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Loss
Death of a loved one
Divorce
Loss of job /Loss of Income
Disability
Trauma
Addiction
War
Poverty
Abuse
Difficulties on the Job
The most common psychological and social
stressors in adult life include the breakup of intimate romantic relationships,
death of a family member or friend, economic hardships, racism and
discrimination, poor physical health, and accidental and intentional assaults
on physical safety (Holmes & Rahe, 1967; Lazarus & Folkman, 1984;
Kreiger et al., 1993). Although some stressors are so powerful that they would
evoke significant emotional distress in most otherwise mentally healthy people,
the majority of stressful life events do not invariably trigger mental
disorders. Rather, they are more likely to spawn mental disorders in people who
are vulnerable biologically, socially, and/or psychologically (Lazarus &
Folkman, 1984; Brown & Harris, 1989; Kendler et al., 1995). Understanding
variability among individuals to a stressful life event is a major challenge to
research. Groups at greater statistical risk include women, young and unmarried
people, African Americans, and individuals with lower socioeconomic status
(Ulbrich et al., 1989; McLeod & Kessler,
1990; Turner et al., 1995; Miranda & Green, 1999).
More familiar to many Americans is the chronic strain that poor physical health and relationship problems place on day-to-day well-being. Relationship problems include unsatisfactory intimate relationships; conflicted relationships with parents, siblings, and children; and “falling-out” with coworkers, friends, and neighbors. In mid-adult life, the stress of caretaking for elderly parents also becomes more common.
Relationship problems at least double the risk of developing a mental disorder, although they are less immediately threatening or potentially cataclysmic than divorce or the death of a spouse or child (Brown & Harris, 1989). Finally, cumulative adversity appears to be more potent than stressful events in isolation as a predictor of psychological distress and mental disorders (Turner & Lloyd, 1995).
Each of these complex issues may require a multi-leveled approach to its resolution. Support groups, psychotherapy, grief work and self help techniques and compassion may all be beneficial. Finding a new job in a soft economy, rearranging your life picture to include unforeseen circumstances such as the loss of a loved one, illness or disability, are among any number of stressors in today's world of uncertainty. If your system is 'overamped' , one more minor thing may feel as if it puts you ' over the edge". You may not be able to focus and set priorities. Therapy can help in a number of ways. Unless these losses involve chronic, unresolved pain and grief, (which may indicate a need for longer term psychodynamic work), brief cognitive behavioral therapy may be most effective treatment choice. In combination with self -help, and relaxation techniques, such as meditation or hypnosis, many stress and anxiety related problems can be well managed or eliminated.
Bringing the issues that are causing stress into the 'here and now', the present. can often help the client regain a sense of control and order and lessen the worry. A simple question to focus on is: "What can be done immediately to alleviate the problem?" Often the answer is 'nothing' because the problem cannot be solved until a future date. If that is the case, we focus on relaxing in the moment and preparing for the future event. For example, if a client is facing an impending lay off, your focus may be on supporting them to update their resume and reorganize their bill payments to accommodate this reality. It is important for us to realize that there is only so much you can do about any one thing in the present moment. And the present moment is all you have to work with at any given time. Worry works against you and raises your anxiety level. Help your client
Set Priorities
Focus on one stressor at a time
Teach simple breathing techniques
Access a relaxed state that they can work to increase
Envision the best possible solution
Take small steps towards the goal
Let us turn our attention first towards the individual stressors mentioned
Divorce
Divorce is frequently encountered when treating stress, anxiety and depression symptoms. Approximately one-half of all marriages now end in divorce, and about 30 to 40 percent of those undergoing divorce report a significant increase in symptoms of depression and anxiety (Brown & Harris, 1989). Vulnerability to depression and anxiety is greater among those with a personal history of mental disorders earlier in life and is lessened by strong social support. For many, divorce conveys additional economic adversities and the stress of single parenting. Single mothers face twice the risk of depression as do married mothers (Brown & Moran, 1997). Due to its common occurrence we must guard against taking its impact for granted. The impact of divorce can be long lasting.
