apart at the seams. Teens and preteens today pulsate with anxiety in a pressure-cooker youth culture and an explosive world, ever at the edge. Not that you'd know it when you first meet them. For the most part, they don't act particularly scared. They don't come in with raging guilt, repression, or conflict--the traditional, "gold-standard" symptoms of neurotic anxiety. They rarely present with PTSD as their main complaint and, in fact, seem quite removed from the world-worries that the media, parents, and trauma experts seem so focused on.

Indeed, today's children and adolescents often present such a convincing front of sophistication, such a steady stream of activity, such articulate, pop-culture babble that they virtually shimmer with techno-energy. No, this 21st-century teen anxiety is different. It's at once chaotic, chronic, and cool--more invisible than the air we breathe. And make no mistake about it, all of this began well before September 11th. We attribute great psychological significance to that horrific day, but September 11th didn't create the new anxiety among so many kids today. It just finally got adults to notice what had been building in our children for years.

Spend time with teens and preteens and you gradually become aware that beneath the seemingly jaded precocity is a fretful undercurrent of worry and fear, unimaginable for 11- or 13- or 15-year-olds just a decade ago. Get into the nitty-gritty of their daily lives and you'll find their thoughts racing, like overheated jet engines, from one source of stress to another--the next make-or-break standardized test, the next totally unsupervised after-school bash, the next late-night, midweek concert they have to be at. Explore a little farther and you'll pick up palpable dread about going on-line with kids who regularly torment them. You'll feel their agitation about whether they should have oral sex after school. You'll catch the gnawing fear that their parents may break up, like so many others, or suddenly move the family halfway across the country.

Over the last decade or so, I've talked to, literally, thousands of parents, kids, and professionals all over the country and across practically all socioeconomic groups. I've gotten the same message in a crescendo: kids everywhere are overwhelmed by a tidal wave of culturally induced anxiety. There's not a town or city--unless it's completely free of rapidly morphing family configurations, impossibly frenetic overscheduling, 24-hour, 500-channel TV access, unlimited cell phone and Internet connections--that doesn't exhibit the signs of epidemic anxiety among its youngsters.

What we used to refer to as the "presenting" problem that presumably masked the real "underlying" issue has become something that requires less clinical detective work: often the problem is the struggle to handle the stress of normal, everyday life. Fifteen-year-old John has been drinking too much and ends up in my office. Yes, his drinking is a troubling concern, but not compared to the viselike grip of anxiety he feels about 30 hours of homework a week, 4 hours of basketball practice every night, 3 hours a week of community service, and, of course, 2 parties a weekend. What about Julia, who's in therapy because of her almost failing grades? Sure, she's worried about school. But what really preoccupies her is the phenomenon The New York Times recently called the "whore wars." She's caught in a bind. She feels she must show as much skin as possible, but how can she do this when she's obsessed by the fact that so many different parts of her body are "absolutely grotesque"? Of course, girls have lived with impossible standards of physical perfection for decades, but now it's happening at younger and younger ages--Julia is 11. And her friend Ethan, also a preteen, is one of the growing number of young boys I know who are obsessed about their bodies, too--not buff enough, too skinny, too small. "Might as well be dead."

Thirteen-year-old Peter is in my office because he's isolated and he turns people off. What's really going on beneath his haughty presentation, though, is that he's been typed as gay. Why? He once put his arm around another boy in a moment of friendship, and, since then, he's been accused of being "ass hungry." Mona's got it all--the perfect look, the perfect body, and she's super-smart. So, what keeps Mona so fearful? Precisely because of her magnetism, she's the object of anonymous Internet insults, online come-ons, and, lately, direct threats on her life. What keeps Michael up at night is that he can't turn himself off after an ordinary evening. What's ordinary? Being online with six people at once while talking on the phone with two friends on call waiting, burning a CD for a pal, doing his homework with a friend, and listening to the TV in the background--just "to keep him company."

Don't reflexively blame their mothers or fathers. Most of these kids have reasonably responsive, competent parents, who feel as helpless as their kids about how to lessen the grip of this half-crazed pressure. After all, they live their own version of the same bind, stretched to the breaking point by their own impossible work schedules, endless social obligations, and gut-wrenching economic worries. Parents feel hard-pressed to protect and soothe themselves, much less their kids, from external pressures that have essentially colonized the family.

