1. WHAT IS THE MEANING OF LGBTQIAA?
L – Lesbian, G – Gay, B – Bisexual, T – Transgender, Q – Queer/Questioning, I – Intersex, A – Asexual, A – Ally. Some shorten it to just “LGBT”, others have “LGBTQQIA” opting to separate the categories of Queer and Questioning into distinct parts while eliminating the inclusion of Asexuals. Regardless of the acronym used, people belonging to this population are sexual minorities. Because majority of the world are heterosexuals (attracted to the OPPOSITE sex; for example, a man who is sexually and romantically attracted to a woman), cultural rules of behavior tend to either ostracize or blatantly attack those who do not have heterosexual tendencies. In many countries, being homosexual (attracted to the SAME sex; for example, a man who is sexually and romantically attracted to another man) is still punishable by law and even thought to be deserving of the death penalty. Under many international organizations related to mental health and human rights though, any act of attack against, or devaluation of the worth of members of the LGBTQIAA, constitute discrimination.
To delve more into the terminology, let’s start with the difference between sex and gender: SEX is the physical and biologically-determined part of your overall sexuality. This is seen obviously in the reproductive organs you are born with. GENDER is the social and accompanying psychological understanding of your identity as a sexual person. In almost every known society, there is gender division where women are supposed to act one way while men act another way. Gender is determined socially and culturally. Thus, if you are born with a penis, society expects you to act in one way as opposed to if you are born with a vagina. These expectations are also called GENDER ROLES.
“Lesbian” is actually a slang term for homosexual women. Homosexual women are women who are sexually and romantically attracted to other women. Another term for them is “gay women”. “Lesbian” was taken from the Greek island of Lesbos, and actually technically means anyone who is a resident of that island. It was also where the famous poetess Sappho lived. She was believed to be one of the first women to write love poetry for another woman, however, there have been scholarly challenges to this notion. There are no unifying characteristics such as appearance or manner of behaving among lesbians, just as any sexual minority cannot be generalized as having the same traits. There have been attempts in the past to categorize lesbians as “femme” (feminine acting and looking) and “butch” (masculine acting and looking). However, this limits the many variations of how homosexuality among females can manifest. Females, as a whole, have a more fluid sexual identity compared to men. This means that across the lifespan of a woman, it is more possible for them to shift sexual orientations back and forth. This is NOT a problem or disorder. It is a natural unfolding of discovery of one’s self.
“Gay” is a term usually intended for men who love other men but may be applied to any homosexual population. Nobody really knows how the term came about. Gay men, just like lesbian women, do not have a unifying set of characteristics beyond their attraction to other men. There have been effeminate gay men and masculine gay men, but these categorizations do not apply to everyone in the gay community. There are other men who are termed “MSM” or men who have sex with other men, but consider themselves to be heterosexual. It is not right to judge them as “closeted” gay men or men who are in denial that they are gay. Everyone has the right to discover and explore their own sexualities and to find the most comfortable term to refer to themselves.
“Bisexual” is a term referring to either a man or a woman who has sexual and romantic attractions to BOTH sexes. They are attracted to both men and women. They are quite rare, maybe because they are afraid to declare themselves as bisexuals to others. Historically, they have been the MOST discriminated among the members of the LGBTQIAA. Gay men looked at bisexual men as being “half in the closet”, meaning they were thought to only partially “come out” and were in denial about some parts of themselves. However, numerous studies have explored and confirmed the existence of bisexuality, and it has been said before that the human body is capable of receiving love from, and giving love to, both sexes. Most bisexuals though tend to have a stronger attraction to one sex. For example, while a woman is sexually and romantically attracted to a man, she might choose to establish a relationship instead with a woman for whom she has a stronger connection and attraction.
Lesbians, gays, and bisexuals are terms we give when we are asked about our SEXUAL ORIENTATION. Sexual orientation answers the question, “To which sex are you SEXUALLY and ROMANTICALLY attracted?” When you imagine being in a relationship, or when you imagine making love to a person, do you imagine engaging in such behavior with a man or a woman, or either at different times? This does not mean that you must have had ACTUAL sex. The above question is answered by mere fantasizing. After all, even gay men have experimented and engaged in sex with women, and lesbian women have had sex with men also. Conversely, there are gay and lesbian virgins – they never had sex with either men or women before, but still identify as being gay and lesbian. Sexual orientation is DIFFERENT from sexual behavior. It does not require that you actually committed the sex act. If you want to know more about sexual orientation and where you stand, you can ask your therapist to conduct an assessment called “Klein Sexual Orientation Grid” or the simpler “Kinsey Scale” with a 0 -6 rating of heterosexuality-homosexuality. Although these are available online for free, try NOT to take them by yourself because the more important aspect of the test-taking is the interpretation of the results. Find a well-trained therapist who has trained in sexuality issues. Almost all foreign-trained therapists have had this training because it is mandatory in first-world countries for therapists to know sexuality issues in counseling. Most Philippine-trained therapists did not have Human Sexuality as a mandatory course in their training.
“Transgender” refers to people who are born with one sex but feels they should be of the opposite sex. Simply, a man strongly feels he is trapped in the wrong body, and desires to be a woman. Transgendered individuals usually (but not always) know from very early on (i.e., in childhood) that the bodies with which they were born with are not a fit with their psychological understanding of their selves. Many become suicidal and depressed at the confusion generated, and many have attempted to “correct” this. An extreme example would be a teenage girl attempting to chop off her breasts, or a boy trying to castrate himself. When people around the transgendered individual are not supportive or knowledgeable about how to approach this variant of sexuality, the transgendered individual start to develop a condition called “GENDER DYSPHORIA“, an extreme depression and despair regarding their gender. Now, to clarify, being transgendered is NOT a disorder. But Gender Dysphoria is a disorder. Gender Dysphoria arises if there is no support or education given to the transgendered individual. Being transgendered is a normative variant of healthy sexuality. They are not abnormal, just as any of the sexual minorities are NOT abnormal. Unfortunately, in heavily Catholic Philippines, even many psychologists and therapists are not trained to understand and help transgendered people. Be careful of the credentials of your therapist when dealing with this matter, and if you start to feel uncomfortable with your therapist because of his or her heavy moralizing, find a better therapist. Transgenderism is a term used for GENDER IDENTITY, not sexual orientation.
“Queer” simply refers to any of the sexual minorities who prefer not to label themselves in any way regarding sexual identity or sexual orientation. They are a growing population among the sexual minorities and more studies need to be conducted to get a better understanding of their issues. “Questioning” are those who are in the process of discovery (or re-discovery) regarding their sexuality. They are probably the most open-minded among the sexual minorities, but also the most vulnerable to wrong information. Guides and mentors must be well-trained to interact with and educate them. “Intersex” used to be called “androgynous”, those who are born with both sets of sexual organs. Both sets of sexual organs do not usually fully mature even if the person has reached adulthood. Some opt for surgery, others are fine with their physical selves. Intersex is a physical condition, NOT a category of sexual orientation. “Asexuals” are extremely rare to the point that some scholars believe they do not exist. Asexuals are by definition anyone who does not feel sexually or romantically attracted to anyone else. This does not mean they have no feelings, it just means they theoretically do not feel sexual desire for anyone. Some have theorized that asexuality could be a temporary state after a relational trauma, but more studies need to be undertaken. “Ally” is anyone who is from the sexual majority (in short, heterosexuals), who is helpful and friendly towards sexual minorities. Allies defend the LGBTQIAA community from hateful people, and actively provide acceptance (NOT JUST TOLERANCE), love, and security to LGBTQIAA. Allies can be close friends, parents, and coworkers who actively support the LGBTQIAA. A good organization to start exploring for allies would be the PFLAG, that used to be known as the Parents, Friends, and Family of Lesbians and Gays.
2. ARE LGBTQIAA DIFFERENT FROM THE MAJORITY OF PEOPLE? IS THAT BAD?
LGBTQIAA are considered sexual minorities. This means that their SEXUAL IDENTITIES (who are you as a sexual being? how do you see yourself as a sexual being?), SEXUAL ORIENTATIONS (to whom are you attracted sexually and romantically), and SEXUAL BEHAVIORS (how do you express yourself sexually, not just in the sexual act?) are different from the majority of the population. Majority of people are heterosexual (see above) and have a relatively fixed sense of what they do to express themselves sexually (sexual intercourse, way of dressing, role in a relationship, speech pattern, etc.). For instance, most men and women follow conventional social rules that women wear skirts as a sign of femininity, and men wear pants and suits as signs of masculinity. However, let’s say someone from the Queer or Questioning community decides he wants to wear a skirt. Most heterosexual people around him would immediately have preconceived assumptions that he must be gay, or transgendered, or just plain crazy. These thoughts are called STEREOTYPES, automatic and overly-generalized thoughts without verifying facts and often lead to discrimination. LGBTQIAA have sexual VARIANTS. They are not DEVIANTS. To put it more simply, yes, LGBTQIAA are different. Being different by itself is not necessarily bad.
The notion of LGBTQIAA as”bad” stems from unverified statements that they are mentally disordered or criminal. No scientific research has proven that they are more disordered or criminal than anyone else in the majority of the population. There is NO EVIDENCE that anyone who is a member of this community is “born abnormal”. In fact, in the early 1970’s the American Psychiatric Association removed homosexuality from its list of mental disorders due to lack of evidence that being gay or lesbian is in itself a disorder. The reason why it was listed in the first place was because of the bias that people had before the 70’s (including many doctors and scholars). Their thinking was, “I don’t like gay people, therefore they must be weird and bad.” Just because we don’t like a group of people does not mean we have the right to judge them as evil. It is merely personal preference, not scientific research.
Many LGBTQIAA do develop mental disorders AS A RESULT OF DISCRIMINATION FROM THE MAJORITY OF THE POPULATION. Can you imagine a teenage boy who is struggling with his feelings for another boy in his class, and being told by his parents that if he does not “stop” his homosexual urges, he will be disowned? This happens a lot still all over the world, especially in highly conservative cultures. That boy would most likely develop depression, whose symptoms include suicidal tendencies and self-blame. The boy could also develop a type of phenomenon called “INTERNALIZED HOMOPHOBIA“. This means he would come to hate himself as a gay person. He would think to himself, “Gay people are evil. I am gay, therefore I am evil. I should not exist.” In the worst case scenario, it would lead to one of two paths: suicide or aggressive proselytization. The second path, aggressive proselytization, means that they would start preaching to others how being gay is evil while struggling to contain their own homosexual urges. They becomes “hypocrites” in short. They start to condemn others who are gay, because they think by doing so, it would slowly “erase” their own homosexuality. Unfortunately, homosexuality and the other sexual variants are not something that can be “erased”. It is a naturally occurring expression of who we are. It is not due to being “recruited” into the LGBTQIAA side, or a behavioral anomaly, or brain dysfunction. There is no satisfactory conclusion for those who force others to change.
