NPI REFLECTS FALL 2019
Volume 9: Issue 3
On Anxiety
this issue
In moments quiet between briars crept An acquaintance old of which strangers wept. Trembling soft with gentle fear Hell is a promise likely kept, And it is all but silent down here.
What is NPI? The Nashville Psychotherapy Institute or NPI is a 501(c)(6) non profit, professional organization. Founded in 1985, NPI now boasts 300+ members. Not a member? Find out more about NPI at www.NashvillePsychotherapyInstitute.org
Jordan House Student Member
Inside this issue: On Anxiety Jordan House
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From the Chair-elect Cathryn Yarbrough, PhD
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ADHD Awareness Terry Huff, LCSW
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Connection Retreat
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Advertise Your Event
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Holiday Party & Raffle
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Attunement to Subtle Cues of the Need for Psychiatric Intervention‌ Philip Chanin , Ed.D., ABPP, CGP
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Psychoanalysis and Psychodynamic 10 Psychotherapy: Barbara Sanders, LCSW Newsletter Credits
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From the Chair-elect As chair-elect, it is an honor to represent the members of NPI and I am excited to announce the newly elected Board of Directors who will be serving our members in 2020:
Cathryn Yarbrough, PhD 2020 Board Chair
Richard Cowan, Chair-elect Lindsay Vaughn, Hutton Historian Bobby Bracks, Student Member Kristin Finch, Board Member Kirk Barton, Board Member Emily Ector-Volman, Board Member
As we look forward to a new year, I want to say a special thank-you to our 2019 Board Chair Sonya Thomas who has provided me a lovely model of leading with grace and efficiency. We will regretfully be saying goodbye to Cynthia Lucas, May Broussard, Kaci Allen, Chris Karcher, Angela Hart, and our student member, Rachel Gladys. I look forward to working with our incoming board to build on the work accomplished this year! I would like to share with the membership of the Nashville Psychotherapy Institute some of the speakers, events, goals and aspirations that are in store for 2020. We recently conducted a Member Satisfaction Survey, and I hope many of you will be pleased to see that your suggestions are already in the process of being implemented. Connection Retreat Make plans to join us February 8-9, 2020 at St. Mary’s Sewanee for this members’ only retreat that will focus on “Connections with Ourselves and Others.” Program and registration information is included in this newsletter. CE Luncheon Speakers and Topics We are excited to announce the line-up for our 2020 luncheons! Ron Salomon, MD
Helping Patients Understand Symptoms thru Chronobiology Awareness
Patricia Dean, LMFT
Somatic Experiencing Trauma Therapy
Janina Tiner, LCSW
Bringing Internal Family Systems into Your Practice
Phil Chanin, PhD
Perspectives on Narcissistic Personality in the Age of Trump: Diagnosis and Treatment of Narcissism and its Survivors
Robert Desalvo, LCSW
Psychedelic Assisted Psychotherapy
Maury Nation, PhD
Bullying: Longitudinal Effects and Best Practices for Treatment
Rachael Tanner-Smith, LPC-MHSP
Mindfulness in Addiction and Recovery
Robin Oatis-Ballew, PhD
Helping Clients Recognize and Respond to Microaggressions
Ramona Reid, LMT
Integrating the Enneagram into your Therapy Practice
Kimberly Yost, JD, LPC-MHSP
Desire Discrepancy in Long-term Relationships (Continued on next page)
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(From the chair-elect, continued)
Fall Workshop – Wellness 66 Event NPI is joining with Wellness 66 to host Kristin Neff, PhD for our Fall Workshop on Friday, October 23, 2020. Kristin is an associate professor at the University of Texas at Austin, and is considered a pioneer in the field of Self-Compassion. She is a much sought-after presenter, and her research has been widely published in both journal articles and book chapters. Her book, Self-Compassion, has been printed in multiple foreign editions. Website Updates Over the next few months, you will see an effort to beef up our online member directory. This is a major member benefit if populated with information such as insurance accepted, treatment modalities, and populations served. We encourage all members to update their profiles on the NPI directory and to add a current photo. Help in navigating the update process will be available at the Holiday Luncheon and the Connection Retreat. Of course, if you ever need assistance with the website, you can email questions and concerns to NPInashville@gmail.com. NPI Reflects Newsletter Have you contributed an article for the NPI Reflects? Submissions are welcomed by all NPI members, and the newsletter is sent three times a year to over 1,000 individuals in Nashville and surrounding counties. This is a great opportunity to share your insight, passion, and experience with others. In an effort to be more environmentally friendly and financially responsible, beginning in 2020, members will receive the NPI Reflects electronically unless otherwise requested. You will see improvements to our online posting of newsletters as well. Like all volunteer organizations, priorities shift with new leadership. Over the last three years a lot of focus has been placed on implementing the Design Team’s vision that included contracting with an executive coordinator for more hours, improving communications, codifying processes, and building community partnerships. We are seeing the results of these efforts in higher membership numbers, greater attendance at monthly CE luncheons, and opportunities to partner with groups like Wellness 66 to bring in nationally recognized presenters. As incoming chair, I want to continue this, as well as work toward increasing diversity, guaranteeing our financial stability, and growing our community. I look forward to serving as your 2020 NPI Chair! 3