First and foremost divorce is a
loss. The stages of loss,
denial, anger, bargaining, depression, and acceptance must be addressed and
accepted as the natural course of healing. The children often experience
this loss most acutely. They are often the ones who will end up living in
two places and being in the middle of the parents' conflict. By far the
best way to avoid this stressful situation has been to have the parent’s move in and out of the
family home and keep the disruption of the kid’s life to a minimum. This is
frequently not the solution. When the child must move back and forth
between parents, give them time and space in each place to adjust. Make
sure each home is welcoming for them and respect that transitions and different
rules and relationships are tough for all of us. The Kids Bill of
Rights is a good guideline to keep a child from having too much pressure in
the middle of the divorce. It is often something we share with families. Please read Kids Bill Of Rights.
Let us state here that we are
addressing divorce in cases where child and spousal abuse are not the primary
issues. Those special cases require a different set of standards and
interventions contingent on individual circumstances. Web sites throughout this
course and the other special issues course address these concerns in greater
depth. Never would we, as therapists, encourage a family to
stay together and negotiate where there is a history and imminent danger to the
spouse or children. Special separate intervention would be mandated for
the violent partner. Please visit www.abanet.org
In the Divorce Handbook it is
clearly stated that divorce has two parts. One is emotional and one is
business. For the business legal advice must be sought. It is helpful
as a therapist to know the laws of your state regarding divorce issues such as
custody and property. Although you will not be advising your client in
these matters, it is helpful to know what they are wrestling with in terms of
these concerns. There is a wealth of information available on the web. Please visit the American Bar Association site.
The parent that is left or the parent who was not actively choosing the divorce is often left with extreme sorrow. Their dreams of how their life was going to be are shattered. Their dreams of the happy couple and family dissolve into illusion. There is often a bitterness and anger that arises. The other parent has often left to pursue a new beginning; whereas, this parent is left often still holding onto what was before. It may take some time for this partner to readjust and refocus his/her energy on him/herself and what is left . There are usually local support groups such as Parents Without Partners or through churches. There are internet chat and support sites. It is important for these folks to stay connected and not isolate themselves with their grief. Encourage their participation and involvement in local events. It will take some time and nothing has to be rushed. It is a whole new identity to be single again. Please visit divorce info .com
Disability
excerpted from Uncharted Waters, Helm-Simpson
Many people will thankfully never have this experience, but for the thousands
of people a year who will deal with this information, it is very important for
the helping professional to try and grasp the impact. The dreams that are
lost are many the parents were not even aware of having until they heard the
news. All kinds of hopes and dreams are attached to births,
childhood and new beginnings. Assumptions are often made that life will
sail along a preset course carefully mapped out using guideposts of established
education, career and job security. The disability can strike like an unseen
boulder rising from below the surface. The once secure map has to be
altered or discarded as doctor and therapy appointments require time from work.
Physical and emotional exhaustion require a spiritual inventory of currently
held values and beliefs and a new search for meaning. We often hear about the
wonderful achievements and accomplishments being made in ever greater numbers
by people with disabilities. In each of these achievements there is often a
grueling 24 hour a day/ 7 days a week schedule for their caretakers. The person
with the disability will struggle with his or her own challenges, thoughts,
hopes and dreams. The siblings will often feel neglected or ignored in the face
of the real demands of the situation. The parent or caretaker will
struggle with all of this plus their own confused feelings and resultant life
impact.
Working with families of
children with disabilities is both challenging and deeply rewarding. Rarely
will you witness the strength of human spirit more indomitable than in these
families as they cope with the impossible schedule and needs of their children,
the grief at not having a typical life and the hope that their child will
overcome the odds before them and not only survive but flourish in their world.
This client situation presents for the therapist a uniquely sensitive arena of
concerns where the impact of our actions and interactions may be magnified due
to the extreme ongoing stress of the situation. The situation of
disability, especially when first recognized, is a situation of loss.
The family and the child depending on age are likely to go through the
stages of a grief process: shock, denial, anger, bargaining, and acceptance.