Let’s clarify the term “internalized homophobia”. Homophobia is actually a misnomer. Homophobia does not involve fear. In fact, homophobia is driven by prejudice, misunderstanding, and hate towards homosexuals. Homophobia has traditionally been thought of as being committed by heterosexuals due to their ignorance of the LGBTQIAA community. If this is “internalized”, this means that a gay person starts to hate himself for being gay. Internalized homophobia is actually self-hate, which ultimately leads to self-destruction.
3. WHAT ARE CONVERSION AND REPARATIVE THERAPIES? IF LGBTQIAA EXPERIENCES ARE NOT DISORDERS, WHY ARE THERE “TREATMENTS” FOR THEM?
In the past, people believed LGBTQIAA members were mentally disordered and should be treated. In many countries today, homosexuality is still considered to be a personality disorder. There have been reports that gay people are deliberately prevented from serving mandatory military service or entering the clergy because they are viewed as mentally “sick”. Most of the people who had this mindset were religious conservatives, predominantly from the Abrahamic religious traditions (i.e., Christianity, Islam, and Judaism) but a considerable number from Asia from the Confucian tradition. They started to develop “treatments” called “conversion therapy” (to “convert” the homosexual person back into a heterosexual one), and reparative therapies (to “repair” their sexualities, as if being homosexual meant that you were “broken”). They are actually similar in techniques which look like torture from a third-party perspective. Treatments included electro-shock, submerging in freezing water, and military-like physical labor. Unfortunately, when real scientists started to investigate and research on these so-called “treatments”, they found these therapies actually did more harm than good! Many who completed the program committed suicide. Others were committed into psychiatric institutions not long after finishing their conversion and reparative treatments due to heightened depression and anxiety. These therapies are called “iatrogenic” treatments, they create problems instead of solving them. ALL MAJOR MENTAL HEALTH ORGANIZATIONS AROUND THE WORLD HAVE BANNED THE USE OF THESE SO-CALLED “THERAPIES”. ANY THERAPIST USING THESE WOULD BE LABELED UNETHICAL. Unfortunately, the Philippines still see many religious and spiritual counselors (mostly priests, nuns, and pastors) using principles derived from conversion and reparative therapies to “counsel” LGBTQIAA into “returning back to God”. There have been psychologists in the Philippines who blatantly expressed their views against homosexuality in the media and in national conferences, stating that homosexuality is a disorder and proposed the return of conversion and reparative therapies. As a reader, please understand that these “therapies” are extremely harmful and have led to the loss of life.
4. WHAT SHOULD A LOVED ONE OR A FRIEND OF AN LGBTQIAA INDIVIDUAL DO?
LISTEN. That is the single most important thing you can do as a parent, family member, significant other, or friend of a member of the LGBTQIAA. Listen without judgment. Do not give half-baked advice. Do not moralize or bring religion into the picture. Keep your opinions to yourself. Ask questions if you don’t understand something, but ask without sarcasm. For example, for those with loved ones who are transgendered, you could ask them how they would like to be called. Pronouns are very important for transgendered people. Offer whatever support and help you are willing to provide. If you feel that you cannot provide the support or help they need, then take the time to tell them you need to do more research. Read up on LGBTQIAA issues, watch documentaries (but not Hollywood movies or t.v. series with LGBTQIAA characters), consult with well-trained therapists or psychology professors in universities (preferrably sending emails to professors in the US, UK, Australia, or other more accepting countries where research on LGBTQIAA is progressing very well).
There is a reason why your LGBTQIAA loved one went to YOU instead of another friend, or family member. It is very hard for someone in this population to open up to loved ones. Imagine the anxiety and uncertainty they feel while they plan on who to talk to, what to talk about, and how you are going to react. What if you react negatively? Who will they turn to next? Do they even have a plan on what to do if you push them away? Try your best to understand, and match the effort of your LGBTQIAA loved one in opening up to you. Put your biases and socially-conditioned “learnings” (or more accurately, “mislearnings”) about the LGBTQIAA away for awhile, and be open to more accurate information. If your loved one is confused and you see the signs of internalized homophobia, you may encourage them to talk to a well-trained therapist. Offer to help them look for one, and offer to go with them to their first session. You could also accompany them in their own personal research about their sexuality. Support is very important. Instead of tolerating, ACCEPT instead. If you are not ready to accept, give yourself some time to study and reflect on this issue.
Our sexuality is part of our whole being. YOU CANNOT SEPARATE SEXUAL IDENTITY FROM A PERSON’S TOTAL IDENTITY. You cannot say, “I will accept you IF you are no longer gay”, or “I will accept you if you don’t act like a lesbian”. These conditions limit the identity expression of your loved one. It does not value who they are totally as individuals worthy of love, no matter who they are. If you are not willing to learn or reflect on this issue, then at the very least, do not criticize or harm the self-esteem of the members of this community. They are people, just like you, with hopes and dreams and imperfections. They also have the right to be themselves just as you have the right to your opinions. If you cannot accept, then just stand aside and walk your own path. Do not attempt to convert. Do not attempt to change them “out of love”, because if you really loved them, you would take the time to put down your stereotypes and prejudices to see them with eyes that value their uniqueness. Do not pity them. Pity and sympathy are for those whom you feel are inferior than you, who are more unfortunate than you. Pity is not love, pity is not acceptance. Do not say, “I’m so sorry your son is gay” to a parent. Do not say, “I’m sorry to hear that you’re bisexual. It must be hard.” For all you know, those who made the excruciating effort to find the path of acceptance and love have learned to celebrate differences instead of being imprisoned in a conservative mindset.
I’m not saying it will be an easy path for you as the parent, family member, or friend of someone who is LGBTQIAA. It forces you to challenge almost everything you know about people, life, love, and the world in general. But try your best to examine your biases, your so-called “truths”. Where did you receive messages about hating other people? Is it worth it to keep these messages? Is it worth it for you lose your loved one over these inaccurate messages? Along the way, you will stumble and wish to give up. But get up and try again anyway. Your loved one is still your loved one. Nothing has changed about him or her.
5. WHAT SHOULD SOMEONE WHO IS LGBTQIAA DO IN TALKING TO THEIR LOVED ONES?
If you are LGBTQIAA, first and foremost, be safe. Not all families and households have open minds. Despite popular media stating that violence against LGBTQIAA is decreasing, there are still reported hate crimes. Majority of these hate crimes are perpetuated in the neighborhood and families of LGBTQIAA. In the Asian perspective, because family honor and reputation is so valued, parents have gone so far as to beat their children to within an inch of their lives. LGBTQIAA children and teens have been kicked out and disowned. Some families even attempted to murder them. So, rule number one is: BE SAFE. Tell a very trusted friend who is an ally what your plan is, and in case something should happen, you can at least run to your friend for help and support. One very positive thing about the LGBTQIAA is that it is a very tightly knit supportive community. There are a number of LGBTQIAA organizations in the Philippines and abroad with international memberships, but it takes some time to go through them and decide which organization serves your needs best. LGBTQIAA also often create very strong “FAMILIES OF CHOICE“, a family that they create out of very close friends, confidants, and close relatives who are allies and support them for being who they are. Most often, families of choice are stronger than biological families of LGBTQIAA. Run to your families of choice for help if you feel unsafe in your own home. The process of telling your parents and family for the first time regarding your LGBTQIAA identity can be extremely daunting. This is often called “coming-out“, a slang term for getting out of a dark place into one potentially of light. If you can, have someone who can support you to accompany you. It could be a close friend or supportive family member who can defend you if things don’t turn out the way you planned. If you feel you’re not ready, don’t force yourself to come-out! Do not ever be forced into coming-out especially if it is not safe to do so. Many movies mistakenly give the message to LGBTQIAA youths that coming-out is the most important thing that they MUST do. This is simply very short-sighted. There are youths who have never come-out to their families and still live happily and comfortably with them. ALWAYS LOOK AT THE CONTEXT before judging. If you can, talk to a therapist or close confidant to help you weigh things in coming-out.
Secondly, plan what you are going to say. Only you know best how your family and friends will react. Plan for it. Have someone help you in creating the right words and how to say it properly. Part of this step is to plan for contingencies in case things don’t go the way you want. What will you do if your father or mother becomes angry? What if they force you to “change”? What would happen next if they just stay silent and stare at you?
Thirdly, do not expect anything grand or extremely positive. Media portrayals of successful coming-out are actually not reflective of actual coming-0ut processes, especially in Asia. You will only be disappointed if you set “Hollywood-type” expectations. Remember that your parents and family may not understand fully what LGBTQIAA is, and may have grown up on wrong information. Be prepared to educate them, which means you have to educate yourself first. Do not force them to accept who you are. For some parents especially, it may take quite a bit of time for them to even attempt to sort through the confusion. If you force acceptance, then it’s not acceptance. Acceptance has to be given freely for it to have any value.
Fourthly, do a lot of research. Self-study, interviews, observations can be very empowering. With every bit of knowledge you obtain about your sexual identity, you gain more power over who you are and build on that confidence into a better way of looking at the world and interacting with it. Remember also that just as there are many good sources of information online, there are also a lot of misinformation. Sort through them diligently, and ask for help from someone who has more knowledge than you on that subject. It would help to talk to an LGBTQIAA mentor, friend, or therapist if you have questions about a particular area of your research. Learn to critique your own researches. Do not swallow any information without understanding and comparing it to other information.
Finally, take some time to reflect on your researches and studies. Your mind might need some time to integrate the information to form a unique perspective of yourself, the world, and of others. It is a very spiritual experience, and you can emerge from it with a coherent sense of self that can stand against whatever the world throws at you. Remember also that the only way others can bring you down is if you allow it.
In recent times here in the Philippines, the word “trauma” has been thrown about a lot. Sometimes, these so-called “traumatic” incidents and their aftermath do not warrant that label. One sees a lot of misappropriated labeling in the media and even among government agencies who are not particularly sensitive to what that term means in the Disaster Mental Health (DMH) world.
“Trauma”, in its most general form, is the collection of experiences (thoughts, feelings, and behaviors) that occurs as a response when one is overwhelmed after being exposed to a horrifying and atypical (which means that this is not seen in day-to-day, normal living) experience. Usually, only 10 to 20 percent of people exposed to traumatic situations actually develop problems later on. Majority of people exposed to trauma are able to cope and use various strategies of resilience to move forward with their lives without complications. For those 10 to 20 percent though, they may develop trauma symptoms manifesting through generalized thoughts about the world (“the world is unsafe!”) or oneself (“I was a coward! I could have done something about it!”); difficulty concentrating and focusing; repetitive feelings of anxiety, distress, and irritability; avoidance behaviors; high startle response (easily surprised and quick to retaliate aggressively); and hypervigilance (always on guard) that may interrupt sleep and rest. Collectively these symptoms may meet the criteria for a diagnosis called “Posttraumatic Stress Disorder” or PTSD.