ADHD Awareness by Terry M. Huff, LCSW Terry M. Huff, LCSW is the author of Living Well with ADHD, an informative and entertaining book that is changing lives. It is available at terrymhuff.com, addwarehouse.com, amazon.com, Barnes & Noble, and Parnassus Books. He presented, “Don’t fix me, I’m not broken: Common Mistakes Helpers Make with
Adult ADHD Clients,” at the NPI October CE Luncheon. October is ADHD Awareness Month, and I want my professional peers to know the risks that ADHD presents to adults who live with it. Those with the diagnosis represent about 4.4% of the U.S. adult population, but the actual prevalence is probably much higher. Experts speculate that most adults with ADHD are undiagnosed. ADHD is a serious health Issue. It is an executive functioning disorder primarily defined by impaired activation, inhibition, and working memory. It is not truly a deficit of attention, but more of a surplus, and an attention management problem. The ability to inhibit attention and impulses is impaired. The ADHD brain is like a symphony of competent musicians with an impaired conductor. Whether diagnosed or not, adults with ADHD most often seek help for something other than the symptoms. Effects of the symptoms show up as other life management problems. The probability of relationship problems, divorce, addiction, wrecks, injury, obesity, legal problems, employment problems, aborted education, underachievement, and other life challenges is, on average, higher than in the general population. Some just have trouble staying out of trouble. Russel Barkley and colleagues have presented important facts about adult ADHD in their book, ADHD in Adults: What the Science Says. When a couple learns that one partner has ADHD, the odds for success increase, as options for treatment increase. Clients feel hopeful when they can see a path to becoming skillful partners. Strategies make sense when the problem is understood and accepted. The disorder does not explain everything, but it is always there, present with everything. Both marriage partners must do the partnership work. Melissa Orlov, author of The ADHD Effect on Marriage, offers solutions for couples. She illustrates typical dynamics and steps for changing them. She challenges both partners. Medicine alone is not the answer in treating ADHD. My view of comprehensive treatment keeps expanding, as I value the work of ADHD coaches, professional organizers, neuropsychologists, neuro-developmental optometrists, psychiatrists, psychological examiners, psychotherapists, meditation teachers, career specialists, and leaders of support groups. In my practice, I often meet first to determine what specialized services an adult with ADHD might need. There is no "cure" for ADHD. It must be managed for life. Mindfulness practices can help. The hardest part is starting and sustaining a routine. ADHD adults often think they cannot meditate because their brains jump around like a monkey in a forest when they begin. I always ask, "Can you run a marathon tomorrow?" It takes gentle effort and a leap of faith to keep the wheels on the tracks. It helps if the therapist has a daily practice. If you don't, consider referring your clients to an experienced meditation teacher. One of the biggest errors therapists make, in my opinion, is failing to connect respectfully and sensitively with ADHD clients. Many carry underlying embarrassment and shame from a lifetime of self-criticism, disappointment, and falling short of achieving their life goals. They are motivated to do better, but they are more motivated to seek immediate stimulation, focus on what is urgent or novel, and avoid uncomfortable feelings. They are usually time-blind and suffer from plenty-of-time thinking. These prisoners of the present live in two time zones, now and not now. They jump into tasks without a plan. Once their attention is locked in, they lose open awareness, oblivious to others and to other priorities. Adults with ADHD are often skeptical of therapists and expect to be judged. A collaborative process is essential. I tell my clients, "I'm your guy; I want to help you achieve your goals." I ask young adults still living at home if they would like my help getting their parents off their backs. Not a single client has ever answered no to that question. I invite them to join me in figuring out how they can become more independent, which is what they want. But they also want their parents, on whom they are dependent, to emancipate them. Likewise, married adults with ADHD want their spouses off their backs. We have to help our ADHD clients find their way through such common paradoxes.