And kids know their parents feel helpless. Many teens have lost faith in the ability of adults to protect them from a culture running off the tracks. Studies repeatedly show that when the unthinkable happened--sadistic bullying, death-defying parties, or schoolyard killings--kids knew something was up, but hadn't approached parents or other adults for guidance. In a vicious circle, the less comfort and trust kids feel at home, the more they gravitate to what I call the second family of the peer group and pop culture to meet their needs for a sense of self-worth and a feeling of connection. But the second family carries its own freight, its own pressures, and its own terrors. Like the culture that shapes it, the second family is a world increasingly gripped by anxiety and flying off the hinges.

The Therapeutic Response

So what's a therapist to do? Does the diagnosis du jour--ADD, AD/HD, PDD, OCD, bipolar disorder--help us, past a certain point? Does any one therapeutic framework or technique, such as cognitive-behavioral, insight-oriented therapies, or EMDR, get at the pervasive anxiety that's as much a cultural issue as a personal problem? Can family therapy make a dent if it incorrectly views the family system as powerful enough to counter the larger social angst?

Living in their parallel universe of overstimulation, endless exposure to disturbing information, and constant change, teens need an ongoing relationship with a grown-up. Therapy is a chance to create exactly those experiences and support those values that are missing in the rudderless, anxiety-driven world that surrounds them. When there's often no follow-through in kids' lives, therapy can offer follow-through. Amidst the chaos at large, the consulting room can be a predictably safe harbor. In a world where adults are seen as two-dimensional figures, a therapist can be a three-dimensional person whose thoughts and feelings command respect and attention.

I think of the critical issues around which a different approach to therapy with kids needs to develop as the "four R's"--Rules, Rituals, Reasons, and Regard. Though simple and straightforward--almost too ordinary for technically accomplished clinicians to be concerned with--they're radical, from the standpoint that they've largely disappeared from family life today.

Rules

"I'm sorry I'm late. Everyone was talking after school, and I lost track of time. . . ." "The bus broke down and I wasn't near a phone, so I couldn't call you to say I couldn't come." . . . "We went to the pizza place and just hung out.". . . "I thought insurance was paying you directly . . . ." "There's a big reading test tomorrow, and I have to stay home and study."

When many of us began doing therapy years ago, we believed our young clients' anxieties often resulted from too many rules and too much authority. So our training taught us that a warm, fuzzy therapeutic embrace was a godsend for children. At the same time, many of us--feeling hounded and harassed ourselves by the convoluted regulations of managed care companies and mental health agencies--are uncomfortable in the role of rule-enforcers. But today's kids are anxious partly because there are few rules that matter. We need to recognize that today a laissez-faire therapeutic frame is indistinguishable from the everyday chaos many of our young clients experience.

Establishing clear rules in therapy creates exactly the secure frame that young clients and their parents need to begin managing the disorder in their lives. In fact, addressing the concrete issues of maintaining commitments, setting priorities, and being serious about the process can bring to the surface issues that might otherwise undermine therapy. Instead of just skipping appointments or prematurely terminating therapy, families held accountable start talking about financial concerns or other fears that are threatening to devastate the home. When therapists challenge a family's casual attitude about showing up on time, parents may begin to openly discuss the everyday chaos that can be so frightening to children. In addition, almost without fail, when a preteen or teen is late to therapy, the missed appointment time is used for the very problem that the family is seeking help for--substances, after-school acting out, and so forth.

I was recently seeing Craig, 14, a very nice boy, who couldn't make friends. Like so many kids, he reverberated with anxiety, which he tried to overcome by being loud and forcing himself into people's conversations, much to the disdain of his schoolmates. Craig and his family were prone to cancel appointments at the last minute. After about the third time this happened, I reviewed the rules with them: they had to show up on time or reschedule within 48 hours. Reluctantly, they began to talk about their everyday concerns. Mom had been laid off and Dad wasn't making enough to meet their expenses. In fact, they were canceling at times when they didn't have the cash to pay for sessions. They felt humiliated and crushed by the pressure, and the situation wasn't at all helped by their son's increasingly expensive tastes for the latest fashions.

We began by cutting therapy back to every other week, and then talked about what the mother might do to activate her job search and how they could reduce some of Craig's expenses. Discussing how to weather this economic crisis avoided a premature ending of the treatment and had a stabilizing, anxiety-reducing impact on the whole family.

Concrete rules run counter to the incessant, 21st-century messages to kids (and adults) about the need for instant gratification. Rules protecting the therapeutic frame provide reassurance that the therapeutic relationship won't, like so much else in kids' lives, melt into thin air.