(Kubler-Ross). It is important for the therapist to recognize and
understand this process. This understanding will go further toward
healing than any other single intervention. In a workshop I attended Ken
Moses appropriately titled this process From Grief to Growth. Families
will move at differing rates from the devastation of the news to often becoming
very empowered. This cycle can repeat many times throughout the life of the
child. As therapists in this field we may see many children struggling and it
is human nature to desire the parents to take a realistic assessment, responsibility
and get on with the therapy of the child. It is crucial to realize that grief
cannot be hurried or forced, that it is a natural and very individual
process. (excerpted from Helm-Simpson, Uncharted Waters, 1999)
Anyone who has
lived in a family where addiction is present knows to an extreme degree about
the nature of anxiety and stress. There
is a constant mental worry about one’s safety, security and stability on every level,
as the unpredictability of the disease progresses through the family’s health
and well being. The only predictable
factors are hurt, betrayal and pain without treatment or intervention.
The Abyss of
Addiction
partially excerpted from Reweaving the Web the Treatment of
Substance Abuse by Phoenix Helm Simpson LMFT and Kate Amatruda MFCC
When addiction is a primary clinical issue it
often can feel as if the family has fallen deep into the abyss. Any
attempts to get out often meet with failure and a deeper falling into
darkness. This makes it one of the most challenging and complicated
issues facing today's clinician. A lack of knowledge
regarding addiction can be time consuming, frustrating and ultimately
destructive in the therapeutic setting. Due to the interwoven symptomology
throughout the body, mind, and spirit, of the addict, our treatment
approach must also be multidimensional and interconnected. Our treatment model
thoroughly addresses each of these in the treatment of the family or
individual.
Currently there is much debate over
whether chemical dependency is genetic or environmental. It is the
intention of this article to introduce the issues of differing opinion and
treatment approaches through our own personal and professional experience to
assist each clinician to develop a broad and compassionate perspective.
Although the use of mind and body altering
substances is documented throughout history, addiction to drugs, alcohol,
people, food or sex appears more prevalent in today's societies. A
standard working definition of addiction is the use of anything that is
compulsive and interferes with the individual's physical, emotional and
spiritual well-being. As clinicians it is our primary responsibility to
discover the role addiction may be playing in the lives of our clients and
treat them with the all encompassing importance they require. The
treatment approach must be multidimensional taking into account the mental,
physical and spiritual well-being of the client and their family when
present. Any less of an approach is highly probable to fail.
Although the prospect can be daunting, there are a myriad of help groups
available worldwide including churches and Twelve Step groups. What we as
clinicians want to avoid is believing our preferred theory and practice of
psychotherapy or counseling is enough to facilitate the recovery of addiction
without actually addressing the addiction itself. Chemically dependent people
have repeatedly shown everyone around them that in spite of their best
intentions and purest will, the mental obsession and physical craving for
their drug or behavior of choice will destroy in days what they have taken
months, years or a lifetime to create. To believe that we, as a single
individual and source of intervention, can counteract such powerful sources is
foolish, misleading and no different from the rest of the well meaning and
beloved individuals who have watched this client's struggle.
We must accept and acknowledge the
power of the disease before us. It is tricky as addiction walks in under
many different guises or symptoms ,e.g.. job dissatisfaction , the inability to
hold a job, loneliness, inadequate relationships, isolation from family and
friends, entitlement, and insecurity. Although the percentage of people
using illicit drugs has dropped significantly in the last twenty years, our
societal attitudes have also changed. This may not for the better as now far
less people perceive drugs as dangerous. In Phoenix's informal poll of young
adult clients the past few years the most frequent age of initial drug use
(85%) was 8. As a clinician Phoenix was shocked since the prevailing
wisdom in treatment says that a person's problem solving abilities stagnate at
the age when use begins due to the choice of getting high superseding the
process of struggling through an issue. It is one thing to work with
adults struggling with issues of adolescence; however, going back to elementary
school problem solving abilities in adult problems presents a monumental task.
Where does this all begin? How do we help
ourselves and our clients navigate these murky waters? Through our own
experience we aim to provide the starting point to understanding and dealing
with addiction in your practice. To wrestle with it in other parts of
your life do not hesitate to make yourself available to the widespread
resources you may also suggest for a client. Many Twelve Step meetings
have open sessions where you do not have to be an addict or alcoholic to
attend. Understanding the journey your client is embarking upon towards
healing is crucial. Denial
is the primary defense in the disease of addiction and coaddiction.