WARNING: Only a qualified clinical psychologist or psychiatrist can diagnose PTSD. Do not diagnose yourself or your loved ones just by reading some articles on the internet or some books you bought! Self-diagnosis is a very dangerous act that can heighten anxiety and create numerous psychological concerns that can complicate whatever problems you or your loved ones may already have.
MISCONCEPTIONS OF TRAUMA
There are many misconceptions about trauma that are being perpetuated not only by non-mental health personnel (such as the media) but also by half-trained or poorly trained mental health professionals themselves! Below are some of these outdated and/or outright false information:
1. Trauma is said to occur when one’s self-esteem is damaged. This is false. Self-esteem is a separate concept from trauma, and damage to self-esteem is not recognized as an essential symptom of a traumatic experience. Low self-esteem may have existed beforehand and may predispose people to think more badly about themselves after a traumatic event, but this is not one of the primary things that clinicians watch out for. A good example for this is when the media reports about students being “traumatized” by teachers shouting at them or punishing them. This is not trauma. The students may have felt embarrassed or ashamed, but this does not constitute trauma. If parents and other adults encourage the belief in students that they were “wronged” or were “traumatized”, these students will grow up developing a vengeance mentality (“if I don’t like something, I can always claim that I was disturbed, distressed, or traumatized by something I don’t like. Therefore, I will not be forced to do or be exposed to that thing.”) and poor resiliency. However, none of these are enough to state there was trauma involved.
2. Trauma occurs if one is exposed to death. This is partly true. PTSD requires that a person witness, directly experience, or learn of something violent happening to a significant loved one. These experiences are required to be repetitive exposures to situations that involve not only death but a threat to one’s bodily integrity (for example, high chance of having your arms or hands blown off or cut off) resulting in disability, a threat of being killed or threat of loved ones being killed, and loss of freedom and quality of life (such as being held captive by terrorists). Examples of traumatic experiences are being kidnapped, being caught in the middle of a war, and struggling amidst a natural disaster such as the recent typhoon and earthquakes in the Philippines. Having a terminal illness is not considered trauma. Being shouted at by a superior such as a teacher or a boss is not considered trauma.
3. Traumatic experiences must be repetitive to qualify for PTSD. This is partly true. In diagnosing for PTSD, it is one of the requirements that the person have repetitive exposure. However, there are many different types of traumatic situations. In recent researches, some situations such as military being deployed to war zones need only one situation of highly traumatic quality to create trauma symptoms. A clinician properly trained in Trauma Psychology and Disaster Mental Health has the appropriate skill and clinical judgment to determine if there is a need for a PTSD diagnosis. If you are unsure of your clinician’s credentials, always ask. This is necessary because different situations of trauma (example, natural disasters versus war versus sexual abuse) require different sets of knowledge and skills.
4. Debriefing is needed immediately after trauma. This is false. The American Red Cross along with other organizations such as the American Psychological Association have deemed debriefing to be potentially harmful and does not have substantial research support. Debriefing has been found in many cases to actually CREATE trauma symptoms in individuals who participated in these activities. To be fair though, the original purpose of Critical Incident Stress Debriefing (CISD, the original term for debriefing) was to prevent traumatic symptoms from occurring in first-responders (for example, police, firefighters, paramedics, military who are the first to arrive in the scene of disasters). CISD was NEVER intended to be used on trauma victims themselves! Unfortunately, the mental health world in the Philippines is not up to date or very accurate in its understanding of Trauma Psychology despite the fact that this country experiences a lot of natural disasters.
5. Art Therapy is best for children experiencing trauma. This is partly true. Art Therapy has been shown to be effective in treating not only children, but also the elderly and adults, after experiencing heavy trauma. For instance, refugees from Southeast Asia have lowered chances of developing PTSD after escaping war and terror in their countries if they are exposed to and interact with religious iconography (such as Buddhist art and statuary in temples). Art Therapy works by giving a voice to something chaotic or formless, allowing victims to give shape and structure to their experiences without having to narrate what happened to them in words. Sometimes, there are just no words strong enough to express all the anger, hate, loathing, and despair these victims felt. Art provides an outlet for all these emotions since art does not require words, mainly because art is tied to the pre-verbal expressions part of our brains (those parts that allow us to communicate even before we learned words as children). However, whether or not Art Therapy is “the best” method is dubious. Strictly speaking, cognitive-behavioral methods of therapy are still the golden standard for treating trauma. Also, there is the issue of training. It is very, VERY difficult to find someone who has been trained properly in Art Therapy in the Philippines. Art Therapy is a separate field of mental health and requires board certification with the American Art Therapy Association. Most people in the Philippines who claim to practice Art Therapy either only took up one introductory class in it, or only read books about it without being supervised or had hands-on training. Art Therapy has many dangers, one of which is opening up deeply rooted memories which can cause nervous breakdowns. Foremost in my training regarding Art Therapy is the warning that unless one has been subjected to formal training and certification in Art Therapy, do not claim to be an Art Therapist. Certain interventions using art are allowable so long as there is research support for it and one does not claim to be an Art Therapist (which is a regulated label and profession). Lastly, what passes for “Art Therapy” with children-victims of trauma is basically just a drawing session. Children are just asked to draw, without any further intervention. This is NOT Art Therapy. Again, when in doubt, always research the credentials of your mental health professional.
6. Treatment must follow quickly for trauma victims. This is false. First and foremost: Safety is always the number one priority. Victims must be placed in secure, hygienic, and safe areas/camps that have an orderly, military-like structure to prevent chaos in service delivery. People need to be reconnected to family members and loved ones. People need to know what will happen next and what to do next to get their lives back on track. These are goals for Psychological First Aid (PFA) which is not classified as “treatment”. These are practical procedures to kick-start victims’ own natural coping skills and resiliency. Second: For those who require treatment (note: part of the work of PFA is to assess those who may need extra help and who are at risk for developing PTSD), interventions can ONLY start AFTER the traumatic incident. NO treatment will be successful if the traumatic incident is still ongoing or recurrent. As an example, any psychological treatment was contraindicated during the Cebu earthquakes as even the government could not predict when the next quakes are going to happen or even if there are other quakes coming. Any treatment provided during uncertain times will be wiped out or invalidated by re-traumatization. Third: treatment for trauma cannot occur when a victim is either suicidal or homicidal (harm to self or harm to others). These must be addressed first before treatment for trauma can occur. Therefore, as noted here, there are many conditions that must be met first before psychological TREATMENT occurs. However, certain NON-TREATMENT procedures can be applied right after trauma such as PFA or a type of psychoeducational coping called diffusing (which can take place hours after the original trauma).
As trauma becomes more and more a household term in the Philippines, be sure to do thorough research to avoid misinformation and confusion. Ask your mental health professional (for a list, go to my Referral Network at the right-hand side of this site) if you have any questions regarding trauma, its symptoms, or general information which you think might benefit you or your loved ones.
The ability to give birth is both a miraculous and fear-inducing experience for many women. Many cultures insist that the worth of a woman is in her ability to give birth, to produce children so that the family can move forward in time. However, while media and social pressure keep on persuading our women that childbirth is the most wonderful thing in the world, childbirth can be quite horrifying especially for first-time mothers. Childbirth can even spell the difference between life and death as many women around the world continue to die in childbirth. The pain that women suffer in childbirth can also be off-putting to many women. Labor pains can last many hours, and complications during delivery are well-known. In many cultures, pregnant women live in a state of anxiety about the gender of their babies. The pressure to produce sons in many Asian cultures, for example, can lead to family and personal conflict. In India and China, women continue to abort female fetuses, preferring male children for economic and status reasons. Women might even feel the loss of control over their own bodies since motherhood is deemed by their culture as the ONLY path that women are allowed to take. There was a beauty queen who won the title of Miss Universe some years ago who declared that “the essence of a woman” was to be a mother. That is quite unfair and untrue. Being a woman is more than being a mother. There are many women who are infertile or who have decided to abort their babies who face discrimination. And yet, they are women who have as much worth as any other woman in the world. Their stories become lost in a world where people deem them as “deviant”. In the field of psychotherapy, we as mental health professionals do not judge. We do not moralize. Instead, we listen to those lost stories and offer healing and comfort to these women.
Infertility and abortion are major topics in themselves in the field of psychology. We know them as powerful issues that impact not only the woman but also her significant other and her family. But what happens to those women who are able to give birth but still feel somewhat sad and uncertain? Many people would label them as ungrateful. Some might say, “What is there for you to be sad about? You are lucky to be a mother! Stop your theatrics and be grateful.” This is an example of an insensitive comment that comes not from strangers but from the family members of many women who suffer from a family of mental health conditions called “Perinatal disorders”.
The term “perinatal disorders” is quite modern. In the past, they were known as “postpartum disorders”. “Post-partum” means “after childbirth”, therefore these disorders are said to occur AFTER a woman has given birth to a child. But more recent researches have shown that the symptoms of many so-called “postpartum” disorders actually occurred BEFORE childbirth. In simpler terms, the disorders began while the woman was still pregnant. Thus, the term “postpartum” is inaccurate. “Perinatal” was elected as a replacement, being more accurate as it means the period of time both just before and right after giving birth.
A serious consideration has to be given also to the fact that fields of healing such as medicine and mental health have traditionally been dominated by men. We have only relatively recently started to focus on the unique health states and functioning of women. Even if an Obstetrician-Gynecologist (OBGYN) is a woman, she is still trained in a predominantly androcentric (male-oriented) medical model. As patients, women with perinatal conditions should make it a point to ask questions if they are unsure of their health professional’s training and continuing education in this sub-field.
Used to be called “postpartum depression” or PPD, Perinatal Depression is NOT the same as the so-called “baby blues”. Perinatal Depression is a full-blown depressive disorder acknowledged in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; the primary diagnostic manual of mental health professionals) as “Major Depressive Disorder, with perinatal onset”. Women with this disorder often present with high levels of sadness, concentration difficulties, fatigue, low self-worth, sleep problems and a difficulty in maintaining self-care and routine. For example, many women forget to shower and even eat. Some forget to feed their babies or change their diapers. Women who have had past depression diagnoses or have relatives diagnosed with mood disorders are more susceptible to developing Perinatal Depression. Women with Perinatal Depression have feelings of disconnection with others, including their babies, and this bothers them so much that they could not bear to be near their babies. Women with Perinatal Depression DO NOT hurt their babies. Instead, they tend to be suicidal.
