Doctors Vicarious Trauma Therapy

Doctors Vicarious Trauma Therapy

Dr. Kate: Good evening Los Angeles, welcome to Behind Closed Doors heard at every Saturday at 6 pm right here on Talk Radio 790 KABC. I’m Dr. Kate Balestrieri.

Lauren: And I am Lauren Dummit, licensed Marriage and Family therapist.

Dr. Kate: And we are the founders of Triune Therapy Group. A Psychotherapy practice based here in Los Angeles. Behind Closed Doors is a show about sex, relationships, mental health, addiction, staying healthy and other related current events. Today, we are going to be talking about a really sensitive topic. It’s hard for a lot of people in our field to really address so transparently and that is what to do when the helpers need help. 

We often work with a lot of professionals who are struggling and can be really challenging to ask for the help we need. So if you have any questions about this topic feel free to give us a call at Triune Therapy Group. We are here to help in a lot of different ways and you can reach us at 3109334088 or you can message us on Instagram and Facebook at Triune Therapy Group. 

So Lauren the reason I thought it would be interesting to talk about this topic is because I’ve been training a lot of our new staff and working with a new group of students at the University where I teach and one of the things that we talk about a lot is how to address vicarious trauma and compassion fatigue and burnout and kind of what’s the difference between all of those things. I know as helpers whether you are a psychologist, a therapist, an attorney, a physician, a social worker, you got the call to action at some point in your life. And you are compelled to help people and that carries with it so many rewards but also can be kind of taxing and I think it’s a hard thing for people to talk about right…

Lauren: When I use to work at Children’s Hospital, the mental health group would actually do yearly retreats to promote self care just mostly as a message about how important it is because when you are working with trauma and when you are working with addiction it is really emotionally draining even though it can be really rewarding and I think it’s so important to have not only a way to practice self care but also to release tension and stress. For me, I know I am very physical so you know doing yoga, running, things like that really are crucial to my mental health maintenance. I think it is also really helpful to do case consultations. It’s very helpful to have you in the office to work with and be able to get support when needed. 

I think it’s really important. There’s a lot of addiction professionals that treat addiction that are in recovery themselves and so I think that we have to remember that we are not always just the professional but the patient too and what do we need to do to maintain that.

Dr. Kate: That’s a really good point. At the end of the day, even the helpers, everybody in the healing professions and the helping professions- we’re still human beings. Often time’s people say to me, Oh God Kate do you take your home with you? I’ve gotten so much better as I have gotten older but I have gotten better as I have gotten older. It’s hard from time to time. When we aren’t taking good care of ourselves then often we run the risk of being ineffective in our personal lives, being ineffective at work, and sometimes even worse.

Lauren: I notice when I am not setting appropriate boundaries, I get resentful. So if I am starting to feel resentment towards families, towards patients, towards coworkers I know that it’s me not taking care of myself and that’s a big red flag.

Dr. Kate: Yeah, absolutely. I think about how much training we get in our field, being in therapeutic world about what is vicarious trauma, what is burnout, what is compassion fatigue, what does it really mean in our lives?. Not every profession places such an emphasis on self care. A lot of the professionals that I speak with and have worked with clinically will talk about maybe we talked about self-care once or twice when I was in grad school or every once in a while the hospital will put on some kind of a lunch and learn event about this topic. But, for some people they really don’t get a lot of exposure to what these terms mean and how to safeguard themselves.

Lauren: Right. There’s a lot of professions where they are not being so educated about the mental health piece. For example like, firemen our first responders and they see a lot of trauma. If they have a history of their own trauma can really be triggering if not in and of itself.

Dr. Kate: Absolutely. When do you remember about the first time you learned about vicarious trauma?

Lauren: The first time I learned about vicarious trauma I believe was probably in grad school. I mean really in depth. I had an idea of what it meant from gathering here and there but I think it was in grad school that I really started to understand what it is in its full complexity.

Dr. Kate: I remember being a pre-doctoral intern at a very rura setting where we treated sex offenders exclusively and given the context of that work our supervisory team was really proactive in teaching us about vicarious trauma and keeping ourselves sane in that environment. It’s very chaotic and very high conflict environment at times and the way that they introduce us to the topic was to play a call from a woman who had been calling 911 and she was in the process of being sexually assaulted and so we heard her call and the reason they chose to share that tape with us was so that we really could get a good sense of what it would be like to be in the room with someone who is reliving their experience. I will never forget the impact of that.

Lauren: I can imagine. Yeah it was heavily stressed at my first internship as well because I was working with sexual abuse in children. That’s a really difficult topic to work with for anybody. Thank God I didn’t have children and I often looked around at my colleagues and was thinking like how did they do this and in that job setting it was really stressed and really modeled for us. 

Dr. Kate: What are some of the signs that you can think of that would tell someone that they are starting to encroach on being burnt out or having some compassion fatigue and they need to start looking at improving their self care?

Lauren: Well time getting which is when we are not balanced and we are spending too much time on this and not having enough time for this. Just feeling anxiety and feeling kind of frazzled all the time, kind of an inability to focus. Again, resentment and betterment, fatigue.

Dr. Kate: I think about the chronic fatigue and often the physiological signs of some sort of burnout or compassion fatigue that might be kicking in. If you are someone who works in a very high intensity environment whether you are first responder or you are working in an inpatient unit somewhere, working in an emergency room or you have a lot of legal cases that require all of your attention and there are lots of deadlines. It’s really important to pay attention to the queues that your body is giving you. Are there changes in your appetite? Do you notice that you are engaging in a lot more emotionally driven eating or not eating rather? Are you suddenly plagued by an inability to sleep effectively, where you once had really good sleep routine?

Lauren: Sleep is so important and that’s what you see a lot especially in our talking about doctors and professions where they are working really long hours. Sleep is often the first thing to be sacrificed and one of the most important things in terms of like restoring their physiological balance. 