Rituals

"Dinner is ready and we're all sitting down. Okay, okay, but as soon as the show ends, come get something to eat." "I have to work late tonight, but there's some of that macaroni and cheese mix in the cupboard that you can make." "We're too tired to go to church tomorrow. I know it's the third week in a row. . . ." "I don't care if it is time for our family meeting. Everybody's busy. Johnny's working on the computer, Lisa's doing her project. The little one's watching TV. We'll skip it just for tonight."

By now, we all recognize that the simple routines that were once part of everyday family life are rapidly disappearing under a tidal wave of overscheduling. I've asked hundreds of children what in their lives they wanted to have happen more often. Over and over, I've heard the same deceptively simple responses: "pizza and a video," "reading before bedtime," "walking with my father to the school bus," "playing board games with my mom and sister," "cooking together."

Clinicians have long understood the significance of ritual, but mostly through a narrow, trauma-related lens. After a loss or a difficult life transition, we help people create rituals that heal and rebuild. Unfortunately, only a few therapists consider simple rituals in the consulting room sophisticated enough to help with anxiety. Yet research shows that the repetitiveness of rituals helps clients not only heal, but also open up. Simple rituals in therapy can soothe fears, help kids communicate, and inspire families to develop their own satisfying routines at home.

The rituals that have worked best in my sessions are invariably those discovered by my young clients. My role is simply to go with the flow. Fourteen-year-old Jeremy suffered from excruciating self-consciousness and anxiety, which provided fodder for other kids' taunts. He was as self-conscious in therapy as outside; he couldn't talk about his life or his feelings. At the time, I happened to have in my office a football-shaped, stuffed hedgehog for the younger children. One day, Jeremy picked it up and, somehow, we began tossing it back and forth. This seemingly boring, nontherapeutic behavior became an anchoring ritual. At every session, the first thing Jeremy did was seek out the hedgehog; if he didn't find it, he'd ask me where it was. And from the first, while throwing and catching it, he could open up about his problems with the other kids.

Soon Jeremy got his father to play a weekly game of catch. During these games, he began to talk about what was going on at school. "What do you think you might be doing that makes the kids act that way?" his father asked as they played. An ongoing conversation ensued with his father and mother about what he could do to improve his image at school--how to initiate conversations, how to ask questions in a way that wouldn't turn everybody off, when and how to respond to kids when they taunted him, and when to walk away. Jeremy's anxiety didn't magically disappear. But over time, these routine games of catch helped him share his schoolyard fears and helped his parents become better listeners and problem-solvers.

Rituals that work are entirely idiosyncratic. Patients make their own preferences clear, often quite insistently. Twelve-year-old Elena was a mass of adolescent angst, dressed in full-Goth garb. Contrary to her anarchistic attitude, she constantly obsessed about what everybody thought of her and worried nonstop about how she looked. She wanted me to listen to the CDs she'd burned between sessions and would invariably jam a few CDs into my boom box and play her ferocious music for me. Listening to the lyrics gave us an easy entree into conversations about her week, her friends, what she was thinking and feeling. If I forgot to ask about her latest CD, she'd remind me.

Eventually, after Elena talked about our "music sessions" at home, she and her mother (who quarreled often and fiercely) established their own music ritual. Mom played that "crunchy-granola '60s crap," while Elena blasted out her hard-edged punk sounds. These interludes became a buffer of peace during which mother and daughter could briefly suspend hostilities and begin to understand each other better. Elena didn't entirely stop obsessing about her looks or what people thought about her, but she did begin to acquire a little less moody perspective. The ritual, as so often happens, provided a structure for a connection with her mother that was both comforting and reassuring.

Other kids read from journals or e-mails at the beginning of every session. And almost every child or adolescent snacks with me. Food rituals have become a staple of my therapy with kids. There's something about sharing a "meal" that seems to calm and soothe. And it can't be just any old food, either; no, they want the exact same goody every single session. Regardless of what's happening in their lives, none veers from a particular choice. Once I asked Lydia, a 13-year-old girl who'd taken a shine to the saltine crackers that came with my take-out soup, why she always wanted the same food--wasn't it boring? "Different is boring," she said, munching away contentedly, "the same is good." In fact, it's the sameness of a ritual that makes it reassuring, and an opening for conversation.