Especially for first-time mothers, the arrival of their first child changes everything, not just their routine. The new mother’s loyalty is split between her child and her significant other/spouse. Also, her role as a new mother changes her relationship to the extended family. The woman’s parents now become grandparents, and her siblings now become aunts and uncles. Depending on the functionality and health of the family before the baby arrived, these changes can be both daunting and exciting.
Most often, women will not seek mental health help for Perinatal Depression. The reasons are: they are told it is normal for mothers to feel just a bit sad or “under the weather” after giving birth (FACT: not really), society tells them they SHOULD feel happy and grateful that they are now a mother and that it is selfish to feel anything negative, and the fear that they may be labeled as “crazy” for having certain thoughts and feelings. Regardless of situation, any woman who has just recently given birth, whether or not they have Perinatal Depression, needs support as a child changes the structure and dynamics of family and couple systems.
The so-called “baby blues” is a layman’s term for a period of “normal” sadness and fatigue after childbirth. It is said to be felt by 80% of women and will dissipate about 2 to 3 weeks after birth. However, these are warning signs that the woman is feeling overwhelmed. Before the “baby blues” can progress into full-blown depression, mental health professionals advise seeking help immediately.
Perinatal/Postpartum Obsessive-Compulsive Disorder
Also called PPOCD, this condition affects about 3 to 5% of women. Women with PPOCD exhibit uncertainty and insecurity revolving around the safety of their babies. They have very bizarre images of their babies getting hurt such that they no longer approach their babies for fear of hurting them. Unlike Perinatal Depression, sadness is not their primary symptom, but the bizarre thoughts and images of their babies getting hurt. They attempt to stop these bizarre images by constantly checking to see if their babies are still breathing. These women constantly worry and are aware that these thoughts and images are irrational which makes them more anxious. Women with PPOCD DO NOT hurt their babies and do not need to be hospitalized.
Women with PPOCD tend to have a family history of anxiety and/or mood disorders, and the risk for developing this condition rises especially if they have a perfectionistic personality (highly responsible, high morals and values, meticulous). Biochemical disturbances have been found in their serotonin system as well as a brain malfunction in the striatum (putamen and caudate nucleus areas specifically) region which governs repetitive thoughts and behaviors.
Also called PPP, this is the rarest of the perinatal disorders. These women DO hurt their babies and are a threat to themselves and others. However, infanticide (killing their babies) is quite rare. They need to be hospitalized. These women lose touch with reality and are not aware that they are already causing distress in others. They also show high levels of suicidality and even after treatment, they tend to relapse. An interesting thing about women with PPP is that they have high religious thought content which leads them to act out in dangerous ways. For example, a woman exclaimed that her baby was Satan and so she needed to “baptize” (submerging her baby in a bathtub filled with water for lengthened periods) him to save his soul.
Things to consider in seeking help
In the Philippines, it is always advisable to check and countercheck the training and professionalism of the mental health professional who provides treatment and diagnosis services. Most mental health professionals (counselors, therapists, and even psychiatrists) do not have specialty training in perinatal disorders. If necessary, second opinions are highly recommended. It is NOT ADVISABLE TO DO PERSONAL RESEARCH ON THE INTERNET without consulting with a therapist trained to diagnose and treat perinatal mental health disorders.
Mindfulness and Cognitive-Behavioral Therapy have proven to be successful in treating Perinatal Disorders. It is also wise to consider couples therapy or family therapy since there is a subsequent change in the relationships of each member of the family with the arrival of a baby, especially if it is the first child of the couple. Family therapy may even be necessary for adjustment and coping if the child is born to “non-traditional” households or unique circumstances (such as the baby being born to a single mother, being born after a series of miscarriages, the mother had abortion before, the mother is not in good terms with either her own parents or in-laws, loss of the mother’s parents around the time of childbirth, or the baby being born to a woman nearing or already at menopausal age). Couples therapy may also be needed if the spouse is showing odd behaviors and symptoms. Fathers have been known to exhibit paternal perinatal mood disorders independent of their wives’ condition.
In terms of medication, a type of medication called selective serotonin reuptake inhibitors (SSRIs) used to treat depression has been found to take 10 weeks for it to work in treating PPOCD. In other words, no change or benefit can be seen for 10 weeks while taking the drug daily. A medication called Zoloft if taken in 50 mg dose over 1 year by a pregnant woman has been found to pose no risk to infants while in the womb. Babies have been found to absorb only 1 mg of the medication, but more studies need to be made to be sure. Another medication called Depakote has been shown to cause cleft palate in kids when taken by a pregnant woman. Pregnant women should not take Lithium, a drug often given for Bipolar Disorder. Lithium stays in the breastmilk of breastfeeding women and is highly toxic for infants. Pregnant women thinking of taking psychiatric drugs should talk to both their mental health professional and physician to balance the pros and cons of ingesting substances while pregnant. Breastfeeding moms should also do the same. The act of breastfeeding aids in attachment, and stopping it suddenly can cause hormonal imbalance. Also, research has found that it is worse for the mom to be depressed than for a baby to absorb a small amount of the medication either in utero or through breastmilk.
When your child is being referred for psychological testing, there are some things you – as a parent or guardian – need to know. For starters, what is “psychological testing”?
Psychological testing is a process of objectively identifying and rating certain psychological factors (for example, intelligence and personality) about a person. Psychological testing requires the administration of test materials/instruments, which are commonly questionnaires and answer sheets. Some psychological tests are in the form of tasks. For example, as part of an IQ test, the child may be presented with blocks and told to form the figure on a given picture. Lastly, psychological testing is part of a bigger process called Psychological Assessment. Not all assessments require the use of tests, but all types of testing fall under assessment.
This is the first phase of all assessment and testing. Majority of mental health professionals fail to consider this most important part of the testing process. Basically, this phase asks the following questions:
1. Who is the client or the TESTEE? – this question identifies who exactly is going to take the test. This question must be asked despite its seemingly simplistic nature because each type of population has unique testing needs. For example, children cannot tolerate lengthy periods of test-taking. They easily get bored and tired. Therefore, tests that stretch beyond one to two hours would slowly lose accuracy in measuring the psychological factors needed. Some IQ tests and personality tests are extremely long, so as time passes and the child loses interest, how sure are you that the test still measures the intelligence or personality of the child? Children are also extremely sensitive to new environments.
2. Why is testing needed? – this is the referral question. The answer to this question must be extremely specific. There is no psychological test in existence that covers all psychological factors. For instance, it is NOT appropriate just to say “to know the IQ of my child”. An IQ test will give you numbers. The interpreter of the results must know why you need to know the IQ results in order to provide you with a specific explanation that is also accurate. Is the IQ for admission to a school? Is the IQ test used to check for Mental Retardation or other special needs? Is the IQ requested by a professional? An example of a specific referral question is: “to determine the presence of a suspected Reading Disorder in the child.” Thus, the administrator would know which test to use, and the interpreter of the result would know how to form the report afterwards.
3. For whom are the results intended for? – is there a professional (for example, a pediatrician) who requested the test results? Ideally, results are immediately sent to the requesting professional without passing through your hands. All psychological test results are numerical in nature. They don’t have inherent meaning until read by a trained professional who understands what that number represents. Be careful! Many claim to understand how to interpret tests but all they do is read the test manual and just copy it! A competent provider of psychological tests must have undergone specific training by the publishers of psychological tests. Many so-called mental health “professionals” here in the Philippines often misuse tests. For example, there are many self-claimed “psychologists” who use personality tests to diagnose personality disorders in their clients. This is a misuse of personality tests since personality tests were never created to be diagnostic of personality disorders. Personality tests merely provide you with a personality profile, without judgment. If a test is misused, the results are invalid. Remember to take note of who specifically is requesting the psychological testing of your child. Only mental health professionals and specially-trained physicians can understand the value and purpose of psychological tests. Also remember: psychological test results are CONFIDENTIAL. That means they must not be revealed to any non-professional. If you suspect that your child’s psychological test result has been leaked to other people not involved in the treatment of your child’s issues, you must immediately file a complaint of unethical conduct of that “professional’s” supervisor/boss/employing institution.
The pre-assessment phase also includes informing you as the parent regarding what tests to use. The mental health professional assigned to your child’s case MUST explain what each test is for and why they chose that specific test. There are hundreds of psychological tests. It is a sign of good training if the mental health professional can specifically describe why a particular test will be used as opposed to other tests of the same type. It would also be good if you as a parent can do your own research into what tests are normally used for the types of conditions your child is being tested for.
Many psychological testing companies will try to convince you that they have a cheap “package” of tests that they commonly give to all their clients. DO NOT ACCEPT! No professional will give the same types of tests to all clients! Some of the tests in that “package” are outmoded, others are irrelevant to the referral question. You end up paying between 5 thousand to 10 thousand pesos. Do not be shy or scared in questioning the employees of test companies. If you find that they are losing their patience, that merely indicates that they are not well-trained and you would be better off finding other companies. It’s your money, and more importantly, it’s your child’s mental health at stake. You deserve professionals who have kept themselves updated and abreast of all the recent happenings in the field of psychological assessment.
When you go to a neurodevelopmental pediatrician, most often he or she will tell you to have your child psychologically tested. Many of these doctors already have a “deal” with one or two testing companies. They refer to each other. For example, a parent was told by a neurodevelopmental pediatrician to go to Company A for testing. Company A charged the parent 10 thousand pesos for tests which were irrelevant to the referral question. The referral question itself was not explicated, and the doctor did not explain the need for testing or what tests to expect (as a rule, physicians do not explain in detail or to the patient’s satisfaction regarding assessment, diagnosis, and treatment. It is your right as a patient to ask for a fuller explanation from medical professionals). After researching the tests that were proposed, she found out NONE of them were important and useful in answering the main issue. But the parent had no choice. The doctor would not accept results from any other company or professional providing psychological tests. In cases like these, I strongly recommend you go to more reputable hospitals and seek out more reputable doctors in bigger cities like Manila or even abroad. It’s not worth the savings if your child has been misdiagnosed and you realized it too late.
The rules for testing kids are: interview with parent/s, interview with the child, ONLY two tests maximum are to be given at any one time, the kids must be given breaks in between testing, kids cannot sustain a whole day of testing. Be aware also that questionnaire-answer sheet types of tests have been found to be relatively ineffective with younger kids. Also, many art-related tests such as Draw-A-Person or House-Tree-Person lack validity (does the test actually measure what it is supposed to measure?) and reliability (does the test produce consistent results over time instead of changing drastically?). Some tests are not indicated for children, but unscrupulous “professionals” continue to use them. Other tests have child-versions which are shorter and easier to understand. Ask the company if there are child versions of the tests they are proposing to give to your child or do your own research. If you don’t understand some terms or concepts, ask your mental health professionals. Most physicians are poor in psychological testing, and lack the ability to explain them properly.