Dr. Kate: Absolutely. When you think about different ways that our nervous system is trying to tell us to pay attention right, we might feel dizzy, we might feel not really present, we might have headaches more and it’s just really important I think to develop a conversation with your own somatic queues and really get real about what’s going on.

Lauren: I think that’s really important because so many people don’t even have that conscious awareness. They as well just side pop a few Advil and not really think anymore about it.

Dr. Kate: Well you know the demands of our work as helpers regardless of what field you are in, are acut to an intense and often times it’s easy to just say okay I’ll deal with that later and we build up this chronic avoidance like you were talk about the time jetting and all of a sudden months and years have gone by and we are like oh yikes. I really need to take care of myself.

Lauren: Even going back a few episodes when we had Stan Tatkin on and he was talking about managing thirds. I think about a lot of people that are in this profession and a lot of helping professions they become very passionate about the work they are doing and in terms of the time jetting, sometimes they have difficulty balancing family life, married life, and relationships and so other things suffer as well.

Dr. Kate: At Triune Therapy Group, one of the things that we do a lot is work with people who are trying to get rebalanced and trying to offset some of the load that working in the helping field can sometimes take on. We do that through lots of different kinds of customized intensives to help people sort through any vicarious trauma or help them get recharged and rejuvenated so they can go back to doing what they love. We have seen the toll it takes on people and when they start suffering in their work with just a thing they were so passionate about to begin with, it really can take an existential toll who they are and how they see themselves as an individual.

Lauren: Right and sometimes even by not taking care of their own needs it can trigger their own early childhood trauma of having been neglected or whatever it may be in their family of origin. So often we are doing these intensives with people and we are seeing that they are having problems at work and had to quit their jobs and it turns out it was triggering all their childhood trauma of not having their needs met. 

Dr. Kate: Right and we don’t work in a vacuum, but our work extends into all of our personal spheres of influence and domains of living to self, when we are not taking care of ourselves personally it affects everything and so it’s really important I think to address of who we are as helpers. We have to take a quick break but when we come back we are going to talk more about helping the helpers with Dr. Greg Skipper and Dr. Matt Goldenberg, two amazing physicians who head at the Centre of Professional Recovery here in Santa Monica. Their program is designed to help the helpers and they are going to tell us about why it’s so critical, so more when we come back. In the interim stay with us and follow us on Instagram and Facebook at Triune Therapy Group. Message us with your questions.


Dr. Kate: Welcome back, you are listening to Behind Closed Doors. I’m Dr. Kate Balestrieri.

Lauren: I’m Lauren Dummit, License Marriage and Family Therapist.

Dr. Kate: And together we are the cofounders of Triune Therapy Group here in Los Angeles. Today we are talking about helping the helpers with special guests Dr. Greg Skipper and Dr. Matt Goldenberg, the dazzling medical team that heads up the Centre for professional recovery in Santa Monica California so welcome to the show. Thank you so much.

Dr. Greg: Thank you. Glad to be here.

Dr. Matt:  Same here.

Lauren: So tell us a little bit about yourselves and how you came to specialize in treating professionals in recovery.

Dr. Greg: So as you said my name is Dr. Greg Skipper. I’m a physician and I got interested in this after my own struggle with addiction 28 years ago and was volunteering to help other docs. So I am a physician. I was an internal medicine doctor. I got addicted to opioids after breaking my leg playing soccer and just didn’t know what was going on but I did all the usual inappropriate things as it progressed and was confronted and so I volunteered to help other doctors and I really enjoyed it and so a number of doctors came back and said you really saved my life. I was feeling suicidal and you gave me hope. So that kind of turning lemons into lemonades sort of thing happened for me where I have gradually started working more and more with health professionals and then I worked for a medical board programs to help licensees, license practitioners.

 About 8 years ago came out to Santa Monica, we ran an evaluation program where professionals were sent to us where there’s a question of are they okay because they came to work with alcohol under their breath or they were diverting drugs or whatever. It’s quite common as you talked earlier the stress and all that of practice and things that happened. Health practitioners are not invulnerable they fall to the same temptations as everybody else as they try to cope and deal with complex difficult lives and so we evaluate them and we have a small a treatment program for focusing on that group.

Dr. Kate: Wonderful. Dr. Goldenberg. How about you? How did you get involved in this field?

Dr. Matt:  So I’m not in my own recovery but through professional experience is how I came on to be in the field or be in the position where I have been treating healthcare professionals. I actually like many of your listeners had some addiction in my family and so I had an early exposure to many high functioning folks including family members who are struggling with addiction despite all the other successes in their lives. During my training some of my mentors who are my program directors were in a position where she was helping other physicians who are in recovery and so it gave me this look and do to what you just described before as helping the helpers. I was really drawn to that and during that process I met Dr. Skipper and about 2 years ago we started working together and it’s just been an amazing experience to be able to help people from all over the country who are themselves helpers get back to their lives and do extremely well.

Lauren: I think there’s a lot of people that are probably listening thinking. You know when you are talking about doctors without their training and knowledge. Like how do they become addicted? Wouldn’t you think that they would know better?

Dr. Greg: Yeah I was on a talk show one time and that was the first question when I came out in that segment. They were like how can doctors with all their training and knowledge get involved in something like this? Well my answer was we are human beings. We have the same needs and struggles that other people have of course and as a matter of fact I think sometimes it’s more intense because you talk about vicarious trauma. There is actually direct trauma in training. The kind of things that particularly physicians used to go through maybe and continue to go through where they work extremely long hours are expected to actually neglect their own needs  because the intensity of focus on helping the patient is so extreme. You get interns and residence they are really traumatized by their training.

Lauren: And the sleep deprivation is rampant.

Dr. Greg: The things they witnessed. Children with leukemia or whatever it is where people have these terrible problems and how do they deal with that. There’s not much focus on taking care of them.

Lauren: There’s a lot of readily available access to pharmaceuticals as well so I know that there’s a lot of nurses and various positions and watch that become an issue.