Knowledge and the ability to confront the truth are the ultimate undoing of
denial. It is also important to recognize that recovery is a lifelong
process. (Note the fact that Twelve Step members often refer to
themselves as "recovering".) Addiction is never cured, rather
attended to throughout the life of the individual. visit
the Recovery web site.
From The Surgeon General's Report
The death of a child or spouse during early or mid-adult life is much less common than divorce but generally is of greater potency in provoking emotional distress (Kim & Jacobs, 1995). Rates of diagnosable mental disorders during periods of grief are attenuated by the convention not to diagnose depression during the first 2 months of bereavement (Clayton & Darvish, 1979). In fact, people are generally unlikely to seek professional treatment during bereavement unless the severity of the emotional and behavioral disturbance is incapacitating.
A majority of Americans never will confront the stress of surviving a severe, life-threatening accident or physical assault (e.g., mugging, robbery, rape); however, some segments of the population, particularly urban youths and young adults, have exposure rates as high as 25 to 30 percent (Helzer et al., 1987; Breslau et al., 1991). Life-threatening trauma frequently provokes emotional and behavioral reactions that jeopardize mental health. In the most fully developed form, this syndrome is called post-traumatic stress disorder (DSM-IV), which is described later in this chapter. Women are twice as likely as men to develop post-traumatic stress disorder following exposure to life-threatening trauma (Breslau et al., 1998.)
Past Trauma and Child Sexual Abuse(
From The Surgeon General's Reports)
Severe trauma in childhood may have enduring effects
into adulthood (Browne & Finkelhor, 1986). Past trauma includes sexual and
physical abuse, and parental death, divorce, psychopathology, and substance
abuse (reviewed in Turner & Lloyd, 1995).
Child
sexual abuse is one of the most common stressors, with effects that persist
into adulthood. It disproportionately affects females. Although definitions are
still evolving, child sexual abuse is often defined as forcible touching of
breasts or genitals or forcible intercourse (including anal, oral, or vaginal
sex) before the age of 16 or 18 (Goodman et al., 1997). Epidemiology studies of
adults in varying segments of the community have found that 15 to 33 percent of
females and 13 to 16 percent of males were sexually abused in childhood
(Polusny & Follette, 1995). A recent, large epidemiological study of adults
in the general community found a lower prevalence (12.8 percent for females and
4.3 percent for males); however, the definition of sexual abuse was more
restricted than in past studies (MacMillan et al., 1997). Sexual abuse in childhood
has a mean age of onset estimated at 7 to 9 years of age (Polusny &
Follette, 1995). In over 25 percent of cases of child sexual abuse, the offense
was committed by a parent or parent substitute (Sedlak & Broadhurst, 1996).
The
long-term consequences of past childhood sexual abuse are profound, yet vary in
expression. They range from depression and anxiety to problems with social
functioning and adult interpersonal relationships (Polusny & Follette,
1995). Post-traumatic stress disorder is a common sequela, found in 33 to 86
percent of adult survivors of child sexual abuse (Polusny & Follette,
1995). In a recent review, Weiss et al. (1999) found that sexual abuse was a
specific risk factor for adult-onset depression and twice as many women as men reported
a history of abuse. Other long-term effects include self-destructive behavior,
social isolation, poor sexual adjustment, substance abuse, and increased risk
of revictimization (Browne & Finkelhor, 1986; Briere, 1992).
Very
few treatments specifically for adult survivors of childhood abuse have been
studied in randomized controlled trials (IOM, 1998). Group therapy and
Interpersonal Transaction group therapy were found to be more effective for
female survivors than an experimental control condition that offered a less
appropriate intervention (Alexander et al., 1989, 1991). In the practice
setting, most psychosocial and pharmacological treatments are tailored to the
primary diagnosis, which, as noted above, varies widely and may not attend to
the special needs of those also reporting abuse history.