During the assessment, try to stay in the waiting room while your child is taking the test. The child would be nervous and need reassurance you are there waiting. You will not be allowed to peek at your child. The room where your child will be taking the test must be clean and organized, without toys lying around as distractions. If there is a one-way mirror in the room, make sure to ask what it is for. As a rule, one-way mirrors can only be used to train future professionals in how to perform procedures. They are not to be used for parents looking in and checking up on their children, nor are they to be used for curiosity. Be prepared with water and other snacks for your child after the testing. Most importantly, do not forget to ask when you can obtain the psychometric report. The psychometric report is the output of the testing process. It is a formal report addressed to the one who requested for the psychological testing (see Pre-assessment phase questions). If a professional has requested it, you may request your own copy but don’t be surprised if the language is something you can’t understand. You may ask your mental health professional to explain the report to you if you don’t understand it. A psychometric report is usually accomplished after 3 to 5 days depending on the complexity of the tests provided. Some tests have very complicated scoring systems. If you do not get the report after a week, it’s time to be suspicious. Is the interpreter and report-maker (usually a guidance counselor or a psychometrician) too busy with too much caseload? If that is the case, how sure are you that your report will be accurately and carefully written, and not just haphazardly done? It is part of the training of mental health professionals to estimate the number of reports they can provide without affecting the quality of their outputs. Ask around regarding the reputation of the outputs from testing companies.
There have been recent revivals of the belief that children are best tested in familiar environments. Some fluctuations in test scores have been seen when children were tested in familiar versus controlled (such as those found in sound-proofed rooms in testing companies) environments. This is something best discussed with the professional providing the test and your treating therapist.
After the assessment, you should be given a formal report called the psychometric or psychological report. The following must be found in the report:
– demongraphic information of the testee (name, birthdate, age, etc.)
– assessment logistics (time and date of test-taking, were there breaks and for how long, how long it took testee to finish each test, place of testing, any unique environmental factors such as the airconditioner breaking down in the middle of the second test)
– test information (the referral question, and around two to three sentences describing the tests provided and how they answered the referral question, the professional who requested the test)
– observational data (behaviors, verbal statements, and overall psychological state of the testee during the entire process of testing. For example, the testee kept on sighing after five minutes into every test provided, consistently distracted and looked around the room for awhile before continuing, kept on swinging legs and humming a tune, verbalized being hungry often)
– test results (numerical data/results of each test taken. In here, the interview findings must be included)
– interpretation (what the numerical results mean, and there must be specific application to the referral question at hand. There must be separate interpretations for each test given)
– summary/conclusion (must directly answer the referral question, and must integrate all the interpretations of the tests provided including the observational data gleaned during the assessment proper)
– recommendations (based on the test result, what are the next steps? If results are unclear or inconsistent, recommendations may point to re-testing after a couple of months or re-testing in a more advanced facility/company. There may be recommendations to seek mental health help. Recommendations must be specific. A bad example is: “check-up and monitoring by Dr. So-and-so, Neurodevelopmental Pediatrician”. Lastly, taking psychological tests CANNOT provide you with a diagnosis. A psychological test may provide benchmarks for the need to diagnose and what diagnosis may be relevant. Unless the mental health professional performing the assessment or test is also the treating therapist for your child, no diagnosis can definitively be given).
You may keep a copy for yourself but be sure that you understand this is confidential information. Your mental health professional/therapist will always be happy to assist you in answering whatever questions you have regarding testing for your child. If you have need of psychological testing, please go to the page entitled “Miscellaneous Resources for Self-Help” on the upper right-hand corner of my website and find the entry on psychological testing. (Note: I do not provide psychological testing services)
Grief is a complex collection of thoughts, feelings, and actions that arise in reaction to the loss of a precious object. In psychology, “object” does not mean an inanimate thing. “Object” refers to any entity, be it human or otherwise, that is infused or filled up with meaning and has a relationship with the target person. Notice that the definition of grief covers not only emotions, but also thoughts and behaviors. Grief is not merely a feeling. It affects how one thinks, behaves in everyday life, and relates to other people. Notice also that there must be loss for there to be grief. There is the pain of no longer being with a loved one. For there to be pain, there must first exist a connection – what we call “love” – toward a person. We are attached to that person so much so that their loss – even if it is only imagined – brings about a reaction of fear, sadness, and even anger. There can be no grief if there is no attachment. Thus, we have a stronger grief experience when we lose a family member than when we are seeing the death of strangers on the news.
Is grief normal?
Yes. Grief is a natural reaction to the severing of an existing bond with another person, animal, or thing. We invest so much emotional energy into that person, animal, or thing; and we also receive the interest of that emotional energy back into ourselves. This investment strengthens with time, and the longer one is invested, the more shocking and painful the loss of the invested person, animal, or thing becomes. Grief is the reflection of how much we have loved someone or something. But it is very important to remember that people exhibit grief in many, many ways. Your way of showing grief is not better than another’s way.
How is grief shown?
In the past, there were therapists, psychologists, and researchers who insisted that there was a “healthy” way to grieve. However, in recent times, we have discovered that there is no single way to grieve in a “healthy” manner. People grieve differently for different situations. One cannot expect the same grief reaction even among members of the same family. One member might cry by herself, alone and separate from the group. Another might show his grief by venting out anger. Still a third might look like he is not grieving, being rational and practical in dealing with legal and social requirements that come with death (for example, arranging the funeral, informing business and legal institutions of the death of the person, dealing with lawyers and creditors, etc.). Not one of them is considered to be healthier than the other. A whole book can be written about the different ways people have exhibited grief. Just because you see someone smiling in the funeral does not mean that she is not grieving, nor is the person who is crying loudly in her seat necessarily grieving healthily. Grief is a function of culture, personality, and connection to the deceased. It has also been found to be dependent on the type of death, cause of death, age of the deceased, age of the bereaved, and spiritual inclination. It is therefore a mixture of many factors. It is not accurate anymore to say that men tend to hold back their feelings, or that women tend to cry out in funerals. As gender variables become more fluid and continue to change in our society, so do patterns of grieving among the sexes.
Is there such a thing as abnormal grief?
Unfortunately, there is. There is something called “complicated grief”, a very vague and often misinterpreted concept among therapists and psychologists without proper training in grief and dying issues. Complicated grief has two aspects: the manner of grieving, and the time of grieving. Remember that grief is heterogeneous in manifestation. It is demonstrated in a wide variety of ways. In the same manner, the length of time a person experiences grief is also heterogeneous. In modern Western society, a person is expected to “get over” the death of a loved one a few weeks after the burial/cremation, and get back to living his or her life. In most traditional cultures though, there are varying lengths of time expected for mourning. This is further complicated by individual preferences and tendencies. Some people will grieve longer than others, and that’s just normal. However, there are some things that make grief a delicate topic among therapists:
1. Grief manifests in a very similar manner to clinical depression and other mood and psychotic disorders. In some countries, it is normal for the bereaved to report seeing the deceased in dreams or to see their spirits in waking life. In the Western part of the world, this would be an indication of psychosis. Therefore, therapists are required to be very thorough in balancing cultural and clinical aspects of the case. A wrong evaluation could lead to further complications down the road.
2. Some people in the midst of grief no longer take care of themselves or their dependents (for example, their kids). This is serious as this could lead to child neglect, and passive suicidality. There is a threat to quality of life, which might spill over to other areas of functioning. For instance, work and school environments are most often affected. If grief dominates the entire life of the person, there might need to be outside help. People who manifest grief in this way risk having their children and elderly parents taken away from them as they could not even take care of themselves, how much more for dependents? Without proper jobs, they experience a very rapid decrease in quality of life through poverty and homelessness.
3. For some people, the manner of grief becomes dangerous to self and others. There have been times when grief was manifested in the form of rage towards existing loved ones, rage towards perceived perpetrator (for example, if the death was due to a crime), or even rage towards the self. Needless to say, this qualifies as threat to safety and security not only of oneself but to others as well. Many who experience this gradually lose a feeling of self-control and become impulsive and have a sudden change of behavior. Assessments of suicidality and homicidality are required.
Is there a need to see a therapist?
It depends. Research has shown that unless there is a traumatic event that surrounded the death, grief counseling is not really needed. However, it might help for the bereaved to talk to someone other than friends and family who may say or do things that can be insensitive. For instance, a common assurance from friends is, “He’s in a better place.” It sounds well-meaning but the hidden message there is, “Being with you is not the best place for him that’s why he had to leave. There is somewhere better than being beside you.” This can cause more pain and distress than what the well-meaning friend meant to impart. Many people are very, very uncomfortable around death. It reminds them that soon they too will die. They try to offset this discomfort by saying “comforting” or “assuring” things but most often it comes out wrong. Some people will see it as their responsibility to direct your life and organize your schedule without anyone asking them to. At first glance, this might be useful and practical especially when it is difficult to concentrate in the process of grieving. But over time. if this goes on, the bereaved will become dependent on that person, and the dominant one will soon resent the bereaved for being “clingy”. This would only confuse the bereaved person.
Remember to ask your therapist also what training and exposure he or she has in terms of grief counselling. This is not something that a therapist can just read from a book or two. There are unique types of death and correspondingly unique reactions. It becomes quite complicated to adjust to certain cultures and how they grieve and the role of religion in the grieving process. Ask if the therapist has had advanced courses in any of the following: death and dying, thanatology, gerontology, psychology of aging, grief and loss, grief counselling, psychology of religion, spirituality in counselling, and other related masteral or doctoral-level courses. If not, ask if the therapist is being supervised by someone who is trained in the above. It has been shown that untrained therapists can cause the same damage as well-meaning but insensitive friends and family members. Why? Because therapists are also human, and most humans are significantly (whether deliberately or not) ignorant about issues surrounding death.
On the positive side though, current researches have started showing that most people who have been exposed to high levels of grief and trauma tend to return to a normal level of functioning by themselves (meaning, without any help from professionals). It takes some people longer than others, but ultimately majority of the population studied (not just clinical populations) have proved to be surprisingly resilient. Resilience is a natural attribute found in all humans. It allows us to metaphorically pick ourselves up after we have had a psychological fall, dust ourselves, and move on. However, “moving on” does not mean that the bereaved must forget the deceased. When a loved one dies, it is only natural and normal that we remember them. After all, our very existence is an enduring legacy to their memories and lives.