Dr. Greg: So nurses, pharmacists, the medical field particularly seem to have higher rate of trouble and it’s just they have all these exotic chemicals that they give every day to help people relieve pain and they get curious. There’s been a lot of debate about why do they fall into this but its access is right there and maybe they have a curiosity about that kind of thing to get into that field. There’s been some talk that there is molecules in the operating rooms of fentanyl and things like that sensitize their brains. People have measure their hair in operating rooms that have these chemicals. Nobody really knows for sure but that type of physician does have a higher rate of trouble. It was more serious drugs as well.

Dr. Matt:  I think physicians and other healthcare providers tend to be more the same than usual public than different. The lifetime prevalence rates are about the same 10-15%. Number 1, tends to be alcohol for both the general public and for physicians and other health care providers. As Dr. Skipper just mentioned, number 2 for the general public tends to be illicit drugs because that’s what they have access to, for healthcare providers especially those who have access in their practice. It tends to be prescribed medications one of the things that they have access to. 

It’s a bit of an occupational risk and I think again typical to the general public, there’s often times underline trauma or attachment issues, depression, and anxiety and then there is pressure to stay in the job. There is no one backing you up if you are a doctor in many cases and so with access to some of these medications they’ll try them to try to help themselves and then they end up becoming addicted to it so self treatment or self care we kind of make the distinction. Self care is really important to sleep, to exercise, the diet. But then if you start treating yourself for things that are outside your scope or even if they are inside your scope. As a psychiatrist I have not treat my own depression. That’s where I think people run into some trouble and that’s where turning over to professionals who help with both mental health issues and addiction is the way to go so you don’t end up kind of going down that snowball effective, becoming addicted after you are just trying to get the help that you need.

Dr. Kate: Why do you think some doctors, attorneys, dentist, other licensed providers or helpers out there would be really good at hiding their addictions?

Dr. Greg: Why are they good at it?

Lauren: Yeah.

Dr. Greg: One is they are motivated to have it because there is so much shame associated with it. They think how can this be happening to me or they are in denial and all that and then they are just smart. They are smart people and they are like most people when they have shame about their behavior they hide it. They know the half life of drugs and they know whether there’s a urine test that kind of thing which usually they are actually which just kind of controversy. It should help professionals be randomly tested like pilots or Wal-Mart employees or other folks sometimes are tested. If they don’t want to get caught they figure out ways and we see all these crazy ways to avoid detection, using breath mints or saying they use breath mints water or mouthwash when they drink or other things to kind of mask taking when you are on an opioid makes your pupils change so they are not quite as obvious and so forth. They have their ways.

Dr. Matt:  I think sometimes they get enabled even if their support network whether it be family or an office manager they might not consciously decide I am going to help this person and not get caught with their addiction. But if you imagine a senior partner in a law firm it may have a drinking issue people are going to be more likely to help them out because everyone livelihood the reputation of that lawyer as well as the firm is at stake. Sometimes I think they accidentally will kick the can down the road thinking there’s a lot of fear about getting somebody help because what’s going to happen if they are gone in treatment or if they get in trouble where it’s really a career extender getting people help. So sometimes it’s their support network I think that actually enable them to get the help that they needed.

Lauren: I’m sure there is also a lot of fear of coming forward. You guys see hands on the process of staying, getting doing what they need to do to stay in their career but I am sure there are so many people that are afraid of losing their license.

Dr. Greg: They don’t know what will happen but they know it will not be good. They could lose their license; they could be out of work for a long time. We see I just want to further what Dr. Goldenberg was saying that in small practices like demo practices or veterinary practices particularly where they don’t go to the hospital it gets to be this closed little universe of employees that are trying to protect their boss. So we have seen a dentist who the staff coming in the morning and he has got the nitrous on his nose and the tank is all frosted up and they try to lock it so he can’t get in it anymore and they try to protect him and so forth and it kicks the can down the road as you said until a future crisis.

Dr. Kate: Absolutely. I think I’ll sometimes employees or other staff in the office in those contexts can be really afraid of what might happen. They might lose their job if they confront their boss about the concerns they might have around any kind of problematic substance abuse or other addictive behaviors. We work with a lot of people whose addictions are behavioral and process oriented. When they come to us often they say things like oh my gosh my employee staged an intervention for me and I didn’t realize what a tyrant as I was being as I was in the thrills of my addiction and thankfully they said something to me but it takes employees a long time sometimes to really decide if they want to intervene and make things known.

Lauren: Right and when somebody is abusing substances I mean clearly boundaries often go out the window and so that really kind of shifts the relationship and I think  a lot of people walk around and fear because they don’t know what the clear boundaries are.

Dr. Kate: It’s interesting, a lot of people will say things to me like Kate you know if somebody has an issue shouldn’t they just not be allowed to practice anymore. If they can’t control themselves how can they be a good provider, a good helper for other people? I am curious what your thoughts are on that.

Dr. Matt:  Yeah we get that a lot. I think addiction is I would say the most stigmatized medical illness there is. There is a lot of data out there showing that the relapse rates and addition some of the relapse rates for if you have high blood pressure, if you have diabetes and so with the right treatment and after care some of the people who come in with really severe cases of addiction end up being the most safe providers there are. We know anesthesiologist who are under monitoring which means it could be drug testing and people keeping a close eye on their care tend to be the most safe and well balanced providers because they are actually having to go to the self care meetings, they are having to see a psychiatrist or therapist and so it’s actually the contrary and if we take the stigma and the shame out of the disease of addiction people who get help with addiction are probably our safest and most I would say balanced on emotional and energy level of the providers out there.

Dr. Kate: I couldn’t agree with you more. I mean a lot of things that I tell my students about self-care the number one thing I try to emphasize with them is that self care is not a luxury in our field. Self care is an ethical mandate and if we are not practicing it then we run the risk of really providing high trauma or ineffective care to our patients I agree. When somebody gets into recovery, recovery is about balance and creating a life that is really integrated. When we have helpers out there who are modeling that for themselves and for their people I think we get a lot more care. 