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The NPI Connection Retreat is for members who are interested in deepening their relationship to the
community of NPI in a relaxed atmosphere free from the demands of the workweek. Make plans to join us for two days of learning, connection, and renewal. Featured presenters include Jill Karcher, Valerie Martin, Julia McAnich, Barbara Sanders, and Rhonda Scarlata.
February 8-9, 2020 Members Only Event
Full Agenda & Registration at www.NashvillePsychotherapyInstitute.org
ADVERTISE IN NPI REFLECTS Promote your workshop or group event with us! The NPI Reflects is distributed to over 1,000 individuals in the Nashville area and posted on the NPI website.
Full Page Ad ONLY $250 Half Page Ad $175 - Quarter Page Ad $100 5
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NPI Holiday Party & Raffle Event Join your NPI Colleagues for delicious hors d'oeuvres, festive drinks, and great company!
Friday, December 13th 11:30am - 1:00pm Scarritt Bennett Center 1st Floor Raintree Lounge The fee is $20 for NPI members and their Registered Guests. There is no presenter at this event.
Holiday Raffle to benefit the NPI Scholarship Fund sponsored by
$10 per ticket/$50 for 6 tickets
Winner chooses one of the following multi-day training options (a $1400 value) •
Psychodrama Training - In this didactic and experiential training institute, participants will be taught the theory and practice of sociometry, psychodrama, and group psychotherapy. Participants will have the opportunity to practice these techniques and exp lore how they can be applied to their current clientele.
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Experiential Training - Gain hands-on experience in applying experiential methods when treating clients with trauma, addiction, sexual and intimacy issues, eating disorders, codependency, and low self-worth. RSVP today at www.NashvillePsychotherapyInstitute.org
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Attunement to Subtle Cues of the Need for Psychiatric Intervention: A Model of Psychotherapist-Psychiatrist Collaboration By Philip Chanin, Ed.D., ABPP, CGP - Board Certified Clinical Psychologist Assistant Clinical Professor, Department of Psychiatry, Vanderbilt University Medical Center “Surely, all mental health providers need to grasp the full range of mental illnesses. Psychiatry is an essential, foundational discipline for all of us.” (Volney P. Gay, Ph.D, personal correspondence, June 8, 2019) Some recent statements from new patients: 1) A 28-year-old female patient states, “I have dealt with anxiety forever. I have very serious fears of people leaving me - I didn’t grow up in a secure family.” 2) Another 28-year-old female patient says, “I don’t really get excited about much. I don’t know how to be happy.” 3) A 32-year-old male patient states, “Meditation isn’t soothing the anxiety. Nothing is soothing the anxiety—today my heart is racing.” 4) A 41-year- old female patient says, “It’s hard to feel anything. I don’t feel. I’m always afraid of failing.” 5) A 72-year old patient states, “I am awake for 2-3 hours each night thinking about all this—wears me out!”