As a professional whose practice is client-based, it is expected and understandable that my schedule remains in a constant state of flux. Clients might call up suddenly to reschedule or cancel despite my policy of informing at least 24 hours in advance. Clients might have emergencies or might have forgotten they have an important prior appointment that overlapped with the counselling appointment. Most of the time, these are legitimate cancellations and reschedulings. After all, we are only human. It is also the protocol for therapists to remind clients to place medical, occupational, and academic appointments over counselling/psychotherapeutic appointments. However, there are instances of deliberate and repeated cancellations and reschedulings that represent unhealthy behaviors.
Difference from physician appointments
Our profession is not like the 10 to 15 minute physician visit where the doctor just prescribes medication for you and then you leave the doctor’s clinic. Our job is hour-based, which means we allot at least one hour per client. Can you imagine if a client scheduled for the day suddenly fails to show up (what we call as a “no-show”) or suddenly wants to reschedule? That would mean one hour of our workday has already been wasted, and one hour of income has flown out the window. We cannot just rush to fill in a new client on that open slot. Counselling professions don’t work that way. We cannot just call up clients to say, “Can you come see me this afternoon? I have an open slot with no one to fill it in because one of my other clients could not come.” Why? Because it is unethical to do so, and it is potentially harmful to the treatment process of the client. Sessions are scheduled to maximize application of learnings and insights in between clinic face-to-face contact.
Everything about the counselling/therapeutic environment (including schedules and time) is carefully prepared by the therapist. We call the overall set-up of therapy as “therapeutic framework”. The fact that there is consistency and constancy of time (schedules are set collaboratively on the availability and consent of both the client and therapist) and place (the therapist’s office must be the same address, not just transferring to coffee shops and hotel lobbies to conduct sessions; and the location must be suitable for confidentiality and emotional release) supports the process of treatment. In other words, adherence to the framework helps clients to progress in therapy. People with anxiety and mood disorders, for example, seem to require a routine or scheduled time-frame to be able to function well. This is why it is not advisable for therapists to keep on changing schedules and/or places for treatment. If this happens often, there is no structure or routine established which can function as a safe place and time for the client to find refuge. The therapist’s office has even been called a “sacred space”, and the therapeutic hour as “sacred time”. This indicates leaving behind everyday worries and concerns to reflect on oneself and find meaning and healing in therapy. Constantly rescheduling and cancelling disrupts the “sacredness” of the therapeutic space and time.
Clients’ rescheduling and cancelling
But what if the clients are the ones who keep on rescheduling and cancelling? Therapists often start to notice patterns and which clients tend to do this, and most explicitly ask why. Most often, clients have professional/job concerns or other important matters to attend to. But sometimes, clients have been found to keep on rescheduling and cancelling because they are escaping therapy. These clients often resist having to go back but are not sure if it’s a good idea to just stop therapy. Children often do this. They are forced to come to therapy by their parents and are blamed for being the “cause” of the problem. Of course it is understandable they don’t want to come! They start to create escape strategies: they complain of sudden stomach aches, head aches, being sick. Some children even say they have school activities when there really are none. In adults, I have found that clients who want to escape therapy just merely do not reply to any form of contact from the therapist (for example, not replying to text messages or calls). Most adult clients who belong to this type were referred to therapy but they themselves don’t like to go to therapy. They just don’t see the point of having to go to sessions and spend time and money when they could be doing something else. In the Philippines, a great example of this is a couple with relational issues: one partner usually wants therapy, but the other seems “forced” to come. The one who feels “forced” usually uses escape strategies.
For others, they have become bored with therapy, thinking they have not noticed any gains or progress in themselves or others. So they just wave off therapy as a nuisance or waste of money and keep on postponing it. Remember, psychotherapy is not like medicine: you don’t just take one pill and expect your problems to go away. Psychological and relational problems are different from physical problems, so they require different methods of healing.
Yet there are some who do notice improvements, but describe themselves as “too busy” to regularly come back to sessions. In short, these are people who don’t prioritize therapy. Your psychological and relational problems don’t just vanish or become stagnant when you put them “on hold” to focus on other things. They continue to grow in the background. That’s why therapists have to balance between checking up on you versus risking your irritation since we might look like we’re stalking you. We are just concerned for you and we understand that just because you don’t give priority to your problems it does not mean it goes away.
There is a sub-group of the “too busy” type”: they understand the importance of therapy but demand that the therapist accommodate their time changes. In this sub-group, there are those who make threats such as, “Well, if you can’t accommodate me this afternoon then I don’t think I want to come back to therapy” or other tactics to put the therapist on the defensive. If this habit goes on, the therapist’s other clients would also suffer because the therapist has to re-shuffle all his or her other clients’ schedules just to accommodate this one! The client would also learn that , “Aha! I can get what I want from this therapist if I make threats!” That’s not healthy, obviously. We as therapists have to find a balance with our time and our other clients’ needs. Our other clients have the same right as you to proper scheduling and accommodation. Thus, please bear in mind that while we try our best to meet your needs and requests, try to understand our side also in attempting to provide the best service to ALL of our clientele.
Please bear in mind that when a schedule is set, try to follow through on the date and time of the next session. I understand that when there are unforeseen emergencies and/or rare instances when you forgot you needed to do something else, you would need to reschedule. There are also instances where you need to really cancel or reschedule because there are more important things to attend to. I’m not demanding that you prioritize counselling sessions over your other appointments. But I request you inform me as soon as you can and that you don’t make this a regular occurrence. When you come to sessions, I assume you understand the weight of your problems and the necessary steps needed to resolve your problem. Therefore, I would like to request you to also spend the time and effort to come on time every time to our set schedule. I am here to help you, but ultimately, you are the only one able to resolve your own problem.
Time is a powerful factor in the experience of psychological problems. Whether chronic (long-lasting) or acute (sudden surge), how often in a week or a month symptoms are observable, and onset (when symptoms first started), time impacts the severity and pervasive diffusion of a problem. One time factor that must be continuously monitored and prepared for is called “anniversary effect“. From its name, this phenomenon can mean:
1. the recurrence of symptoms every year at the approximate time of its first onset.
2. the recurrence and worsening of symptoms at special times of the year, every year.
From the first definition, problems arise every year at the “anniversary” (thus, the name) of when the problem first started. The most obvious example is that of death anniversaries of loved ones. Let’s say the wife of Person A died in May in a vacation accident. Thus, every May for an indeterminate period of time, Person A would experience grief symptoms as if his wife just recently died. Memories of the accident, memories of good times spent together, depressive symptoms, and behavioral changes can be experienced anew every May. Notice also that the definition only requires “approximate time”. This is because Person A might experience symptoms not specifically on the very day his wife died, but might experience them weeks before or even after the exact time. This varies every year, and further varies per person. How severe the symptoms are might also fluctuate every year. A less severe example might be the re-experiencing of sadness or anger every year around the time you and your significant other (for example, spouse, lover, or committed partner) had your worst fight. This might mean a sudden feeling of irritability toward your significant other which you can’t explain, or you might notice that conflicts with your significant other during this time seem more intense and frequent.
From the second definition, there are certain times of the year in which one should be especially careful of since these points are especially stressful. For instance, Christmas is coming. Christmas might not be associated with stress for most people, but instead is considered “happy” or “fun”. But one has to remember, stress is not always negative. There is the concept of eustress (the “good” kind of stress such as the nervousness experienced by a bride before she walks down the aisle) and also distress (the “bad” kind of stress such as clashing with your boss at work). Christmas, among all other holidays, is a type of eustress. Unfortunately, this is not true for all people. Families with unresolved issues find that these holidays tend to increase conflict and heighten their symptoms. Since Christmas and other holidays of note (such as Valentine’s Day, birthdays, etc.) occur every year (therefore, another meaning for “anniversary”), problems occur in cycles. There is the slow rising of dread as the holiday approaches and everyone feels tense but don’t understand why they’re feeling that way. Then the actual explosion of conflict and everyone feels that the holidays have been ruined, starting a “blame game” (for example, “She’s always depressed during the holidays, ruining everything for us! Everyone has to coddle her and walk on eggshells so she doesn’t become crazy. It’s so exhausting. My holidays are ruined because of her!”). Then as the holidays end, the problems slowly dissipate as the family system re-balances itself to normal before another cycle comes up next year.
Exhausting, isn’t it?
The worst thing is that these are all unconscious, meaning that nobody deliberately “wants” this to happen, but everyone does something without becoming aware of their actions and thoughts that they are building up the conditions for another horrific holiday gathering. Everything is automatic, as if your movements are driven by an evil auto-pilot. Another bad thing about this is that EVERYONE does something to set up the fight or ruined holiday, without meaning to. One relative could have “good” intentions to reconcile two warring family members by inviting both to the family gathering, thereby causing the entire family to suffer the drama of the clash of these two bitter members during the gathering itself. Another relative might try to comfort the “good” intentioned-relative by saying what she did was right, reinforcing this relative’s behavior to try to do it again. Thus, the seeds of a new family fight are planted for the next year, all because of a not-well-thought-out “good” intention.
During holidays, people with diagnosed disorders must also be well-monitored. Why? Isn’t this supposed to be a “eustress” event, where people are happy? Any kind of stress – whether eustress or distress – is not GOOD for people with certain disorders. It triggers the feeling of pressure and unpredictability. People with depression for example might feel pressured to act happy, pushing themselves to exhaustion (people who are depressed get tired very easily). People with paranoid symptoms, because of the gathering of large numbers of people, might feel that they are being talked about. Anxious people cannot handle being in the same place with more than eight to ten people at a time, and this might heavily tax their ability to endure conversations and make them misinterpret nonverbal behaviors of other people (for example, “Why are people smiling at me and while talking to others? Do they know about my panic attacks? Do they think I’m crazy?”).
Lastly, families can experience BOTH definitions of anniversary effects every year. It does not mean that people only experience either the first or second definitions stated above.
While it is normal practice among therapists to assess and provide strategies for anniversary effects every year, you as a client must also be proactive in bringing up this topic with the therapist. Asking things like “I’m not sure what Christmas would be like now that my son is diagnosed with this disorder. Do I tell the other family members? What if they ask? I don’t think it’s any of their business, but if I don’t tell them they might be upset that I don’t trust my own family.” Don’t be afraid of bringing up feelings of fear, anxiety, anger, sadness. Your therapist is there precisely to help you sort through them and help you come up with solutions. Don’t be afraid of voicing out negative emotions about your family members to your therapist. Remember that many – if not most – of our problems can be tied back to our families as they are our first social environment and we have genetic links to them. During the holidays, a lot of heavy intense feelings come up upon meeting relatives and family members. This is normal and expected. After all, no one has shared that much history and experiences with them as you. It is only understandable that you develop very strong feelings toward them, and not all of them are good strong feelings.