Lauren: It’s interesting because I have had people comment like oh you are so disciplined with your yoga or your exercise. I often think it’s not really a choice, I do love it but it’s actually a necessity. 

Dr. Kate: Well we have to take a quick break but when we come back more about helping the helpers with Dr. Gregg Skipper and Dr. Matt Goldenberg from the Centre of Professional Recovery. Stay with us we’ll be right back.


Dr. Kate: Welcome back you are listening to Talk Radio 790 KABC. This is Behind Closed Doors. I’m Dr. Kate Balestrieri.

Lauren: I’m Lauren Dummit, Licensed Marriage and Family Therapist.

Dr. Kate: And together we are the cofounders of Triune Therapy Group a Practice here in Los Angeles. If you are just tuning in we are discussing a really important topic today, helping the helpers with Dr. Greg Skipper and Dr. Matt Goldenberg, two of the medical professionals at the Centre for Professional Recovery. We just were talking about what happens when the professionals in any given industry or the helpers get in trouble and find themselves not coping well and struggling with an addiction. I’m curious, what’s your experience of the wreckage that untreated addiction can cause in the lives of professional helpers.

Dr. Greg: So I always talk about the 5 Ls. Liver which like health issues so people start running into difficulty with their health, lover, which relationships so they have that trouble. The Law so way to get people help unfortunately, their Livelihood start having difficulty at work and then with health professionals their License. That’s usually the last. For some reason particularly physicians I think probably all health professionals know the value of their license. They have worked hard for many years to become trained and that’s usually a last thing that goes. Their marriage will be wrecked. They might get a DUI or start losing a job here and there but they try to protect their workplace. So we sort of see that as the end stage when they start coming in intoxicated or stealing drugs from work, that kind of thing is at least when it’s overt. That’s sort of the last stage but we see it quite a bit and people are afraid to get help.

Dr. Kate: Well as helpers, especially licensed helpers we work so hard to get those licenses and it takes a really long time so that is something that most people in the helping professions really cling to as kind of a badge of honor and a badge of identity in addition to it being a function.

Dr. Matt:  I do think they do work exceedingly hard to protect so it sometimes makes them so effective at not getting the help they need earlier because they are in a way kind of covering it up. But I think that also when you look at there’s underline things, difficulty with coping, difficulty finding reward with drugs or alcohol and if those things aren’t addressed eventually those may take their toll. So we know that burnout is associated with depression and anxiety and medical conditions as well and so suicide and so we worry is somebody who has burnout or underline trauma and then on top of it addiction which can decrease your ability to make reasonable decisions and make you more impulsive leading to things like suicide or disruptive behavior at work. So it’s really looking at those underlying processes that aren’t being addressed and what happens when those go down the line without treatment in addition to the addiction on top of it.

Lauren: Do you often get people that are referred into treatment with you because they have made medical errors due to intoxication. I’m sure there are a lot of listeners that are interested in that in terms of their own health care providers.

Dr. Greg: It’s a relatively rare phenomenon. I think for the reasons we just said is doctors do try to protect the workplace. So more and more we see people referred because they have been missing work or they may come in with the remnants of alcohol in their breath over party last night. They are not overtly intoxicated but somebody can smell them or they are just unkempt or they don’t look happy. Or there’s this rumors about what they do on their off hours. There was a party the other night and they came out of the bathroom with white powder on their nose and seemed out of it or things like that will a lot of times trigger a report.

Dr. Matt:  I think it’s a big reason to get treatment because if there is an allegation made you have to defend your license, you have to defend if it becomes a criminal issue. So it’s a big reason why we recommend getting treatment when you need it and not putting yourself at risk of those types of things. We know the data shows the doctors who get treatment and get monitoring do exceedingly well I think from the doctors who are in the physician health programs which will monitor them after treatment. There is I think no published data that I am aware of where they showed patients who are put at harm. I look at a similar program which is pilots for the FAA and I just went to a training last year and they have been doing this for a couple decades now and there has been no pilot who has been in aftercare monitoring with them that has safety issues related to substance use. I mean the data is there that this treatment works so we can decrease stigma and get more people in.

Dr. Kate: Do you have any data on the rates of recovery effective sustained recovery for people who go through a professionals program such as yours versus the general public in terms of maintaining?

Dr. Greg: Yeah, there is really good data now. There have been a number of studies. We just actually compiled all those studies of over 20 studies. The largest, I was one of the principal investigators. We looked at over 900 docs all physicians who had signed monitoring contracts and they had about 79% 5+ year total abstinence rate. So that’s a lot higher than the general population. People tend to relapse about 50% at 6 months so much better. For a number of good reasons I think health professionals are more kind of forced to get good health and they can’t just say I am done after 2 weeks, thank you very much I’ve had enough. They kind of have to get completed so when we work with them we want them to start exhibiting what we call recovery behaviors. Self disclosure and asking for help and doing things that show us that they have some recovery going. The other thing is they are monitored for a long time so they do get after care that’s really required if they want to go back to work. And so we have looked at other populations like the criminal justice systems now have some programs. They are not all great but there are a few like hope probation out of why 24/7 is a program and they’ve looked at managing people on probation similar to how we manage doctors and they do really well. So starting to look like there is a system for care of addiction that really works and we would like to see more people have access to it.

Dr. Kate: Absolutely.

Lauren: They have a lot at stake.

Dr. Kate: They do.

Dr. Greg: Everybody has a lot at stake. If you can find what they have at stake, their family, their health so we look for that and we try to plug everybody into that same kind of model of long term follow up.

Dr. Kate: That’s a really strong algorithm, the model of recovery but particularly one of the things that are so big in recovery is accountability and what I am hearing is that the professional programs really have established a solid plan for accountability and really helping people to develop that. 