Reason

Fifteen-year-old Mary says, "I went to the guidance counselor because there are these kids who keep saying horrible things about me and threatening me. I can't avoid them; they're on the school bus, they're in my class, they're online sending me gross messages. I wanted to know what I should do. So what does the guidance counselor say? She says, 'Tell me what you think you ought to do.' Do you believe that? Why the fuck does she think I asked her in the first place? Is this supposed to be helpful? What is it with you people, anyway?"

Mary's complaint is well-founded. Unfortunately, counselors and parents are often terrified of offering advice to kids and giving good reasons for not engaging in bad activities. But there's never been a time when kids needed more unapologetic adult direction. The fear factor is everywhere. Whether it's elementary-school ostracism or middle-school taunting or high-school revenge, binge drinking, drug use and shoplifting, or Internet threats for anyone old enough to sign on, kids face scary issues every single day.

What in the world is this child to do, and why in the world don't we tell her? Well, many clinicians and parents have long bought into the theory that telling kids what to do will somehow stunt their emotional development. But kids' anxiety is, in part, a reaction to being left virtually on their own. The children of ineffective parents, stymied by a youth culture that often seems to dominate our entire social landscape, need a therapist who isn't afraid to give advice that supplies reasons, creates dialogue, and ultimately strengthens kids' thinking. In fact, behaving like an adult with kids, drawing on adult authority and knowledge, challenging them on their often screwy assumptions, dangerous desires, and unwise choices engages them at a visceral level. They feel they're in touch with a force that's real--authentic, strong, trustworthy, and dependable--utterly unlike the will-o'-the-wisp ethos of their own world. Straightforward advice based on experience relieves anxiety. And most therapists have a lot of solid advice to offer.

Advice isn't something to hide from your supervisor or peer supervision group; it's an absolutely essential aspect of treating 21st-century teens. There's nothing wrong with saying to young clients: "Read your e-mail to me and I'll tell you whether, in my opinion, it sounds okay to send. . . . When they get into your car, it's your responsibility what happens. . . . It'll be almost impossible to keep crashers from your party; it's a huge worry to deal with. . . . If you approach that kid in front of his group, he'll most likely turn down your offer. . . . Don't think that will be kept a secret; everybody will know by the end of the day." But certain guidelines are important. To give effective advice in treatment, a clinician needs to get the whole story, with as many nitty-gritty details as possible, while trying to suppress the almost hard-wired therapeutic urge to ask, "How does that make you feel?" It's also very important to let kids know that their situation deeply touches you; this isn't the time to retreat behind clinical neutrality. And, finally, it's essential you say that you won't be there to see whether your advice is taken.

For example, Jimmy, 16 years old, asked me if I thought he should drive a bunch of his friends to a party after the prom ended at 2 a.m. The prom would include tequila-braced punch, and the after-prom party was 100 miles away. Jimmy had a beat-up old car, a girlfriend to impress, and a couple of pals he'd already made promises to. Jimmy's parents weren't thrilled about this plan, but told me, "This is what kids do now. We basically trust him; he's a good driver, and he'll have a cell phone." Jimmy was ambivalent--he felt important, but was worried about the responsibility.

Me: How much will you have had to drink by the time you leave the prom?

Jimmy: Somewhere between six and eight drinks--but it's over a long night, and the drinks are pretty weak.

Me: And your friends?

J: Oh, they'll be wasted. I'm the designated driver. That's why I have to drink less that night.

Me: And you think six to eight drinks is taking it easy, right?

J: Yeah. I'm not going to be chugging. I'll be eating all night, and look, I weigh almost 175 pounds.

Me: I think you're absolutely out of your mind. I know I can't stop you, but I don't think you should do it. No way!

J: What are you talking about? My parents know about it and they think it's okay. The school even wrote a flyer home about it.

Me: I don't care who thinks what. It's going to be really late. You'll have had too much to drink and you're legally responsible for everybody in that car.

J: I don't believe that. They know what they're doing and they're responsible for what they do.

Me: No! You're responsible, even if they don't buckle up their seat belts. Look, I'm telling you again, I won't be there and can't stop you, but this is a crazy, insane, lunatic idea, and I'll do anything I can to talk you out of it."

We argued over every detail until the last minute of the session--what his girl might think, what his friends expected, why he thought he had to do it. I had absolutely no idea of what he'd do, but the anxiety Jimmy came in with had now been transformed into engagement between us and at least a few questions within himself. Two weeks later, Jimmy came in again. The prom was long forgotten by now, a distant speck on an adolescent's constantly shifting horizon. "The after-prom?" I nudged. "Oh, we didn't go. I was too tired. We were all wasted, and it felt pointless to drive 100 miles. So we crashed at somebody's house and went to sleep." Not a single reference was made to our heated discussion.