On your own, take some time to reflect about your family’s traditions. What have you noticed every year? Reflect on those points where conflicts seem to be more frequent. Ask yourself questions like:
1. Does conflict occur in an explicit way, or does conflict manifest more implicitly such as a sudden change in conversation or everyone falling silent suddenly?
2. What topics seem to be “off-limits”? Why?
3. Which relatives seem to always be at odds with one another? Why are they at odds?
4. What are the rules regarding invitations in your family? Who makes them? What expectations are there in your family regarding attendance?
5. Who usually decides regarding gatherings in your family? Does it end well? Or are there people who grumble at the sidelines but put on a plastic smile in front?
6. What is the feeling of gatherings every year? At the end of gatherings, do you feel tired as if you exerted too much effort to be happy? Or do you feel fulfilled? Is this due to meeting certain members of the family either you are especially close with versus those you don’t like?
Awareness of these things can help you spot unconscious thoughts and behaviors not only of others but also yourself. When you are able to spot them, you can do something to stop the “evil auto-pilot” of your behaviors and thoughts. For instance, when you notice that this one uncle of yours is playing the leader again for the hundredth time causing his other siblings to frown and backbite him, you might be able to diplomatically and explicitly say, “What about you Aunt So-and-so, what can you suggest so that this year we might have something different?” instead of just thinking evil thoughts about your uncle and joining your other uncles and aunts in backbiting him.
A warning however: traditions and rules in a family are not easily changed. If anyone attempts to change them, the system will fight back because it loses its usual balance and wants to reclaim the previous state of balance. Thus, be very careful about how to negotiate and be diplomatic. If needed, seek help from a therapist who is knowledgeable about systems perspectives.
Most of all, understand that you alone have the power to choose whether to be happy or not during the holidays. Choose to be happy!
One of the most difficult, but unfortunately also the most common, forms of couple crises is infidelity. First of all, what is “infidelity”? Experts and researchers may have their own definitions, but many therapists and practitioners have found that the most important and significant definitions are those that the couples themselves make. So in other words, how do you and your partner define what INFIDELITY or CHEATING is? Here are some questions to guide you:
- When your partner views pornography online or through a magazine, do you consider it cheating?
- When your partner kisses another person, is it enough to consider it infidelity? Or perhaps do you think that it’s not cheating unless your partner keeps it from you (like a secret)?
- Do you consider sexual affairs (example, one-night stands) as enough for you to accuse your partner of cheating, or do you need to know whether your partner LOVES that other person as well? In short, do you need to know the EMOTIONAL CONNECTION or INTIMACY that your partner has with that other person?
- If you are heterosexual, would it be more painful for you to find out that your partner is homosexual? When would you consider him or her to have cheated? Is it okay for you even if your partner is homosexual as long as he or she did not act out homosexual behaviors with other people?
- If you are homosexual, would it be more painful for you to find out that your partner is heterosexual? When would you consider your partner to have cheated on you? Is it okay for you if your partner is heterosexual as long as he or she did not engage in sexual behaviors with other people?
- How would you think you will react to the news that your partner might be bisexual? What criteria would you have for your bisexual partner to indicate that he or she has cheated on you?
The meaning of infidelity is defined ONLY by the couple itself. Unfortunately, majority of couples have never talked about this issue, and continue to avoid it assuming that there’s no need to talk about infidelity. Take some time to talk with your partner regarding what you consider to be cheating, and what he or she considers to be cheating. You might be surprised to find out that you and your partner might not agree with some important points. It is always better to find these things out early in the relationship so negotiations and agreements can be made to avoid miscommunication and divergent views later on. Even if you are in a long-term relationship for years already, it’s never too late to start this conversation on a lighter note. Take it as a type of spending quality time with your partner, talking about deep things that are significant for both of you. You will discover many new things about your partner that will allow you to reflect on how you yourself engage with him/her.
A deeper layer of infidelity is a series of self-reflection questions regarding WHY you think that way about infidelity. Let’s take a closer look at some of the powerful contributors to our understanding of what constitutes cheating: family/parents, changing cultural values, media/internet, and brain research.
FAMILY/PARENTAL TEMPLATE :
Most of us take our parents’ relationships as templates for our own future relationships.
- What do you notice in your own parents’ interactions?
- How do they talk with each other, or share opinions and feelings?
- How are conflicts handled when they fight? Is there violence and abuse at home?
- Does one parent have a history of cheating? How is this cheating manifested (example, sexually, emotionally, etc.)?
We tend to repeat what we have seen from our own parents’ relationships. For some people, they are exposed to traumatic households and grow up thinking that they have the right to beat their partners and engage in relationships with other people aside from their committed partners because that’s what they learned from observing their parents.
In families, there are patterns that are unconsciously and indeliberately passed down across the generations. Not all of these templates and patterns of interaction are healthy! They continue to be passed down because there is no other alternative present. As long as alternatives exist, the power of choice is in your hands: do you choose to continue the pattern of cheating and unfaithfulness in your family? Or do you choose to break away from it? A big CAUTION however is necessary at this point. It is certainly NOT easy to just choose to break away from unhealthy family traditions. Traditions and patterns are very rigid. They are fixed in a way that is tied to the identity of the family. Because the family is a system, if anyone tries to change it, it will fight back. You might not have support from your other family members when you try to change certain traditions. As an example, try to think of what might happen if you tell your family to eliminate the practice of going to mass as a family on Christmas Eve. You will most likely be met immediately with various negative reactions from your family: shock, anger, sadness, pain. Something that has been practiced for a long time is not that easy to change. But there is hope: just because it’s not easy to change does not mean it cannot change. It will take huge effort and sacrifice to re-mold the family system for the benefit of future generations.
There is also a sibling difference. One sibling might grow up to be a serial cheater, while the others might not have that problem. Some theories exist why this might be the case. For instance, a favorite child might be coddled and given everything he/she wants so that he/she grows up entitled to a hedonistic (pleasure-seeking) lifestyle without regard or understanding of how his/her actions might affect others. This could be seen to some extent in some Asian families with an only son who is treasured and spoiled. People like these would look like they think the world is theirs, and that they have the right to do anything they want. They appear narcissistic, but in truth, they are easily hurt deep inside. Why? Because they never had the opportunity to undergo difficult circumstances as an effect o being spoiled. Therefore, they do not know how to cope and adapt to difficult circumstances.
CHANGING CULTURAL VALUES:
The Philippine cultural setting is rapidly changing. Children are now English-speakers and majority can no longer even understand their native dialects. Many Filipino children have a difficult time even passing their Filipino Language subjects in school since they are heavily Westernized already. They also take in American and Western values over Filipino ones from exposure to foreign media like the internet and cable TV. Parents are now more sensitive than ever to issues of bullying, “positive” ways of disciplining their children such as reasoning with them as opposed to the strict punishment they experienced from their own parents when they were children, and making sure their children are world-wise (example, by traveling with them to other countries, exposing them to international media, etc.). There is an unfortunate side effect to this that was not probably seen by most parents: children grow up becoming sensitive to negative stimuli. They learn to say to themselves, “Nobody has the right to hurt me.” When they grow up they are going to be disappointed when they realize reality does not work that way. Unfortunately for them, they never developed skills and coping mechanisms as children on how to deal with difficult people and situations.
On a larger scale, American and other Western cultural values that emphasize independence and confidence are pushing aside Filipino values of modesty and interrelatedness. There are positive effects to these, as well as negative effects. One negative effect is the argument that “I have the right to be happy no matter what”. There is this often-quoted “prayer” (it’s not really a religious prayer, more like an affirmation) in Gestalt psychology, a branch within the science of psychology: “I am I, You are You. I am not here in this world to live up to what you expect of me, nor are you here to live up to mine.” On the plus side, it provides the individual the right to pursue his/her own dreams and goals in life without any hindrance from others. This is a basic human right. However, on the negative side, this can be interpreted as an irresponsible statement. We all live inside interrelated systems and contexts. Everything we do affects other people, no matter how small our actions. We are relational beings. Therefore, if we apply this to relationships and cheating, the cheater would feel self-righteous thinking that he/she has the right to feel happy and that his/her partner has no right to stop him/her! Does that not make you angry or irritated? The cheater would say, “I am I, You are You. This is what makes me happy. You don’t have the right to stop me. Find what makes you happy, and mind your own business.” That is a very irresponsible thing to do.
As the internet becomes more common as a part of life in many households, experts are becoming more attuned to internet-related intimacy problems. Going back to the questions above, do you consider it cheating if your partner views pornography online? What about sexual chatting? Or sharing naked and sexually explicit pictures with other people? Is that cheating for you? Many women think so. Men are more likely to not think these are cheating behaviors. The internet has three main characteristics that make it a tool for the development of actual affairs: anonymity (users online can hide their identity, allowing them secrecy in interacting), affordability (all you need is an internet connection), accessibility (very easy to install internet connections nowadays, and all you need to do is switch on your laptop or computer or iPad to start sexual adventures). This is called Cooper’s Triple A engine. Some researchers have added the following characteristics: acceptability added by a researcher named King (behaviors that are unacceptable in society can be expressed secretly and safely online, for example, fetishes), and approximation added by the researchers Tikkanen, Ross, and Kauth (the quality of the internet has improved in such a way that it can create a very realistic situations or world online that is similar to real life). Two other researchers, Katherine Hertlein and Armeda Stevenson, added two more characteristics: ambiguity (it is difficult to draw a line regarding when sexual behavior online becomes problematic, again going back to the questions asked above), and accommodation (the internet is very “generous” in providing different scenarios for the expression of different personas of people with identity crises). This then would point to the internet as a potentially deadly tool and should be included in conversations between you and your partner regarding how cheating is defined.