Child Abuse (excerpted from Exploring the Edge,
Helm- Simpson 1999. )
There are few wounds that reach deeper than those inflicted in
childhood by parents. There is no way to minimize the affect of having an adult,
whom you depend on for survival and support, tease, scream, hit or fondle
you as a child. It cuts into your core and leaves a scar for
life. It is a gross misuse of power in a relationship that depends
upon love, encouragement, attention and support to grow and flourish. Yet
as parenthood is increasingly becoming a one person and divided family
affair, the stress on parents that leads to such aberrant behavior is
increasing rapidly. Approximately 3 million children are reported as
abused in the United States yearly. The leading causes or precipitating
factors are:
1) history of generational abuse
2) alcohol/drug addiction
3) mental illness
4) extreme stress on the family.
In spite of the overwhelming statistics people are more aware of
their behavior whether or not they have self control. Abuse issues
continue to come out of the darkness of silence into the light. As a tree
can heal from its wounds and continue to grow in beauty with the scars of early
trauma adding just one more interesting to their swirled pattern of protection,
people, too, are able to incorporate the early traumas and add depth and
character to their being. Compassion and empathy flourish as wounds are
healed and shared.
In our experience there are certain factors that quicken a
resolution of these issues. If
there was also love and encouragement expressed in the household to towards the
abused child in addition to the maltreatment, there is at least a base to build
upon for healing. If the child was consistently only related to in
a negative way it can be very difficult to heal the split that occurs in these
clients and families. It is very difficult to get over being told you are
worth nothing if you have never had a counterbalance in terms of support and encouragement.
A coach, a teacher, a grandmother an aunt an neighbor, a minister a friend,
anyone of these voices can provide a place of beginning for self esteem and
self worth. Childhood wounds of abuse are often accompanied by ultimatums
of silence. Children are often threatened if they dare reveal their
mistreatment. Symbolic work such as sandtray, art and dream work
can circumvent these edicts and allow the material to emerge and be
healed.
Domestic Violence
from the Surgeon General's Report
Domestic violence is a serious and startlingly
common public health problem with mental health consequences for victims, who
are overwhelmingly female, and for children who witness the violence. Domestic
violence (also known as intimate partner violence) features a pattern of
physical and sexual abuse, psychological abuse with verbal intimidation, and/or
social isolation or deprivation. Estimates are that 8 to 17 percent of women
are victimized annually in the United States (Wilt & Olsen, 1996).
Pinpointing the prevalence is hindered by variations in the way domestic
violence is defined and by problems in detection and underreporting. Women are
often fearful that their reporting of domestic violence will precipitate
retaliation by the batterer, a fear that is not unwarranted (Sisley et al.,
1999).
Victims
of domestic violence are at increased risk for mental health problems and
disorders as well as physical injury and death. Domestic violence is considered
one of the foremost causes of serious injury to women ages 15 to 44, accounting
for about 30 percent of all acute injuries to women seen in emergency
departments (Wilt & Olsen, 1996). According to the U.S. Department of
Justice, females were victims in about 75 percent of the almost 2,000 homicides
between intimates in 1996 (cited in Sisley et al., 1999). The mental health
consequences of domestic violence include depression, anxiety disorders (e.g.,
post-traumatic stress disorder), suicide, eating disorders, and substance abuse
(IOM, 1998; Eisenstat & Bancroft, 1999). Children who witness domestic
violence may suffer acute and long-term emotional disturbances, including
nightmares, depression, learning difficulties, and aggressive behavior.
Children also become at risk for subsequent use of violence against their
dating partners and wives (el-Bayoumi et al., 1998; NRC, 1998; Sisley et al.,
1999).
Discussed in this Brief:
Results of a nationally
representative telephone survey of 8,000 women and
8,000 men about their experiences with rape,
physical assault, and stalking cosponsored by the
National Institute of Justice and the Centers for
Disease Control and Prevention and conducted by
the Center for Policy Research.
Key issues: This study
provides empirical data on the prevalence and incidence of rape, physical assault,
and stalking; the prevalence of male-to-female and female-to-male intimate
partner violence; the prevalence of rape and physical assault among women of
different racial and ethnic backgrounds; the rate of injury among rape and
physical assault victims; and injured victims' use of medical services.
Key findings and policy
implications: Although the survey sampled both women and men, this report
focuses on women's experiences with violence.