What do all these patients have in common? None of them came into psychotherapy thinking about medication. Yet all have benefited greatly from psychiatric intervention, in addition to their psychotherapy. Prior to returning to Nashville 28 years ago, I worked closely with psychiatrists in my private practices in Philadelphia and then in New Hampshire. I grew to value their diagnostic expertise and acumen when we shared patients. Beginning my private practice in Nashville in 1991, I sought out psychiatrists to whom I could refer my patients. One of my early experiences here involved a young psychiatrist to whom I referred several patients who needed psychiatric help. One of these patients was hospitalized at Parthenon Pavilion, and was managed there by this psychiatrist. We had a family meeting at the Pavilion, including the patient, the psychiatrist, myself, and another psychotherapist who was working with the family. Evidently, during this meeting, the psychiatrist felt that I was challenging her authority over this patient’s care. The following week she abruptly terminated her relationships with all the patients I had referred to her, which was quite disturbing to me and disruptive of their care. I vowed to try harder to find psychiatrists who were more open to working with psychotherapists in the community and value what we offer to our patients. Fortunately, since that time, I have been able to develop mutually beneficial relationships with a number of Nashville psychiatrists. Currently 43 of my patients (almost 50 per cent of all my patients) have had (or are scheduled to have) evaluations with psychiatrists who only schedule 90-minute initial evaluations and 45-minute follow-up sessions which combine psychotherapy and medication management. Having also paid for weekly psychotherapy supervision for the past 30 years, I have enormous appreciation for the perspectives that another seasoned psychotherapist or psychiatrist offers to me in understanding and treating my patients. In recent years, I have grown in my knowledge of which patients would benefit from psychiatric intervention. This is particularly true as a result of my relationship with the psychiatrist who has evaluated (or will be evaluating) 43 of my patients, including 11 over an 8-week period this spring and early summer. When I make a referral to him, with my patient’s permission, I send him a long email summarizing my clinical impressions from my work with the patient. The psychiatrist then sends me an appointment time for the patient, which I then email to the patient and copy the psychiatrist on the email, so that the patient can confirm with the psychiatrist whether this appointment time works for her/him. Following the evaluation, the psychiatrist sends me a long and thorough email, summarizing his diagnosis, clinical impressions and recommendations. And whenever relevant issues arise during my ongoing psychotherapy with the patient, I email the psychiatrist so that he can address these concerns when he meets in 45-minute follow-ups with the patient. An experience this week is illustrative of my working relationship with this psychiatrist. On Friday, 3 days ago, I met with a 28-year-old patient with a long history of depression. When I had first met this patient six weeks earlier, he had scored a 7 (mild depression) on the PHQ-9, a paper and pencil questionnaire that I find extremely helpful in evaluating depressive symptoms. On Friday, when I re-administered the PHQ-9, his score was 17 (moderately severe depression), with passive suicidal ideation. The following morning (Saturday), I sent the psychiatrist a long email, with my clinical impressions. Within a few hours I got a return email from him, saying that he had had a cancellation in his schedule in 4 days, and would this appointment time work for the patient? I immediately texted the patient, who greatly appreciated getting such a timely appointment! (Continued on next page)
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(Attunement to Subtle Clues, continued)
Not only do my patients get additional skilled psychotherapy from this psychiatrist, but they also get medical and scientific expertise that has been invaluable in furthering their overall progress in psychotherapy and in their lives. He sends all his patients for lab work to check for vitamin levels and genetic mutations, which most of our patients have, and which can be a major contributing factor in their depression and anxiety. Recently, after getting lab work back on one of my patients, who has struggled with depression off and on throughout the 15 years I have seen her, the psychiatrist sent her the following message: “1) Your vitamin B12 level is in the low normal range. 2) Your vitamin D3 level is very low. D3 is important for dopamine production and thus low levels are a causal factor in depression. 