It doesn't matter. The therapeutic action is the dialogue in which the advice is embedded. Engagement "holds" kids, calming them just enough to allow reason to begin trickling down into their feverish, revved-up psyches. In Jimmy's case, his inchoate, almost unrecognized, anxiety was transformed into a good kind of resistance to me, like bumping up against a familiar object after racing through pitch-black darkness. In their lightning-paced, careening lives, kids have few adults to slow them down. Twenty years ago, a teen's reaction to all this might have been, "Stop preaching; you sound like my parents!" Today, more often than not, it's relief.

Regard

"Express yourself!" "Think it, write it, send it. Now!" "At least my parents aren't involved in a vicious divorce the way yours are!" "You think you're special just because your mother died?" "Don't come to school tomorrow, if you plan to stay alive." "You're fat, you're bulimic, you're a loser." Mean Girls . . . Bad Boys . . . "Hey, is that any way to talk to your therapist?!"

From playground back-talk to schoolyard mean-talk to high-school rap-talk to online death-talk, casual communication between kids pulsates with a verbal brutality that makes most adults wince, turning "the wonder years" into years of anxious vigilance.

And this carries over into the home, where many parents tolerate enormous abuse from kids because they're frozen in place by 30-year-old pop-psychology bugaboos: if kids aren't allowed to freely express themselves, they won't talk and develop proper self-esteem. Yet kids today are verbally abusive, not so much from deep, festering rage or rebellion, which might once have been the case, but because they genuinely seem oblivious to the impact of their own actions on others. They've never been taught that what they do and say actually matters, that laserlike one-liners can deeply wound people. And when you don't have to face the person whom you insult--via cell phone, beeper, e-mail--it's even easier to do. As one 12- year-old told me, "I can say anything I want online because I don't have to see how it makes the other kid feel."

The parental reaction is all too often a post-Freudian, pseudo-Rogerian, Zenlike acceptance of kids' communication. Just about every clever utterance no matter how hurtful, every negotiating ploy no matter how outrageous, every power play no matter how maddening is okay in the name of self-esteem, self-expression, and mental health. Until, of course, the inevitable adult explosion--a blast of unenforceable threats ("You're grounded for life!") or fits of physical force (8 out of 10 parents still believe in hitting their kids). It's clear which is more dangerous, but which is more anxiety inducing: the out-of-control abuse of parents or out-of-control threats by parents?

Both. At home, in school, on the soccer field, or online, kids are rarely asked by adults to feel the impact of their actions. By "regard", I mean that in 21st-century treatment, we need to help a child feel the impact of who she is and understand that what she says to other people makes a difference. It's about turning treatment into a microcosm of interpersonal dialogue in which both participants understand their own experience and their impact on the other.

Fifteen year-old Nick was in therapy because he had such a hard time making friends, and didn't know that his imperious demands turned people off. At lunch, for example, he'd go to a table full of classmates and shove his way into a seat, saying something MTV-ish, like "move your ass!" The kids at the table weren't impressed; they'd tell him to get lost. So, time and again, Nick's anxiety about his lack of friends would spike.

I quickly began to understand why he had difficulty making friends, because Nick acted the same way with me, demanding, "Where's my food?" After a few times of grudgingly going along, I told him, "You know, usually I look forward to these snacks. But I don't feel like eating with you when you talk like that." Looking deeply puzzled, he said, "But that's just the way I always talk."

"And what do the other kids say when you start telling them, 'do this, do that?'" I asked.

Nick paused and thought. He wasn't defensive--when I ask these kinds of questions, kids often aren't. They're just surprised; it hasn't occurred to them that an adult might have feelings about what they do and that there may be a reason why peers don't find them inviting. Over the course of several months, he developed a little more self-awareness. At school, Nick gradually learned when and how to ask if he could sit with others. Slowly, he was accepted at the outer edges of the "nonloser" table--not the highest rung on the adolescent social ladder, to be sure, but better than before.

Mandy was a sweet girl of 15, who "mysteriously" alienated other kids. After a few sessions, it became clear why. Mandy got so wound up telling me a story that she'd repeatedly leave her chair and stand directly in front of me, completely lost in the details of her experience. I felt myself shrinking back in my chair. Mentally pushing aside the neat diagnosis of "nonverbal learning disorder," I decided to respond in the moment, saying, "Please, Mandy, move back a little and tell me from a little farther away. I can't concentrate with you practically on top of me."

