Please Send My Cat Home: What Our Health Dept. Doesn’t Want You to Know

Bear, on his 15th birthday, one month before his death.

I feel compelled to post this, even though it’s not part of the typical focus of my blog, because the New York State Department of Health (NYSDOH) is trying to keep you–anyone–from reading it. Silencing people’s voices is a behavior I actively challenge, so I feel a need to make a record, here, that can’t be silenced. To my loyal readers: I promise this won’t be a focus of many, many posts. And, as always, feel free to not read anything that doesn’t interest you.

I left a letter/appeal to the NYSDOH on their Facebook Page on Thursday, February 27th; by Friday the 28th they had evidently received enough separate posts, as well as comments on my entry, that the NYSDOH staff turned off their “Posts by Others” pane (the one that allows you to see what people other than NYSDOH staff have posted).

What doesn’t the NYSDOH want you to know about?

Warning–This could be triggering to animal lovers:

Overview of Trauma-Informed Care – Podcast

It just occurred to me that I never posted this interview here. Dr. Jonathan Singer, founder of The Social Work Podcast, was gracious enough to invite me to be interviewed as part of his podcast series:

Trauma-Informed Social Work Practice: What Is It and Why Should We Care?

Over the last 20 years there has been increasing recognition of the role that psychological trauma plays in a wide range of health, mental health and social problems. When people think of trauma, they think about experiences like war and the diagnosis of post-traumatic stress disorder. But the reality is that trauma includes a wide range of situations where people are physically threatened, hurt or violated, or when they witness others in these situations.

Virtual Worlds as Immersive Treatment Settings: The PTSD Sim

One of the advantages of virtual worlds is the ability to created simulated experiences that can help us learn something about experiences other than our own, as well as providing a an opportunity to help us make sense of our own experience. The  Virtual PTSD  (Post-Traumatic Stress Disorder) Sim in Second Life is an example of such a place. I recently went exploring there to check the out the “build.”

Welcome to the Virtual PTSD Experience

The experience starts when you transport into the Sim into a reception area in the Visitor Center. The first thing you see is information about how to reach someone if you are in crisis now. This welcome area also has an information desk (complete with pamphlets) staffed by “Ranger Jane” (a bot) who will answer questions that you ask in chat. In another part of the room, there is  an animated diorama that provides you with an overview of what happens in the simulation. This is important, as it will make the entire encounter more predictable and, therefore, less likely to trigger extreme PTSD symptoms while going through the simulation. There is also an option to transport to a Relaxation Room in the event that you start to feel too anxious. This “room” is actually a choice of several very different relaxation environments (e.g., the beach, outer space) so you can choose the one that fits your needs.

Power & Social Media: Thoughts for Therapists Working with Trauma Survivors

Power and the Mind: Lacking power impairs thinking Writing in Psychological Science, Smith et al (2008) report that when randomly assigned participants are made to feel powerless they become worse at keeping on top of changing information, filtering out irrelevant stuff and planning ahead to get the task done.

I very much appreciated a recent post by Susan Giurleo on The Real Challenge of Health Care Social Media where she talks about the subtle shifts in power in a relationship that comes with health care professionals using social media. Social media requires more of an accessible, collaborative stance and certainly flies a bit in the face of the “mysterious therapy office.”

Social media will challenge therapists to carefully think through and articulate our boundaries for this new medium. That’s not a bad thing. However, as a trauma therapist and a trauma-informed therapist (they are not the same thing!), I am especially intrigued by any medium which helps at all to equalize some of the power differences that occur in therapy.

Trauma-informed practice requires that we examine all aspects of how we organize our services in light of what we know about how trauma affects people. Here’s a definition from The National Center for Trauma-Informed Care:

What is Trauma-Informed Care?

Most individuals seeking public behavioral health services and many other public services, such as homeless and domestic violence services, have histories of physical and sexual abuse and other types of trauma-inducing experiences. These experiences often lead to mental health and co-occurring disorders such as chronic health conditions, substance abuse, eating disorders, and HIV/AIDS, as well as contact with the criminal justice system

When a human service program takes the step to become trauma-informed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.

Trauma, Power & Trauma-Informed Therapy

Understanding power is key to trauma-informed therapy. Most clients who are survivors of childhood trauma were abused by someone with power, someone who should have been trustworthy and then abused that trust.  Therapists are authority figures who you are supposed to be able to trust, a characteristic we share with our clients’ abusers.  Abuse involves the misuse of power–people who have been victimized feel helpless, vulnerable, and powerless. Healing from abuse involves recovering (or achieving for the first time) a sense of our power in the world. For this reason, a trauma-informed approach is based on the assumption that recovery from trauma must include collaboration and empowering clients whenever possible.

So What Does This Have to Do with Social Media?