Dr. Matt:  The average contract is about 5 years which is data driven because relapse rates decrease over those 5 years getting people on recovery having solid program around them. One of the things we do even for the non healthcare professions they have private monitoring companies who do much of this work. You can be using a  breathalyzer device to make sure there’s no alcohol on board or random drug testing’s, somebody who is taking accountability of the meetings you are going to. So even if you are an accountant, but if you are not a health care provider and you do accounting or you are a CEO or you do stock brokering there are monitoring companies that we will set people up with so that they can have the same level of after care and accountability as their healthcare providers do. I think that’s something the general public doesn’t normally know about. We see well over 30 days of rehab but this is a pretty evidenced based after care model that’s been shown to decrease relapse rates and improve outcomes so I think that’s one of the messages we spread today that this is an important piece of recovery is getting monitored.

Lauren: So when people come in for treatment I am curious the rates of cross addictions you see with other process addictions and things like that and how that affects your treatment. How do you treat that?

Dr. Matt:  What I see a lot is it’s the underlying thing that’s coping, rewarding and escaping. And so somebody may come in with cross addictions. We see depending on the drugs abuse but if you are using stimulants and cocaine there might be some sex addiction or sex and love addiction going on but what also happens is if you just treat the addictions, if you come in with say an alcohol use disorder and we just take that away and that’s what you use to escape or cope or to reward yourself. It tends to be something else that will pop up. So now it’s an eating disorder that comes aboard or now it is a sex and love addiction issue and so I think both if somebody presents with it or if the addiction the underlying issues related to the addiction aren’t addressed properly then it tends to present itself later. So more often than that there’s something related underneath that needs to be addressed.

Dr. Kate: You bring up a really interesting point Dr. Goldenberg and I think a lot of people in the helping field and also in a general population don’t necessarily understand that the function of an addiction is that it started as a coping strategy. So this is a way whether it’s through our relationship with money, with food, with sex, with love, with alcohol, with cocaine, this is a way that we try to feel better when feeling bad was the norm. I think when we really break it down in that way there is no shame in trying to acknowledge the help that we need to find new coping skills and develop coping strategies but you are absolutely right. When people try to quell one addiction as we talk about in the recovery rooms, they are not really addressing the underlying mechanism that the addiction serve for the, which was learning how to just cope. So we do see something pop up where there was no eating disorder before for example. 

Lauren: Moreover on this topic, that’s actually where we got our name Triune because we are talking about the triune brain which is relative when you are addressing trauma with the idea that we really want to focus on the underlying issues behind addictions and other mental health issues because it’s usually not the problem. There’s usually some underlying trauma even if they are not aware of it.

Dr. Kate: Absolutely.

Dr. Matt:  I think that can be helpful for the families to understand how addiction takes place. It’s the same areas of the brain that we evolutionarily need to be able to care for our young, to eat, to procreate; you to do the things that sustain life where the addiction takes over. So family members won’t understand and say well why this person would start isolating from the family. Put their own career at risk and it’s well because our brain feels like we are doing everything we need to because the same areas are being lit up where you normally would get from coping in more healthy ways or being with the family and things like that. So I think when we look at the science of the addiction as well as just kind of the emotional toll it takes we can just look back and say we need to treat the addiction as a brain disease and be able to address those deficits in dopamine that happen in early recovery and so that’s where the monitoring comes in because we know getting people doing certain activities and holding them accountable would keep that moving forward until the brain has fully healed itself and it takes a year you getting into recovery.

Dr. Kate: That’s such a good point and Dr. Skipper you brought up something really interesting a few minutes ago about how difficult it is for people to ask for help and I think when you are the helper often times people who go into the helping professions really struggle with accepting help from other people, asking for help from other people and they are in this double bind because they know they need help. If they ask for it would they be perceived as somebody who is not capable as helping or will they be perceived as somebody that can’t handle the work load? That’s a really difficult thing for people who are compelled to help to really navigate so on that note we have to take a quick break but when we come back more about helping the helpers with Dr. Greg Skipper and Dr. Matt Goldenberg from the Centre of Professional Recovery Stay with us we’ll be right back. 


Dr. Kate: Welcome back you are listening to Talk Radio 790 KABC. If you have just tuned in you are listening to Behind Closed Doors. I’m Dr. Kate Balestrieri.
Lauren: I’m Lauren Dummit, Licensed Marriage and Family Therapist.
Dr. Kate: So before you forget make sure to find us on social media. You can follow us at Triune Therapy Group on Instagram and on Facebook and message us with your questions or comments now. You can also call us at Triune Therapy Group at 3109334088 if you have any questions about anything you have heard on this episode of behind closed doors or any other episodes. We are here today with two really well respected and nationally recognized providers, Dr. Greg Skipper and Dr. Matt Goldenberg, the medical team at the Centre for Professional recovery in Santa Monica, talking about what it’s like to treat people in the helping professions and other industry. We were talking a little bit about some of the wreckage that gets caused in people’s lives when they are not adequately addressing any addiction issues that arise.

Dr. Greg: Correct. So as I think about it, it’s so hard to ask for help. You keep thinking you can do it on your own, why can’t I just quit. It’s not logical that I would have to keep using alcohol and drugs when I struggle with my own issue every day I would quit. I would say no more of those, this is wrong. I’m not doing it anymore and it’s so discouraging because you find yourself falling back into that hole day after day and you start feeling worthless and hopeless and it’s really hard and you know that if you ask for help it’s going to be humiliating and it’s going to be costly and you keep thinking well maybe I will quit at some point trying to do it your own way. You should be smart enough so it’s so hard when you are in that hole to actually raise your hand and say I have got a problem.

Lauren: That’s so emotionally draining all the mental space that goes into that process.