She stopped, looked surprised, and said, "You mean I'm making you nervous?"

"Yes," I said, "I really feel pushed."

She looked taken aback.

"I know you don't mean badly and want to tell your story," I continued, "and maybe I'm doing something that makes you feel I'm not getting it. But it really is too much for me when you get that close."

Mandy was quiet for a minute. "You sound just like my parents. They say the same thing to me." I asked if she ever noticed anybody else shrinking away from her. "Oh, no, never."

"Well," I suggest, "maybe you could just watch and see if this happens at school."

The next week, Mandy again started to stand up as she got into her story, but this time, she saw the look in my eye, caught herself, and sat back in her seat. "You know, I did notice that I get right in kids' faces--and talk louder and faster. It makes me very nervous when I think people aren't listening."

As it turned out, I discovered that Mandy's mother was also a "close talker." When Mom felt Mandy needed to know something, she stood over her daughter and delivered high-decibel lectures. I worked with her to establish a more user-friendly style of communication, emphasizing simple, basic techniques: when Mandy needed to know something, tell her in a calm tone of voice, make it short, and then leave. Of course, like all of us, parents often fail at first-time assignments, so a little family-of-origin work (and eventually, some cognitive testing for Mandy) became part of the treatment.

Both of these situations required a number of interactions to get the point across. But teens take honest feedback to heart. Its directness pales in comparison to what they're used to hearing at school or at home. And the chance for kindly discussion is a true gift. Developing regard for an adult's experience increases kids' awareness of the world and lessens the out-of-control feelings that engender anxiety in so many of them.

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Creating rules to protect the therapeutic frame, establishing rituals to soothe children and open up dialogue, offering passionate advice to encourage reasoning, and asking to be treated with respect may seem, at first glance, unsophisticated, especially compared to the hundreds of clinical approaches now on the therapy marketplace. But at a time when the stable building blocks of family and society are disappearing into the maw of a ravenous mass culture, these old standards of civility and security make a lot of sense, and are good therapy. For all their apparent bravado, kids need the felt presence of adults---the undeniable evidence that we can be emotionally there for them, keeping them safe and providing them with the structure and guidance they crave in a frighteningly chaotic world.

Nothing less seems to hold their anxiety, or capture their digital-speed, supersaturated attention. The other night, I gave a talk for parents and kids in a suburban high school. "How do kids want adults to talk to them?" a parent asked. A sudden jolt of electricity ran through the teens and preteens, "Why don't you just tell us what you really think, for a change" one shouted, with the nodding approval of her buddies. "Only, keep it short, will you?!"

"Rules, Rituals, Reason, Regard--not a bad way to work with kids. Cell phone's ringing. Hmmm, maybe it's a referral. "Refinance, now!" Wait, my continuing-ed application is due tonight--when am I going to get it done? "You've got mail!" I can't believe Sam and Julie are splitting up! They've been married 25 years. "Dear member, your group's medical coverage is being dropped as of . . . ." Tim has cancer, and they don't know whether they caught it in time. "Today's new unemployment figures are out." I'll have to stay late at the office again. But, I promised the kids I'd be home in time to kiss them good night. Oh, no!

Ron Taffel, Ph.D., is founder of family and couples treatment at the Institute for Contemporary Psychotherapy in New York. He's also the author of the professional guide  Getting Through to Difficult Kids and Parents . His latest book on adolescence is The Second Family . Address: 155 Riverside Drive, New York, NY 10024. Letters to the Editor about this article may be e-mailed to Letters@psychnetworker.org.

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Bringing Mindfulness to Your Practice

When meditation helps . . . and when it doesn't

By Lorne Ladner

Q: I'm interested in integrating meditation into my psychotherapy practice. What's the best way of doing this, and are there situations in which meditation can be

A: Meditation has been clearly linked to decreased anxiety, improved immune function, better emotional regulation, enhanced empathy, increased feelings of happiness and contentment, decreased stress effects, and relapse prevention for depression. Given the strength of the research, recommending meditation as part of the treatment for anxiety or stress can be done as readily as recommending exercise.

