Last month the San Francisco chapter of the California Association of Marriage of Family Therapists (SFCAMFT) approved a Statement on the Ethical Treatment of Sexual Orientation and Gender. The statement addresses when a therapist’s personal, cultural or religious beliefs conflict with evidence-based practice, particularly in regard to working with sexual minority clients and clients with non-conforming gender identifications.

As a member of SFCAMFT, I’m pleased to share the whole statement with you below. The statement is in line with similar ones adopted by the American Association of Marriage and Family Therapists, the American Psychological Association, and many other mental health and medical organizations.

Statement on the Ethical Treatment of Sexual Orientation and Gender
San Francisco chapter of CAMFT

Recent events regarding the debate over marriage equality have raised larger concerns about ethical treatment in areas where the personal, cultural or religious beliefs of the clinician conflict with evidence-based practices and the standards of care accepted by our profession. Nowhere has this conflict been more profound than in matters concerning the treatment of sexual minorities (i.e., LGBT clients) and people with non-conforming gender identifications.

We recognize that some clinicians feel bound to offer treatments that are line with their personal, cultural and religious convictions, even when these beliefs conflict with evidence-based research. We also recognize that some clients feel compelled to try and change aspects of themselves to better fit into cultural and religious norms that privilege heterosexuality and certain stereotypes of masculinity and femininity.

Recognizing these pressures, the board of the San Francisco chapter of CAMFT wants to clarify that it is unethical for clinicians to recommend or support treatments that seek to alter a person’s sexual orientation or mode of gender expression. Rather, we believe that therapeutic treatments should be aimed at helping clients come to terms with their sexual orientation and discover authentic modes of gender expression rather than try to change them.

This ethical position is consistent with the empirical research accepted by our profession, which holds that sexual orientation change efforts (SOCE) do not lead to effective, enduring or beneficial change. Moreover, much of the literature emphasizes the harm to clients that can result from such efforts (Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation, 2009; Serovich, et. al., Journal of Marital and Family Therapy, 2009). Likewise, therapeutic approaches that force a person to conform to culturally expected modes of gender expression can result in harm to the person’s identity formation (APA Policy Statement: Transgender, Gender Identity, and Gender Expression Non-Discrimination, 2008).

photograph copyright Susannah Conway

I’ve written a lot about mindful awareness in relationships, and this practice can apply to many other areas of life, as well. Food and eating is one of them. I read a book by Evelyn Tribole and Elyse Resch called Intuitive Eating, which I really liked, and wanted to share their 10 principles with you. Mindful awareness plays an important role.

Intuitive eating is a practice that involves distinguishing between physical and emotional feelings. Tribole and Resch write that it’s also “a process of making peace with food — so you no longer have constant ‘food worry’ thoughts.” Their approach calls for recognizing our self-worth regardless of what we eat. In our culture, this is still pretty revolutionary. Their approach also naturally leads to cultivating a more trusting and compassionate relationship with ourselves.

Here’s an abridged version of their 10 principles of intuitive eating, which you can find in full on their website and in their book:

1. Reject the Diet Mentality Throw out the diet books and magazine articles that offer you false hope of losing weight quickly, easily, and permanently. Get angry at the lies that have led you to feel as if you were a failure every time a new diet stopped working and you gained back all of the weight.

2. Honor Your Hunger Keep your body biologically fed with adequate energy and carbohydrates. Otherwise you can trigger a primal drive to overeat. Once you reach the moment of excessive hunger, all intentions of moderate, conscious eating are fleeting and irrelevant.

3. Make Peace with Food Call a truce, stop the food fight! Give yourself unconditional permission to eat. If you tell yourself that you can’t or shouldn’t have a particular food, it can lead to intense feelings of deprivation that build into uncontrollable cravings and, often, bingeing.

4. Challenge the Food Police Scream a loud “no” to thoughts in your head that declare you’re “good” for eating under 1000 calories or “bad” because you ate a piece of chocolate cake. The Food Police monitor the unreasonable rules that dieting has created. The police station is housed deep in your psyche, and its loud speaker shouts negative barbs, hopeless phrases, and guilt-provoking indictments.

5. Respect Your Fullness Listen for the body signals that tell you that you are no longer hungry. Observe the signs that show that you’re comfortably full. Pause in the middle of a meal or food and ask yourself how the food tastes, and what is your current fullness level?

6. Discover the Satisfaction Factor In our fury to be thin and healthy, we often overlook one of the most basic gifts of existence — the pleasure and satisfaction that can be found in the eating experience. When you eat what you really want, in an environment that is inviting and conducive, the pleasure you derive will be a powerful force in helping you feel satisfied and content.

7. Honor Your Feelings Without Using Food Find ways to comfort, nurture, distract, and resolve your issues without using food. Anxiety, loneliness, boredom, and anger are emotions we all experience throughout life. Each has its own trigger, and each has its own appeasement. Food won’t fix any of these feelings.

8. Respect Your Body Accept your genetic blueprint. Just as a person with a shoe size of eight would not expect to realistically squeeze into a size six, it is equally as futile (and uncomfortable) to have the same expectation with body size.