Dr. Greg: So exhausting and people are so beat up by themselves and then others try to help them but there is all that anger that comes in leave me alone I can do it on my own and people have a hard time asking for help. So we always say that if you think somebody has a problem you should help them because they can’t help themselves and so how do you do that. It’s tough. Most states in the United States have various medical licensing arenas assistance programs. They have recognized that for example with physicians that they do have a 10% lifetime rate of addiction so the licensing boards have said we will have programs that like a family member or a colleague can call and get professional help but do it confidentially so that people will come forward and say I am worried about my doctor. If you don’t know there is such a program or if there is not a program like that then you don’t really want to go to the cops so to speak to the licensing board because they are going to get in trouble maybe lose their profession. And so delays getting help and in California we did lose what they call the diversion program for medical professions back in 2008 and we are still trying to reestablish it. We think those kind of programs are really good. I ran a program like that in Alabama for 12 years and so family members would call me and say I’m really worried about my husband or a partner that kind of thing so I would able to help them and do it confidentially. When I left it we had 450 physicians and monitoring and it was very successful program. 

Dr. Kate: That’s amazing. You put up a really interesting point. I’m not as that people can call other treatment centers in states where there aren’t these diversion programs and really start the ball rolling. If there is any willingness on the part of the helper to get engaged in treatment it’s a great opportunity for them to really get ahead of any of those really big dire consequences that they fear. 

Lauren: What happens if there isn’t a diversion program?

Dr. Greg: If there is not a diversion program there can be a disaster because people will get shuffled around their hiding employers don’t want to get involved because HR departments just sometimes just say fire them you don’t want to get involved in that and they move on to another job and another job and it can end in disaster, it can end in death.

Lauren: I believe I was recently reading a story in the news about someone who had been had an issue and had been shuffled around from job to job. I don’t remember which state it was in. Are you familiar with that case?

Dr. Greg: Yeah there have been cases reported like that where a professional, there was a recent case where profession had a known problem and for years had been sort of shuffled around and ended up with the death of a patient and now there has been a murder charge against him. So the medical board and some consumer advocates came forth and say we should have harsher punishment for addiction. We need to get these people punished sooner. I say we need to have better programs for early detection because if there had been a helping program for those professionals I think it would have been a better chance they would have been referred, could have been intervened on, gotten help, needed long term monitoring and it can save lives.

Lauren: A lot of people I think that don’t really understand addiction can be really harsh and judgmental and punitive and their views of it unfortunately.

Dr. Kate: It’s a similar mindset to the idea of what we do when people commit a crime in our country right. Send them to prison; throw away the keys, the mentality of a lot of people. I think a lot of people want to believe that there’s rehabilitation that happens in the prison systems and to some degree perhaps there is but the majority of the systems that I have worked in if someone has a long-term or life sentence rehabilitation is not the focal point of their lives. So if we think about addiction as being a lifelong ailment that needs to be addressed we are thinking about how we set the stage for proactive recovery and really helping people to avoid all of those big pitfalls especially when they are in the helping industries. 

Lauren: If we think of addiction as a coping skill we want to punish people for having trauma which is really sad if you think about it from that angle.

Dr. Matt:  One of the ways our program is designed to help with us especially in California where there isn’t an early detection program that’s sponsored by the state is we have an evaluation program so what we do is we assemble a team. Both addiction medicines, I do addiction psychiatry. We bring in a neuropsychologist and we can really do a 360 evaluation of an individual. It might be prompted by their employer. It might be prompted by a medical board in another state or even in California and we can really try to understand and answer questions. Is there an addiction issue going on? Is it really trauma, is it early dementia that’s causing some of these issues. We look at it in a way as secondary intervention so if somebody has gone to that doctor or that dentist and say look I think you might have a problem and they are like absolutely not, I’m good they are not ready to kind of face that they need some help. The question is do they really need some help. The can come, participate in for in our programs the 72 hour evaluation so spend about 3 days with us and they get fully immersed with our team and so we can answer that question and give them an accurate diagnoses and then if needed treatment recommendation so that hopefully if they get early enough that can be early detection and it’s a little bit lower level of a bar so if you are an employee and your concerned about your doc you can get them in for an evaluation which is a lot maybe an easier threshold to cross than saying you need to get treatment. We can use that the evaluations in that way.

Dr. Kate: That’s great.

Dr. Greg: We don’t confined that to just health professionals so we have evaluated executives, attorneys even spouses and so forth of people that are worried about them and they deny having a problem. So it can be easier to say well why you don’t go get an evaluation and it’s actually a therapeutic evaluation in a sense because we want them to hang out with us for a few days. See what our program is like and hopefully lowers their fear and shame and guilt and they start realizing I could maybe beat this. So we see after a few days a lot of people will sign up and say I want to deal with those. 

Dr. Matt:  And also think I’m not the only one. There’s other highly successful individual here in the program and I can get some help which can be eye opening. They are on an island by themselves suffering and then they realize there are the people here who need help as well. 

Lauren: And that they are being treated with respect instead of like a criminal.

Dr. Kate: Yeah that’s such a key component. One of the things that we do at Triune Therapy Group is work with employer groups to do in house consultations around things like sexual harassment and addiction and to help them reorganize the company culture to be more proactive around these things. We can also work with them to address any problematic complains that have come in about employees who maybe are engaging in some kind of inappropriate relationships at work or whose chemical addictions have traversed over into more ineffective strategies in the workplace. 

Lauren: When you are seeing people abusing substances that they have a lot of inappropriate behavior and so it can get sticky.

Dr. Kate: Absolutely. So what do you think needs to happen in order to have a better system in place for California? 

Dr. Greg: So we need to have a program in place that does that kind of care. And so fourar attempts have been made to get it through our legislator that was recently passed. About a year and a half ago a new legislation was passed and now it’s just stuck in a bureaucratic process of rule making and so forth and we are concerned that they are making it so unpleasant that it won’t be as effective as it could be. So we are still struggling with that whole concept of should we be punishing people or helping people.

Lauren: Another thing you bring up is that sometimes people have an issue with wanting to get help and having to miss work and leave work and that can be difficult. In this case it sounds like that’s what needs to happen. We often work with people that are struggling with other issues and one of the things we offer as well is evening IOP for men who are struggling with any type of relationship, intimacy, sexual compulsivity. So we have designed in the evening so that for professionals they can get treatment in the evening.