Early on in psychotherapy, I'll often explain to patients just how and why meditation may help them, offering this as a treatment option and asking them if they'd like for me to teach them one or two simple meditation techniques. Of course, if you're going to teach basic meditation, then it's important to at least occasionally practice the techniques yourself. While I don't introduce meditation to every patient, I've often been surprised that even quite conservative clients are willing to engage in practice. It's usually my more high-strung, driven, and stressed-out patients who benefit the most from these techniques. For those who express a strong interest, I'll also sometimes offer to refer them to local meditation groups for further training and support.

I usually start by telling my patients about the impressive amount of research on the benefits of meditation. I also explain what meditation does: it helps increase our experience of being in a calm, relaxed and yet alert state of mind that, in most ways, is the opposite of how we feel when anxious or stressed. It also teaches us how to be aware of our thoughts without identifying with them or allowing them to "take over," which can increase our capacity for introspection. Meditation helps people who habitually get caught up in the negative thoughts associated with anxiety by helping them learn to recognize those recurring cognitive patterns simply as passing thoughts, and let go of them, thus preventing relapses into anxiety or depression.

Once I've suggested meditation and explained its benefits, nearly all patients agree that it's worth a try. Even many conservative patients--who are likely to think meditation is "fringy"--prefer trying it to starting medications, because it allows them to feel more in control of their inner mental processes and doesn't put them at risk for side effects. Roughly half of my patients who've learned a meditation technique have continued to meditate, at least occasionally, for months or years.

In the Buddhist tradition, there are, literally, thousands of different meditation practices. These include methods for developing positive emotions, doing complex visualizations, cultivating deep concentration, and analyzing the ultimate nature of the self. However, when working with patients, I generally introduce a basic form of meditation--mindfulness breathing.

In a session, I'll spend 10 or 15 minutes leading patients through the practice of sitting comfortably and focusing awareness on the natural process of breathing in and out. I teach them that when thoughts come up--as they inevitably do--the practice is just to be aware of those thoughts, but not to follow them. When they notice that a certain thought has arisen, they simply note "Ah, thinking" and then let the thought go, returning their attention to the process of breathing in and out. Patients often comment that the technique is very simple, although once they've spent some time trying it, they also observe that developing awareness and concentration isn't easy.

There are definitely patients for whom I don't recommend meditation practice. People who are experiencing a major depressive episode, for example, tend to find it particularly difficult to practice mindfulness, and there's no clear research on the benefits of meditation in such cases. However, I often recommend mindfulness practice to people who've recovered from major depressive episodes, and they've frequently found the practice useful. The increased self-awareness can help them become more alert to signs that their depression is returning, so they can intervene early to head off the recurrence of major depressive episodes. Also being able to watch negative thought patterns arise and then go away without getting caught up in them can help prevent negative cognitions from deteriorating into full-blown depression.

Therapists also have to be cautious about introducing meditation to people with tendencies toward psychotic symptoms, including those with serious personality disorders. One patient with borderline personality disorder began meditating and quickly decided to attend a retreat. Imagining that "enlightenment" would free her from her inner turmoil and agitation, she began meditating more and more, until her already shaky psychic defenses were undermined and she began experiencing hallucinations and paranoid delusions. So for those at risk for psychotic symptoms, meditation should be used cautiously and probably for only brief periods--say 15 to 30 minutes per day. Even for people with less serious problems than hers, deeper levels of meditation can open them up to unconscious forces, which many aren't ready to face.

Another common dynamic to keep in mind is that some people use meditation as a way of avoiding difficult emotions. One patient, Paul, was very excited about the idea of integrating meditation and psychotherapy, and had come to me primarily because he knew I was familiar with Buddhist practice. As we spoke, however, it became clear that when difficult issues came up between him and his wife, instead of hashing things out with her, he'd go off and meditate to clear his mind of anger and anxiety. Thus he avoided ever working through the problems in their relationship. He also had deep conflicts in his feelings toward his parents, but again used meditation to avoid thinking about or experiencing these emotions, so his relationship with them remained superficial. He was quite surprised when I advised him to spend less time meditating and more time talking openly with his family.

I also suggested that Paul replace some of the meditation techniques he used to avoid emotion with meditation specifically designed to put people in touch with their feelings. So he began spending a little time each day meditating on loving-kindness. He'd focus on people in his life and practice thinking "these people are very precious; may they experience happiness and the causes of happiness." He'd imagine warm, loving energy radiating out to them, bringing happiness and joy. And he'd focus his attention on the feeling of being warmly and intimately connected "from the heart" with those people.