In research, there is a theory that men tend to have the drive to be sexually active with many women because in ancient times, the survival of the tribe depended on the birth of many babies who would eventually grow up to support the tribe. Women, on the other hand, are said to have evolved to forge a relationship with a primary male partner for economic reasons: she has to be sure that when the child is born, the man who made her pregnant can bring her food otherwise she and her child would starve! These are practical reasons during the Stone Age period of human history. Even though we are already in modern times, the pattern of behavior among men and women are still largely driven by these now-defunct or useless evolutionary functions. Why? Because these traits and behaviors allowed us to survive through thousands of years as a species, and therefore very firmly embedded in our genes. If you remember your biology, whatever is important to the survival of an organism becomes more or less permanently passed down to its descendants. This is also supported by brain research: results have shown that men are able to separate love and sex, while most women have difficulty doing that. In simpler terms, men can be emotionally faithfully to one partner even as they engage in sex with other people. This can be very difficult to understand, especially for women. When men tell their partners, “I love you. It was only sex with that person, but it’s you I love.” after they had a sexual one-night stand with another person, they may not necessarily be lying. However, this does not mean that it is okay for them to sleep around. Many women are seriously hurt when their male partners cheat on them sexually. This is another important reason why couples need to talk beforehand what is allowable and not allowable behaviors inside their relationship. If the couple decides on an “open relationship” where they are both free to be SEXUALLY NON-MONOGAMOUS with other people as long as they remain EMOTIONALLY MONOGAMOUS, then it works for them. One has to remember also that non-monogamy (having more than one relationship partner) whether your are heterosexual or homosexual, carries the risk of Sexually Transmitted Diseases (STDs) especially Human Immunodeficiency Virus (HIV) which causes Acquired Immunodeficiency Syndrome (AIDS).
If you or your partner need help in discussing these things, please consider having a qualified and trained therapist as a facilitator in your conversation about infidelity. You might also want to consider pre-marital counseling if you are about to get married and want to make a smooth transition to being spouses. In pre-marital counseling, various topics are discussed which include financial issues (who budgets the money, who earns, what should money be spent on, how many accounts is necessary for both of you or do you share a joint account, etc.), child-rearing practices (how children are to be raised, up to what point in-laws are allowed to have a say in child-rearing, etc.), and religious traditions (what traditions you want to continue from your own family to this new family, what new traditions you want to form as your unique practice, etc.) aside from issues of infidelity.
Everyone has heard of Alzheimer’s Disease (AD). Technically called Dementia of the Alzheimer’s Type, this disease is the second most feared disease after cancer in the US and Canada. In the Philippines, awareness of this disease and its implications are only beginning to gain speed in the general population. As today’s baby boomers head on to old age, the threat of AD becomes a major mental health concern.
What is it?
AD belongs to a group of mental health disorders called “dementias”. Under this category are disorders that involve loss of brain functioning which are progressive, meaning that once you lose a certain ability, you will never get it back again. The disease “progresses” onward until totally eliminating all cognitive functioning. No amount of psychotherapy or medication can bring back that which has been lost. Dementias also interfere heavily with daily life and cause great impairment because the abilities that are lost are important cognitive functions like memory and communication skills. Can you imagine how it would be like if you forgot what a spoon is and what it’s used for? Can you imagine forgetting how to swallow?
AD is the most common form of dementia. It is one of the most expensive disorders to treat. To be diagnosed with AD, a person must have exhibited huge memory impairments, starting with short-term memory (memory of recent events and recently learned information) and progressing on to long-term memory (memory of past events, procedural skills, familiar faces). Aside from memory, the person must show cognitive impairments like aphasia (language disturbance, such as difficulty enunciating or pronouncing words or even inability to sound out a letter), apraxia (motor disturbance, such as not being able to coordinate legs to walk, performing activities that require multiple procedures), agnosia (inability to identify familiar objects, such as not being able to tell what a “hairbrush” is, and becoming confused when holding a pen because he or she doesn’t know what it is and what it is for), and executive functioning impairment (difficulties in planning, prioritizing, and abstract thinking). Changes in personality are expected, although not everyone with AD have the same type of personality change. Some people with AD become more mellow and calm. Most become agitated and paranoid. Understandably, if you no longer have memories of who your neighbors are or you start to realize that you are losing your vocabulary, wouldn’t you also feel scared and on-edge? Another unique aspect of AD is called sun-downing, when people with AD become more active and agitated in the afternoon and early evening. Extra care is needed during these times as people with AD have been known to become physically aggressive and harmful. Fugue (wandering off and becoming lost even in familiar surroundings) can also occur more at these times.
AD is NOT normal in aging. Memory loss is NOT normal when one becomes old. Small warning signs have been known to be exhibited as early as ten years before full-blown symptoms are observable. Early diagnosis makes a whole world of difference. AD can be roughly divided into three stages, with each stage becoming more difficult to treat:
Preclinical: before the disease is apparent. Small warning signs are present but difficult to link to AD. Some people and their loved ones deny the impact and importance of these small signs. Preclinical stage ends when mild symptoms start to alert the more sensitive members of the family that something is wrong with their loved one. Research has found that one early warning sign is that people with AD had gait problems that affect their walking style before being diagnosed with AD. Thus a change in how one walks is a good reminder for health professionals to inquire about the presence of other AD symptoms. Ideally, people should be diagnosed at this stage to start treatment.
Mild-moderate: All prior symptoms are becoming stronger: more aggressive personalities, mood shifts, unable to learn new things, unable to cope with new situations, confusion rises in intensity and frequency along with paranoia. Sometimes, hallucinations and delusions occur, prompting them to become impulsive.
Severe: Totally dependent on others, bedridden. Requires assistive devices for feeding and movement.
What causes it?
AD is a mix of genetic, environmental, and lifestyle factors. It is difficult to pinpoint a cause that is true for everyone since each person with AD is different: personality-wise, where he or she lives, how he or she lived his or her life, etc. However, the most recent neurological findings have pointed to a breakdown of communication between brain cells and the build-up of harmful beta-amyloid proteins that produce “tangles” and plaque in neural (brain cell) circuits. There is also the finding that excess glutamate cause brain cell damage by allowing too much calcium into the cells. As brain cells continue to die, damage spreads to important major areas of the brain. One of the first to be hit is the hippocampus, that part of the brain that is important in forming memories. This explains why memory problems surface first.
Some genes have been identified to be commonly found among those who suffer from AD. The most commonly studied is the apolipoprotein E gene. But this doesn’t mean that having this gene immediately causes you to develop AD. Some people without this gene even go on to develop AD. Another set of risk factors: People who have family histories of cardiovascular and metabolic diseases such as stroke and diabetes are at higher risk of developing AD
How do we make it go away?
Currently there is no cure for AD. Once AD has been diagnosed, treatment can only delay its progression and try to curb damage to other areas of life that have not yet been affected by the disease. Educational efforts from mental health professionals aim at preventing AD by imploring relatively younger people to lead active physical lifestyles, to keep their minds sharp by learning something challenging to continually exercise their minds, and eating healthy foods to reduce the risk of developing certain diseases connected to AD. Medication-wise, there are five drugs approved by the US Food and Drug Administration (FDA) but unfortunately, all five have been known to be effective only to fifty percent of those who took them. Even then, the beneficial effects of the drugs last only up to 12 months after which there are no observable therapeutic effects. Research funding, lack of priority, and sampling have all contributed to the relatively poor results of possible treatment for AD.
The family of the person with AD is highly affected with the following issues:
1. Caregiving duties. Who should care for that loved one? How should the care be given? When should more drastic efforts (for example, placing the person with AD in a nursing facility) be performed? Who should make the decisions (for example, is there a living will left by the person with AD?)? Along with caregiving duties, sibling conflicts could arise. Sometimes, each family member has his or her own opinions about treatment which might clash with the opinions of other members. Also, when a family member becomes a caregiver, there might be the reliving of past bad experiences. For example, a daughter who was constantly criticized by her mother becomes her mother’s caregiver. What do you think could happen? A lot! There are opportunities for forgiveness and reconciliation, but there are also opportunities for vengeance and continuance of resentment. The caregiver also faces a lot of problems once the person with AD passes away. After taking care of the person with AD for a long time, his or her identity and routine has started to revolve around the person with AD. Now that the person is gone, what would happen to the caregiver’s identity and routine? This might lead to the caregiver’s depression. Last but not least, caregiver burn-out or compassion fatigue is very common. Caregivers do not have an infinite supply of caring and love for the person with AD. They need to rest also and replenish their strength. A person with AD is not a cooperative “patient”. They can be irritating, even harmful!
2. Reactions of children and loved ones. What would you feel if you walked into the room and your mom just stares at you as if you were a stranger? What would you do if your grandfather asked you who you were and why you were in his house? AD can be confusing not only to the person suffering it, but also to the children and grandchildren of the person with AD. Parents have to take the initiative to seek help for their own emotional issues about AD before being able to educate their children about what has happened to their grandparent.
3. Role changes. There are many changes in the family when a member is struck with AD. The most important change is the change in family roles. For many, children become the caregivers of their parents, shifting the roles of power and balance. Along with a change of power comes responsibilities to make difficult decisions and handling everyday crises that used to be done by the parent who now has AD. How would you interact with a parent who was once lively and smiling and energetic, but now stares blankly at you while drooling? What would you feel? Are you comfortable being the “parent” to your parent? Does it mean that your parent is no longer an adult but a “big child”? Or do you still treat your parent with the dignity of someone who has lived a full life, an adult with integrity? Research has shown that if people with AD were treated like children, they lose their sense of self faster and their AD becomes worse.
4. Grief and loss. Family members grieve for the person who is no longer the same person they knew even though he or she is still alive. This is called ambiguous loss. The person with AD is still physically present, but his or her spirit or mind is no longer there. Most families deny the feeling of grief, they avoid it. This leads to a lot of complications after the person with AD dies. Depression and anxiety, along with other disorders, may manifest in the family members later on if grieving is not done properly. While grief is understandable, research has also shown that seventy-two percent of family members who have a loved one with AD are relieved when their loved one dies. They become guilty for feeling it. But, relief is normal. After years of struggle, the loved one with AD is now at peace. After years of caregiving, the family members can now also find peace. It is important to remember this to avoid complicating grief reactions.
How psychotherapy can help
Psychotherapy can provide education (what to expect and how to deal with it), support (a venue to share feelings and opinions), and solutions (brainstorming possibilities, connecting to resources in the community and online, and figuring out the next step). Instead of fighting this insidious disease and having the fantasy of returning the loved one with AD to “normal”, psychotherapy with AD helps family members understand and accept the disease and create a soothing space for the person with AD to minimize confusion and agitation. Not everything about the AD experience is negative. Many people have shared funny and positive moments with their loved ones who have AD. Family members learn to be with their loved ones “in the moment” instead of constantly striving to make them remember (which is irritating and confusing to the person with AD). Past issues of hurt can also come to the surface during the course of AD, and psychotherapy is well-equipped to handling complications of these sort. Psychotherapy could also take the form of symbolic activities such as rituals of reconciliation and forgiveness, or of last communication to a loved one who can no longer speak or understand what is being said to him or her. In other words, psychotherapy can bring closure to both the person with AD and to the family members.
As more and more elderly people are living longer lives, it becomes more likely that families will come into contact with AD sooner or later. AD is a very painful and scary experience, but armed with education and support, the burden can be shared and even reframed or reinterpreted as an opportunity of change for the better.