Dr. Kate: Concurrent to their work is loss of income is a real issue. If we don’t have the resources to pay for treatment how can we get it? We are going to wrap up today but lastly, how can people get in contact with you or your program if they or someone they know is struggling with an addiction?

Dr. Greg: So it’s or they can…

Dr. Matt:  This is probably the best way because they can find the phone number there. We are located in Santa Monica so really in the middle of town.

Dr. Greg: Google Skipper Santa Monica.

Dr. Matt:  But our website has a lot of information about the program and then professional treatment in general so would probably be where I would start.

Lauren: Well Lauren and I got to see your space a few months ago it’s so beautiful. I knew if I had to go to treatment that would be my number 1 pick because it’s really lovely being right in Santa Monica. You can’t ask for anything more than that. You are listening to Behind Closed Doors today. I’m Dr. Kate Balestriere.

Lauren: And I am Lauren Dummit, Licensed Marriage and Family Therapist.

Dr. Kate: You are listening to Talk Radio 790 KABC. Thanks so much for joining us today, tune in every Saturday at 6 for more Behind Closed Doors. Thank you so much everyone has a great weekend.


Ask the experts

Often, when anger is the first response, it’s considered impolite, crazy, bitchy or dismissed as overly emotional. Yet, there are many instances in which one’s anger is stirred, and the key is putting it to good use. For instance, when a loved one is unfaithful, or when insensitive remarks are made concerning one’s ambitions or dreams, when feelings are questioned or when a woman is told to be more vulnerable and subservient. Though family and social expectations place unnecessary burdens on women (and men too), they can channel their anger-filled responses into action by going against the grain, pursuing their own interests or business, going to graduate school and much more. In turn, they’re encouraged to surround themselves with like-minded individuals, committed to supporting and cheering on one another, and ultimately helping the other discover their true potential. This system of support will continue to help individuals convert their anger into action, and perhaps enjoy a few laughs, too.

Yes. One hundred percent. Women are socialized to put relationships before themselves, and this often leads to stifling anger or any feeling that might compromise the bond between two people. This is especially the case in their relationships with men, or in competition for men, and over time, women’s anger and aggression has become more user wraps, or covert. Passive aggression seems to be both the only “acceptable” means of communicating anger, but women are also labeled “manipulative” when they attempt to express themselves indirectly. It becomes a vicious circle of anger, denial or minimization of anger, and then make ourselves smaller just to avoid being a “problem.”

While it is becoming more acceptable for women to show anger, progress is slow. Most of the time, female anger is couched in comedy or parody, and only accepted in small soundbites. Those invested in a patriarchal perspective, men and women, hold firm in their beliefs that women ought to act a certain way, or not make waves. The vary act of saying “we’re angry!” is a bold and pioneering move. Further, some women hold more internalized oppressive views, and refuse to participate in a movement that is labeled feminist or angry. For some women, to do so would compromise their social standing, romantic relationships, financial security, etc. It is scary, because the backlash is real. To take a stand is mark of bravery, and not everyone is ready to avail themselves to the fiery response of those in opposition. My opinion is that over time, the backlash will subside and change will take place. Cultural growth is a slow moving process, and with every voice heard, the collective voice of a paradigm shift grows louder and more effective. I don’t think women (or men) should care about acceptability. The more those who are angry attempt to hustle for the approval of their oppressors, the more power is given away. From my perspective, those who are angry a well suited to unite and establish new norms, refusing to tolerate mistreatment any further.

There are so many way to channel one’s anger constructively. I do not condone any violence (unless in self-defense) and instead think about using anger as a collaborating force within and with others. Being of service to others is one way to channel anger. This is especially relevant because so many women today do not have strong female role models, who they can turn to for advice. Get engaged. Mentor younger women, get a mentor, get creative. How can you pass along the resources (i.e., emotional, financial, logistic, etc) that were not available to you and resulted in your marginalization? What do you wish existed that could have helped you through a particularly challenging experience? Create it. I did, and it changed my relationship with anger and helped me take it for what it is a healthy emotion that lets us know when we feel disrespected or mistreated. This is key information that keeps us psychologically and rationally healthy. Anger is invaluable and an essential part of the human experience. When we embrace that, we can make it work for us in myriad ways.

As a psychologist, patients, friends and family are always asking me advice on their relationships and, let’s be real, everyone else’s relationships. One of the biggest questions they have, is why are there no good men or no good women out there? There are good people out there, I reassure them, but they inevitably come back with some retort about having to settle or face being single forever; for some, a fate worse than death. So herein lies the conundrum stay single forever or settle. Well, let’s back out of the black and white thinking that keeps us stuck for a moment and think about what it means to settle. Most of us have arbitrary ideas or checklists we drag around to assess our swiping situation. Does he make a certain amount of money? Is she pretty enough to take around my friends? Is she/he tall enough/too tall? Is she/he fit enough? What kind of car does he/she drive? Do they like dogs? All-important questions, but what do they really mean about a person’s character or how well you’ll get along? When considering the question of settling, it is important to ask what we:

  1. need in relationships
  2. want in relationships and
  3. won’t tolerate in relationships?