3) Inside your body, folate is converted into L-methyl-folate, which then forms neurotransmitters important for mental functioning. The rate limiting step in this process is controlled by the MTHFR enzyme, which has its DNA blueprint on chromosome #1 at the 677th and 1298th set of alleles. You have two mutations at the 1298th position. It is possible that you are having some trouble making needed neurotransmitters. 4) Homocysteine is an inflammatory amino acid that at high levels can be associated with depression and possibly dementia. Your homocysteine is mildly elevated. 4) The solution to #2, 3, & 4 above is for you to take a vitamin complex by the name of Enlyte-D. It has L-methyl-folate and methyl-B12 and can lower homocysteine levels. Also, it has 5,000 IU of vitamin D3.” As almost half of my patients are (or will be) working with this psychiatrist, I have great confidence that their anxiety, panic attacks, dysthymia, depression, obsessive-compulsive disorder, or insomnia are being adequately treated from a psychiatric and medical point of view. Sometimes when I suggest to a patient that they have a psychiatric evaluation, they respond with “I don’t want to be on medication.” I usually then say that “nobody is going to force you to take medication, but I believe you would benefit from a psychiatric perspective on your situation.” Some patients who have seen this psychiatrist have greatly benefited from having their vitamin deficiencies and genetic mutations addressed and treated, even when they did not take medication. I hear back from my patients frequently about the benefits they are getting from their psychiatric treatment and from the psychiatrist’s perspectives on their lives. Because he is not just a medication provider - he is also a psychotherapist. As another psychiatrist, who clearly values psychotherapy, stated in a New York Times article, Medication is important, but it’s the relationship that gets people better.” (“Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” by Gardiner Harris, NYT, March 5, 2011) I have written this article in the hope that more NPI psychotherapist will seek out psychiatrists who have not submitted to insurance reimbursement pressure to only offer 15-minute medication management follow-ups, but instead take a deep and genuine personal interest in providing skilled scientific expertise as well as psychotherapy to their patients. Certainly, we do have patients who cannot afford the cost of seeing psychiatrists who do not accept insurance. In those cases, we can endeavor to find psychotherapy friendly” in network psychiatrists (unlike the psychiatrist I profile in the 3rd paragraph above!) who value and support our work. 9
Psychoanalysis and Psychodynamic Psychotherapy: An interview by Barbara Sanders, LCSW As a psychodynamic psychotherapist who works with individuals, couples and families, I would like to share with NPI some of my exposure to psychoanalysis. I have participated in a wide variety of therapies throughout life as a client and in much training as a professional, and my psychoanalytic education and analysis have been valuable to me personally and professionally. John Waide, PhD, LCSW, Marsha Robertson, LCSW, and Paul Morris, LCSW, share some of their experiences in this interview. John, Marsha, Paul and I are all intrigued by the transformational nature and process of healing, and over 20 years ago, we joined the Nashville Psychoanalytic Study Group, now named the Nashville Center for Psychoanalysis and Psychodynamic Psychotherapy. Some NPI members have participated in this group’s Advanced Psychodynamic Psychotherapy program (APP), a 2-year post-graduate program for therapists which began in 2002. John, Marsha and Paul have each been Directors of APP, and John, Paul and I have been NPI Chairs. I want to invite NPI members and other therapists to attend this group’s monthly meetings for continuing education training, and I am posting its meetings on the NPI list serve. Barbara: Why did you each become a psychoanalyst?
Marsha: I first became aware of psychoanalytic ideas when I was a teaching assistant working on my Master’s in English Lit. I discovered that I did not want to teach but that I was fascinated by analytic theory. It was as exciting and profound as anything I had come across. I went on to become a therapist and read many theories; none however had as much depth and complexity as psychoanalysis. Then, when I entered my own analysis, I knew becoming an analyst was the path for me. The self-understanding I gained was the most empowering experience of my life. The heart of psychoanalysis is and always has been self-understanding. Paul: Barbara, thank you very much for asking. My education helped me to find my way, however, I think I made the decision to be a therapist and later an analyst based mainly on my own psychology. I tend to see people as finding psychotherapy careers for personal reasons although I am sure there are many other important reasons. I think the core values of learning to be honest with oneself and to develop good relationships are at the heart of the work, and are what psychoanalysis is supposed to be about.