Extending therapists’ reach into social media requires a level of transparency and accessibility that is a change from the traditional therapeutic model of the therapy room being a space set apart from the world. As Giurleo points out, this is a subtle shift in power dynamics. I hadn’t considered how much a difference this might make until I reflected on a recent conversation with a former client–I’ll call her Ann*. She remarked on the difference in my accessibility compared to more traditional/non-social media using therapists and noted that their limited accessibility made her interactions with them feel slightly “triggering,” that is, evoked some of her trauma-related symptoms. It’s not surprising that experiencing an authority figure/caregiver as inaccessible might evoke feelings of fear or abandonment related to experiences with caregivers from childhood.  Her observation eloquently captures the impact of non-trauma informed practice and how a therapist’s willingness to use social media to enhance collaboration might shift some of those power dynamics. While some therapists might observe that such reactions are transference and provide important grist for therapy, I would point out that I rarely find that there’s a shortage of grist for therapy with people who grew up in abusive environments, and that people need to feel some measure of safety before they will take the risk of a connection with an authority figure after a lifetime of many authority figures who have either failed them or hurt them.

For all of the reasons discussed above, I think that with the proliferation of Web 2.0 in our society the trauma-informed therapist now has to consider moving into the world of social media. If your clients are there, you really need to be there too. If they aren’t there, they probably will be soon.

So How Should a Therapist Use Social Media?

Clearly there need to be boundaries on how this is done to protect confidentiality and to ensure that therapists get enough disconnected time so they can maintain wellness. In my own practice I have not used anything especially innovative, I have used social media/technology in only a few ways: allowing clients to text me information regarding appointment changes or to send me information we might need for an insurance form that they needed to verify at home; on request, reading a client’s blog entry; posting information that I thought might be helpful to clients on my therapy practice blog. I worked out any boundary issues with clients that needed to be addressed in the process of using those tools (“if you’re suicidal call me, do not text or email me anything that is a crisis”). Using these tools in limited ways hardly makes me an expert on all the most effective ways to do this. Fortunately, there are skilled, experienced people to help guide therapists in this process (e.g., see Mike Langlois, LCSW: How to Have a 100% HIPAA Compliant Online Presence, see Susan Giurleo, PhD’s posts social media for therapists), and–here’s a bonus–they, too, can be found in the social media world.

*”Ann” has seen this post and has given me permission to refer to her comments-and she may well decide to read this blog post.

Photo provided courtesy of Will Lion

Mobile Devices in Psychotherapy: Bane or Benefit?

Mobile Devices and Clinical Practice: Unlikely Partners?

Every therapist has probably had the experience of a client’s cell phone ringing in the middle of a session, usually at the most inopportune moments. So it might come as a surprise for some therapists to hear that these devices might actually help with therapy. I think that smartphones and other mobile devices have the potential to enhance therapy in many ways and that we’re only starting to explore these possibilities.

One straightforward example is measuring mood and symptoms with mobile apps. I realize that many therapists don’t use ongoing measures in their therapy practice. However, I have found that using brief, repeated measures provides significant value in my practice. It provides a way to track progress with enough sensitivity to pick up small changes over time–or the lack of changes. It allows the client and I both to quickly assess how the week has gone. And it illuminates patterns in symptoms or growth–when we track these on a graph over time and then note the timing of significant life/therapeutic events, we can learn things together about what might be happening for a client. For example, we might learn than a person’s anxiety symptoms got significantly worse after a schedule disruption or a change in diet. Measurement scales can be standardized, where the scores have meaning in relationship to some clinical and normative data. Or scales can simply be a self-monitoring tool, a scale that helps an individual rate levels of symptoms, but where the scores don’t have any specific meaning related to clinical standards.

So I was particularly excited when I learned of this new application for Android phones developed by the National Center for Telehealth and Technology (T2), T2 Mood Tracker. It has several categories of symptoms to rate: anxiety, depression, general well-being, head injury, post-traumatic stress, stress, and a custom category that will allow users to create their own scales. It also will graph the ratings, allow you to enter a note for a particular date,  and allow the notes to be password protected. It even will allow the user to set reminders to enter a mood rating.

T2 Mood Tracker General Well-Being Scale (Droid X)

While T2 Mood Tracker is not yet available for the iPhone, there are plans for an iPhone app in the first half of 2011. And while I haven’t had a chance to look at it closely, I did notice that there is a different app in the iPhone app store called MoodReporter that also seemed to track symptom levels and allows you to add a brief note.

T2  has also developed an app for the iPhone and Android called Tactical Breather, designed to be “used to gain control over physiological and psychological responses to stress.” This highlights another fruitful area for mobile phone application development: apps to teach specific coping skills, for example, use of soothing imagery and anxiety reduction breath training. I haven’t yet seen any good apps with this type of content–would love to hear of any you have found.

What roles can you see, if any, for mobile devices in psychotherapy?