People who avoid facing their negative emotions also inevitably find it hard to feel any strong positive emotions--even love; so this technique wasn't easy for Paul. I encouraged him to use what warm feelings he could develop in meditation as a starting point from which to approach his family members, and talk with them about difficult issues in a respectful and loving way. As he practiced this meditation, he found that it became easier to talk to his family, and that the feelings of loving-kindness he'd nurtured in meditation expanded from inside himself to outside in his relationships with them.

Among the many meditation techniques that exist, basic mindfulness and loving-kindness practices are particularly easy to integrate with psychotherapy. Once patients understand how to do such practices and what the potential benefits are, many will be very happy to experiment with these tools.

There are many benefits to integrating meditation into your psychotherapy practice. Practicing these techniques yourself as part of your work will naturally bring you the same sorts of health and emotional benefits that they bring to your patients. Also, researchers have found that, for professionals, engaging in meditation can increase their sense of satisfaction and purpose.

Meditation is a powerful and well-researched tool that works well alongside other clinical interventions. And more important, perhaps, bringing a meditative awareness--with its natural sense of acceptance and compassionate presence--into your therapy practice helps create the sort of empathically attuned, intimately connected interpersonal space that facilitates meaningful, lasting change.

Lorne Ladner, Ph.D., is a clinical psychologist in private practice in Northern Virginia. He teaches workshops and lectures on positive emotions and the integration of meditation and psychotherapy. He's the author of The Lost Art of Compassion: Discovering the Practice of Happiness in the Meeting of Buddhism & Psychology. Contact: maniwheel@verizon.net. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

Is Your Waiting Room Still Waiting?

Receiving Continuing Education Credit for Your Attendance

The 32nd Annual Networker Symposium has been approved to provide continuing education by several major mental health organizations. We've also listed the organizations whose approval is pending. Previous symposia have been approved by these organizations, and we anticipate their approval prior to this year's conference.

How to Get Your CE Certificate of Attendance

Click here to evaluate the Symposium and all the events you attended. Once you've completed this process, your Certificate of Attendance will immediately print out right at your desk.

Please note The hours listed for Thursday and Sunday are the number of hours that will be awarded; hours listed for Friday and Saturday are the maximum hours that can be awarded. Attendees registered for Friday and Saturday will receive 5 hours for attending the morning keynote and both the morning and afternoon workshops. The following events have also been approved for one hour of CE credit: the Thursday evening welcoming event with Jeffrey Zeig, Ph.D.; the lunchtime, afternoon, and evening videos on Friday and Saturday (you must sign in and out); lunch on Friday with Helen Fisher, Ph.D..; lunch on Saturday with Louis Cozolino, Ph.D.; dinner on Friday with Mary Pipher, Ph.D.; and dinner on Saturday with Salvador Minuchin, Ph.D.

Attendees must have been pre-registered for all meals.

The following groups and states have approved the Symposium for a maximum total of 21 continuing education hours: (Friday, 5 - 8 hours; Saturday, 5 - 8 hours; and Sunday, 5 hours)

APA (American Psychological Association)

California MFTs and LCSWs

Illinois Social Workers, MFTs, and Counselors

Indiana Social Workers, MFTs, and Counselors

NAADAC (National Association of Alcoholism and Drug Abuse Counselors)

NASW Collaborative/Social Workers

Nebraska Social Workers

Pennsylvania Social Workers

The following groups and states have approved the symposium for a maximum total of 29 continuing education hours:  (Thursday, 8 hours; Friday, 5 - 8 hours; Saturday, 5 - 8 hours; and Sunday, 5 hours)

ASWB (Association of Social Work Boards)

Note: the maximum number of CE hours approved by ASWB depends on each state agency

CAADAC (California Association of Alcoholism and Drug Abuse Counselors)

Connecticut MFTs

Florida Social Workers, MFTs, and Counselors

Georgia Social Workers, MFTs, and Counselors

Maryland Professional Counselors

Maryland Social Workers

Massachusetts MFTs

Minnesota MFTs

Missouri Social Workers

NASW Credentialing Center

NBCC (National Board of Certified Counselors)

Nevada MFTs

New Mexico MFTs and Counselors

Ohio Social Workers, Counselors, and MFTs

Oklahoma MFTs and Professional Counselors

Rhode Island MFTs

Texas MFTs

WMHCA (Washington Mental Health Counselors Association)

Wisconsin MFTs

Galleries

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Gallery Symposium Selects (90)

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Gallery 8 - Danish Friends(28)