Analysis of survey data produced the following
results:
--Using a definition of
physical assault that includes a range of behaviors, from slapping and hitting
to using a gun, the survey found that physical assault is widespread among
American women: 52 percent of
surveyed women said they were physically assaulted as a child by an adult
caretaker and/or as an adult by any type of perpetrator; 1.9
percent of surveyed women said they were physically assaulted in the previous
12 months. Based on these estimates, approximately 1.9 million women are
physically assaulted annually in the United States. More research is needed to
understand the relationship between physical assault experienced in childhood
and physical assault experienced in adulthood.
--Using a definition of
rape that includes forced vaginal, oral, and anal intercourse, the survey found
that rape is a crime committed primarily against youth: 18 percent of women
surveyed said they experienced a completed or attempted rape at some time in
their life and 0.3 percent said they experienced a completed or attempted rape in the previous 12 months. Of the
women who reported being raped at some time in their lives, 22 percent were
under 12 years old and 32 percent were 12 to 17 years old when they were first
raped. Given these findings, research and intervention strategies should focus
on rapes perpetrated against children and adolescents.
--Among women of different
racial and ethnic backgrounds, the difference in the prevalence of reported
rape and physical assault is statistically significant: American Indian/Alaska
Native women were most likely to report rape and physical assault
victimization, while Asian/Pacific Islander women were least likely to report
rape and physical assault victimization. Hispanic women were less likely to
report rape victimization than non-Hispanic women. More research is needed to
determine how much of the difference can be explained by the respondent's
willingness to report information to interviewers and how much by social,
demographic, and environmental factors.
--Women experience significantly
more partner violence than men do: 25 percent of surveyed women, compared with
8 percent of surveyed men, said they were raped and/or physically assaulted by
a current or former spouse, cohabiting partner, or date in their lifetime; 1.5
percent of surveyed women and 0.9 percent of surveyed men said they were raped
and/or physically assaulted by such a perpetrator in the previous 12 months.
According to survey estimates, approximately 1.5 million women and 834,700 men
are raped and/or physically assaulted by an intimate partner annually in the
United States. Because women are also more likely to be injured by intimate
partners, research aimed at understanding and preventing partner violence
against women should be stressed.
--Violence against women
is primarily partner violence: 76 percent of the women who were raped and/or
physically assaulted since age 18 were assaulted by a current or former
husband, cohabiting partner, or date, compared with 18 percent of the men. It
is therefore imperative that strategies for preventing violence against women
should focus on ways of protecting women from risks posed by current and former
intimates.
With such staggering statistics the
clinician is well advised to have support and consultation for dealing with
this issue. As is stated repeatedly domestic violence is a social
problem. We must look for both clinical, physical, legal, social and
spiritual responses to this challenge.
Given the many forms and facets
and stages of spouse abuse, generalizations about counseling are hazardous.
Those women who are currently being battered need physical protection,
advocacy, financial resources, and a reliable support system. Practical
training to assure independent survival is necessary. No single counselor
can provide all the help that is usually needed at the outset. A
successful intervention is multidisciplinary, proactive, and well coordinated.
Survivors who have learned to cope not only with abusive spouses, but with
intimidating bureaucracies are valuable allies. Attorneys who are willing to
help with civil orders on short notice are critical assets. Shelters are often
necessary. Doctors who will document wounds and testify to their findings may
save a life. Police and welfare professionals are now more educated, aware and
specialized. Unfortunately, other obligations frequently intrude. The therapist
or counselor helps initially by opening the door to all of these resources, by
assuring that life threatening issues are appropriately addressed, by deferring
any exploration of self defeating patterns of behavior until safety is achieved
and
a new network has been formed.
Understanding the Victims
of Spousal Abuse, Frank M. Ochberg,
M.D.
Many victims of domestic violence may not voluntarily enter counseling.
Key elements of these relationships is denial,
shame and submission. There is often the feeling on the
part of the victim that they are being punished for something and if they can
just figure out what that "something" is they can make the
situation better. There may be people or support systems in their world
that support that belief. Other persons with an unresolved history of
abuse can still harbor the belief that they did something to deserve it.
If the victim’s support system includes these people there will be support for
this misguided thinking.