9. Exercise — Feel the Difference Forget militant exercise. Just get active and feel the difference. Shift your focus to how it feels to move your body, rather than the calorie burning effect of exercise.

10. Honor Your Health — Gentle Nutrition Make food choices that honor your health and tastebuds while making you feel well. Remember that you don’t have to eat a perfect diet to be healthy. You will not suddenly get a nutrient deficiency or gain weight from one snack, one meal, or one day of eating.

photograph copyright Susannah Conway

Money is often one of the hardest subjects for couples to talk about. First, each of us has a unique history around money, beginning with our family of origin, and this can be hard to articulate. Second, money is such a multidimensional topic, connected to issues of independence, safety, freedom, work and pleasure. Couples can easily fall into misunderstandings.

Sometimes my work is to help couples get the conversation going and keep it on track. Sometimes my work is to help each partner figure out what’s important around money and identify their deepest values. When the conversation becomes more collaborative instead of combative, real understanding and change can take place.

Conversation around money are also very practical. Couples have to make tons of financial decisions together. When they don’t have a share language or vision, it can be that much harder.

John Gottman writes that the task for couples and money is “balancing the freedom and empowerment money represents with the security and trust it also symbolizes.” He suggests taking three practical steps, which I recommend to couples, if you’re willing to try.

First is to itemize your current expenditures. This is everything from rent to laundry to haircuts. Second is to manage everyday finances. This involves prioritizing expenses, strategizing around any compromises, and deciding who’s going to get the bills paid. Third is to plan your financial future. This means talking about your hopes and fears for the future, figuring out the similarities and differences, and taking steps to meet each partner’s goals.

You can read more about each of these steps in Gottman’s book, The Seven Principles for Making Marriage Work, in the section titled, “Coping with Typical Solvable Problems.” And although her TV personality can be a bit odd, I like Suze Orman and think she offers solid practical advice. The Motley Fool is another good site, especially for more info about investing.

My task, which I enjoy, is to help couples talk about both the practical and emotional aspects of money and come up with creative conversations, compromises, and solutions.

Let me know if you have any specific questions about couples and money that I can answer in a future post.

antique cash drawer photograph – copyright Sue Hammond 2009

Arthur Kleinman is a medical anthropologist, psychiatrist and former chair of the Department of Social Medicine at Harvard Medical School. Some time ago, I came across a series of questions that he suggests asking clients to better understand how they view their difficulties.

Kleinman emphasizes understanding a patient’s perspective, or explanatory model, on his/her illness or problem. He advocates becoming therapeutic allies around treatment and expected outcomes. His questions offer a powerful bridge to understanding clients whose cultural backgrounds and assumptions may be different from our own. I really like his approach and find it to be humane, respectful and contemporary.

Here are some of the questions he suggests asking:

• What do you think has caused your problem?

• Why do you think it started when it did?

• What do you think your illness does to you?

• How does it work?

• How severe is your illness? Will it have a short or long course?

• What kind of treatment do you think you should receive?

• What are the most important results you hope to receive from this treatment?

• What are the chief problems your illness has caused for you?

• What do you fear most about your illness?

Kleinman’s books include Patients and Healers in the Context of Culture, Pain as Human Experience, and Rethinking Psychiatry.

I’ve been reading a book by Glen O. Gabbard where he outlines some of the goals we work on in psychotherapy. Gabbard is a professor of psychiatry at Baylor College of Medicine and a respected writer in the field of psychodynamic therapy. Below I elaborate on some of his outline in my own language.

Just as each person is unique, so are his/her goals in therapy. So this list is more of a guideline than a prescription. Ideally, a therapist and client work together to figure out the right goals, and they can change over time. Gabbard’s outline helps us think about the overall process of therapy and some of its unique benefits.

Resolving inner conflicts
We all have inner conflicts — parts of ourselves that want different things. For example, one part of us may want a relationship (i.e. love and companionship), while another part doesn’t want to feel tied down. One part of us may want a promotion at work, while another part doesn’t want the new responsibilities. These kinds of conflicts naturally bring up anxiety. In therapy, we can explore and identify these inner wranglings and resolve some of the anxiety. Often we’re not even aware of our mixed feelings until we talk about them. Then we can make more effective and adaptive choices.

Knowing yourself
Therapy is an opportunity to take one hour out of the week and get to know yourself better. Discover more deeply how you think and feel and why certain patterns appear in your life. This is the difference between knowing who you really are, instead of who you’re supposed to be. As Gabbard says, “The outcome of therapy should result in feelings of ‘living in one’s own skin’ and of being authentic.”

Making good relationship choices
We all need people and relationships in our lives. This is about choosing people who treat us well, who we enjoy being with, and who will support our deepest goals and aspirations.

Being self-responsible
It’s easy to blame relationship problems on other people. This is about knowing our own sensitivities and taking responsibility for them. Therapy provides a unique space to learn about our relationship patterns, which may arise in the therapy relationship itself.