John: I was first drawn to psychoanalysis in the 1970s when I read Freud, Fromm, and Erikson. While changing careers from philosophy professor to clinical social worker, I had a group of friends who were all becoming therapists. Our daily conversations about what we were learning, and reading were among the most stimulating experiences of my life. We read widely and voraciously about all sorts of therapy but psychoanalytic and psychodynamic readings in our omnivorous diet stood out. A friend began psychoanalysis and I watched the slow, beautiful transformations that followed. I had benefited enormously from long-term experiential group therapy and Jungian therapy, but those modalities weren’t touching some aspects of my own personality. I wanted/needed more. I finally sought out analytic treatment when my private practice was well enough established. The draw for me was the profound interaction/relationship (á la Winnicott’s work) to deepen my relationships with my wife, child, and friends. In 1997, I began analytic training to see what it might be like to operate on such a deep, intimate level with patients. I got what I wanted. (Continued on next page) 10
(Psychoanalysis, continued)
Barbara: What are the fundamental guiding principles of both psychodynamic psychotherapy and psychoanalysis, and how are they similar and different? Marsha: While both deal with self-understanding, both intra-psychically and interpersonally, psychoanalysis is a more intense process, and unconscious patterns of relating emerge in the relationship with the analyst which reveal early reactions and adaptations to pain, loss, and fears of closeness and distance. The experience, which is a lengthy one, provides for a truly examined life and can lead to greater empathy for oneself and others. I think it is particularly important for mental health professionals who must learn to deal with their own anxiety in order sit with all kinds of mental suffering in a way that is non-reactive and empathic. Paul: I think the fundamentals for both are 1) self-understanding; 2) self-honesty, and 3) developing good relationships. How is analysis different from dynamic therapy? I think psychoanalysis deals more intensely with the mixed positive and negative transferences that play out over lengthy periods of time in any long-term relationship. Importantly, I think in psychoanalysis the “pandora’s box” of the unconscious is opened over a longer time period so things that are unwanted and unexpected come to the surface. The frame of treatment aims to protect individuals during the process and promotes the goals of the treatment (insight into one’s own motivations and tendencies.) I think that certain people—mental health professionals or people dealing with complicated family issues especially—are bound to find a good analysis helpful. Again, I see the aims as self-understanding, being able to “straight talk” with oneself, and getting along with people in one’s life. John: Frequency makes a huge difference. I wish I knew how to convey the experience (as analyst or patient) of meeting 4 or 5 times per week in a setting where the analyst mainly listens for deeper resonances beneath the surface of what the patient says, and where patients learn to listen to themselves on a deeper level, honoring the feelings, connections, and relationships that are mainly expressed indirectly. The power and intimacy of such sessions can be at once beautiful, terrifying, and healing. Analysis isn’t primarily cerebral but a whole-body experience—of past trauma, grief, or present anxiety. As patient and analyst together learn to notice the subtle, automatic, unconscious defenses against disturbing primal perils of life—e.g., losing loved ones, losing their love, mutilation, or at the deepest core, a disintegration of self—it is possible to develop the capacity to connect more deeply with others, remaining emotionally close even through storms of longing, rage, love, and hate. It isn’t easy, but it is deeply satisfying— mostly. Barbara: Thank you, Marsha, Paul and John! If the monthly meetings or APP intrigue you, please view the website at www.Nashville-Psychoanalytic.org 11
Nashville Psychotherapy Institute
P. O. Box 158626 Nashville, TN 37215 npinashville@gmail.com www.NashvillePsychotherapyInstitute.org
2019 NPI BOARD Sonya Thomas, LCSW; Chair Cathy Yarbrough, PhD; Chair-elect Cynthia Lucas, PhD; Immediate Past Chair Angela Hart, LPC/MHSP ; Hutton Historian Glenn Sheriff, MA ; Treasurer Kaci Allen, MSCMHC; Website April “May” Broussard, LCSW; Spring Workshop Robert DeSalvo, LCSW; Website John Nichols, MS, LPC/MHSP; Development/Newsletter Rachel Gladys; Student Member Chris Karcher, PsyD; Connections Retreat Linda Manning, PhD; Social Justice/Connections Retreat Patrick Nitch, LPC/MHSP; Spring Workshop/ Speaker Research Hannah Reynolds, LPC/MHSP; Fall Workshop/Social Justice Rob Rickman, LPC/MHSP; Membership Melissa Vickroy, MS; Executive Coordinator
WANT TO GET MORE INVOLVED IN THE NASHVILLE PSYCHOTHERAPY INSTITUTE? We have several committees that you can join! If you are interested in becoming a more active member of NPI, visit our website at www.NashvillePsychotherapyInstitute.org or email us at npinashville@gmail.com
NEWSLETTER CREDITS Editor: Layout & Design: Printing:
John Nichols, MS, LPC/MHSP Melissa Vickroy, MS PrintNetUSA
***Editor’s Note: The content and opinions expressed within this newsletter do not necessarily reflect the views of nor are they endorsed by the Nashville Psychotherapy Institute, the Board of Directors of the Nashville Psychotherapy Institute, or the Editor of the newsletter. 12