During my training years, I worked in a number of community mental health settings and really appreciate the work of these organizations. Listed below are a few good places to know about, whether you’re a health professional or a client.

In future posts I will create a more comprehensive list of resources specific to substance use, sex information, and post-traumatic stress, among other areas. If you know of good, local organizations to include, or would like me to cover a specific health area, please let me know.

San Francisco Suicide Prevention & Crisis Line
www.sfsuicide.org
24-hour crisis line: 415.781.0500
Institute on Aging – Friendship Line for the Elderly
www.ioaging.org
415.752.3778
The Riley Center
www.rileycenter.org
Safe and confidential services for women in abusive relationships and their children.
24-hour crisis line: 415.255.0165
Community United Against Violence (CUAV)
www.cuav.org
The nation’s first LGBTQQ anti-violence organization. Will also provide services to men in straight relationships.
24-hour crisis line: 415.333.HELP (4357)
San Francisco Women Against Rape
www.sfwar.org
Provides direct services and community education for survivors of sexual assault.
24-hour crisis line: 415.647.7273
Ohlhoff Recovery Programs
www.ohlhoff.org
Residential and outpatient programs for chemical dependency and eating disorders.
877-677-4543
Harm Reduction Therapy Center
www.harmreductiontherapy.org
Offers outpatient therapy and treatment services to people interested in an alternative approach to addiction help.
415.863.4282

KQED’s Forum with Michael Krasny had a good program earlier this month on Obsessive Compulsive Disorder. The guests included Dr. Tracy Foose from Langley Porter Hospital at UCSF and the comedian Howie Mandel, who has written a memoir about his struggles with OCD.

The third guest, Jeff Bell, is the author of Rewind, Repeat, Replay and a national spokesperson for the Obsessive Compulsive Foundation.

I thought the program offered a compassionate understanding of the disorder and some good information on how it works and the brain/environment relationship. I always appreciate when people affected by a disorder are willing to speak out about their experience. Both Howie and Jeff were generous and thoughtful in their comments. I think the program is worth listening to if you’ve suffered from OCD, are a family member of someone impacted by the disorder, or just curious about it.

Hearing the program reminded of another memoir that’s been on my list for a long time, Jennifer Traig’s Devil in the Details. Jennifer suffered from OCD, among other things, throughout her childhood. While her illness sounds incredibly painful, she’s a terrific writer and wrote a compassionate, hilarious book.

My colleague, Isadora Alman, has a very good article in her online library called “Saying No Gracefully.” This seems like a good reminder for us all, especially around the holidays. You may recognize Isadora’s name from her “Ask Isadora” columns on sex and relationships.

Why is it so hard to say no? Sometimes we’ve never learned how, or we forget, or we’re with new people in new relationships. In the article, she offers 9 guidelines for saying no with grace. A few of my favorites include using “I” language, such as, “I enjoy your holiday parties, but I can’t make it this year,” and saying no clearly and firmly, such as, “I’m flattered, but no thank you.”

She also talks about allowing the asker to retain his or her dignity. She advises that we acknowledge the other person took a risk, saying something nice about them or the encounter, while maintaining our stance. For example, “I can’t make plans for next week right now, but I’ve enjoyed spending this time with you. Thanks for asking.”

The full copy of Isadora’s article is available in her online library — it’s the fourth one down from the top.

Earlier this year I wrote an article for Bridge, a local journal for therapists and other health professionals, on helpful practices for couples to build and strengthen their relationship. The three practices I wrote about are mindfulness, cultivating wise mind, and sharing appreciations.

You are welcome to download a copy of the full journal with my article.

Practicing mindfulness allows us to become more aware of our own sensitivities. Knowing our sensitivities, or triggers, can help explain why we get so upset with our partner, and why certain things he/she does drives us crazy. This also helps regain some presence of mind in heated moments.

Cultivating wise mind allows us to bring both our emotional mind and our logical mind to the situation. Sometimes we get in trouble when we rely too heavily on one or the other. The integration of these two states of mind is known as wise mind.

Sharing appreciations is another good practice. In the article, I describe how it works — basically, each partner takes a turn sharing something he/she admires or appreciates about the other. This brings both people into the present moment and really increases honesty and intimacy.

Again, here’s the full journal with my article, and please let me know if you’d like to join the Bridge mailing list for future issues.

“There is not one kind of healthy self — there are many kinds.”
— Heinz Kohut

In the past couple of years, I’ve started teaching graduate students and providing informal consultation to MFT Interns. This work has inspired me to revisit some of the foundational literature in our field, including self psychology.

In my practice, I use a variety of approaches and work with many different kinds of clients, including adults, couples and children. Self psychology provides a helpful starting place for all of this work. Basically, self psychology says that a healing therapeutic relationship is based on empathy, understanding and repairing any ruptures that may occur. This provides a foundation for clients to address the deeper concerns that bring them in to therapy.

I recently wrote a two-part article on self psychology in the San Francisco-based professional journal, Bridge. If you’d like to see a copy of the journal, please drop me a line and I’d be happy to send one to you.