No two relational blue prints will look the same, and there are no right or wrong answers. Let’s look at needs first. We all have intimacy needs, like support, trust, security, communication, touch, respect, etc. They may change over time. That’s okay. Its hardwired in us. We also have relationship wants, the qualities that might ignite our fire a little more intensely. Physical appearance, fitness level, similar hobbies, values, job, financial standing, etc. are examples of wants. There is nothing wrong with wanting whatever you want in a partner. But many times, we mistake our wants for needs and then we feel like we’re settling if the want boxes are not checked, because we’re ignoring the meaning we assign to these traits. For example, consider meeting someone who is two inches shorter than your preferred height in a partner. He or she is funny, witty, charming, consistent, honest, and generous with their time, all of the other wants and needs you’ve identified. They just happen to be a little short-changed in the height department. What does height mean to you? Does it represent strength? Safety? Protection? Status? What does it mean about you if you date this person anyway? Whose judgment do you hear in your head? Why is their judgment so important? Asking these tough questions can help you decide if this is a want or a need, and if the underlying meaning is a need, can that need be met in other ways by this partner or other people in your circle? We often expect our partner to meet all of our needs, and overlook the inevitable disappointment in that expectation. Many people do not know what they need or want in relationships, because they are so eager to be in a relationship that they haven’t stopped to consider what they are looking for in their other half. They accept what is available, to avoid being alone. One day, they wake up and think, “Hey, I think I want more than this. I wish my partner would….” and realize that they might be settling but are afraid to leave. This brings me back to the last point, knowing what you won’t tolerate in relationships. It is just as important to know what doesn’t work for you when considering whether to start, stay in or leave a relationship. For some, deal breakers might include violence or infidelity. For others, perhaps smoking or liking heavy metal is the end of the line. Knowing yourself is key in defining your needs, wants, and deal breakers for relationships. If you don’t know some answers to these three factors, perhaps you’ve been neglectful (and settling!) in the most relationship of all, the relationship you have with yourself. Only when you set intentions and cultivate a relationship with yourself can you invite in the kind of love you are seeking and deserve to have. Until then, you’ll be running in circles, chasing ideas and looking to define yourself in the reflection of another.

Obsession, a thought that continually preoccupies or intrudes on a person’s mind, is often what drives addiction. Obsession is about hypervigilance. When we feel the object of our affection (whether real or in fantasy) may not feel the same way, we perseverate about them, ourselves and the relationship. This rumination and over-focus is an emotional survival strategy that keeps our brain playing out all of the what-ifs and looking for answers to the sometimes unconscious ques- tion, “How can I make sure my partner doesn’t leave me?” A milder version of obsession can look like ruminating thoughts. “What if he likes her more than me?” “Did she talk to her ex-boy- friend last night?” “If only I lost those last 10 pounds…” Perhaps you find yourself checking their social media accounts for proof they are with you, or have moved on. Maybe you enlist your friends or family to investigate or check on your desired. At the extremes, obsession can morph into stalking and domestic violence. If we feel threatened at the loss of someone, and re- taliate with this level of possession, it can be dangerous for everyone involved. Contrary to what may be glamorized in movies, extreme jealously and stalking are not healthy courtship behaviors, and can lead to emotional and physical trouble.

Obsession with another person may be a symptom of love addiction, which is essentially an ad- diction to the experience or “high” of being in love, and generally appears on the form of putting another person on a pedestal, creating the fantasy that they are perfect or the one, ignoring their faults or certain red flags that point to the contrary. Love addicts often expect their partners to care for all of their needs. Love addicts often neglect to care for or value themselves while they in the relationship. There often exists a toxic bond or an obsessive attachment in love addicted relationships. Love addicts often continue to engage in the relationship, trying desperately to connect as they search for their self-worth in the relationship, even if the object of their desire is pejorative, hurtful, or abusive. Inappropriate boundaries, abuse, neglect, intimacy issues, chaos, drama are some of the deleterious characteristics of these relationships. Love addicts suffer from profound feelings of shame, anguish, and fear of abandonment.

Since love addicts typically suffer from an anxious or preoccupied attachment (hypervigilance about their partner or the relationship), some signs to watch out for would be someone who is wanting speedy closeness, says “I love you before the first argument, has poor boundaries, is constantly expressing insecurities and worrying about rejection, is often very unhappy when not in a relationship, plays games to keep your attention, has difficulty with direct communication, struggles to effectively express their wants, needs, thoughts, and feelings, expecting you to guess or read his or her mind, acts out, tries to make you jealous, always makes things about him/her- self in the relationship, lets you set the tone of the relationship, seems preoccupied with the relationship, calls or texts excessively, stops by your home or work unexpectedly, fears that the small acts will ruin the relationship, seems to be trying too hard to keep your interest, and is extremely jealous.

If you suspect that the person you are getting to know has obsessive or love addicted tendencies, this does not mean you have to cut them out of your life completely. However, it is important to take things slowly, establish very clear boundaries, assess what works for you and get consulta- tion from friends and loved ones about your experience, pay attention to any attempts to get you to change or disregard your boundaries or needs, use direct, clear communication, and effectively verbalize your wants, needs, thoughts, and feelings. – Dr. Kate Balestrieri, Psy.D., CSAT-S, Licensed Clinical and Forensic Psychologist, and Lauren Dummit-Schock, LMFT, CSAT, CoFounder

The first step to getting help from this type of toxic relationship is to recognize narcissism in your partner or spouse. This involves identifying the traits and warning signs of this disorder, which you may have been living with for quite some time. At Triune Therapy Group, we have skilled clinicians who are highly trained to treat those that are in a relationship with a narcissist.

To help you understand the condition and how you may or may not have been affected, please explore the following Frequently Asked Questions and Answers provided by Licensed Psychologist Dr. Kate Balestrieri: Read More FAQs About Narcissistic Personality Disorder

Perhaps the greatest hope surrounding the #MeToo movement and other similar movements is that it will generate an awareness of the magnitude of sexual assault and harassment, particularly in the workplace. In doing so, maybe it will initiate and rebirth conversations regarding equality that have since gone underground. This is important, because many people fail to see the ways in which others misuse power and privilege, and how this leads them to engage in predatory behaviors. In another sense, the #MeToo movement could educate people on how to avoid being exploitative, while enlightening them on affirmative consent, power imbalances and how to classify and pursue intimacy and happiness in a authentic, healthy manner.

I work with new mothers and I have on multiple occasions worked with mothers who have experienced a the loss of a pregnancy close to becoming a mother. It is indeed a double whammy. There is so much that gets stirred up, and it intensifies the transition into motherhood and the processing of these loss, exacerbating common life-cycle events, and resulting in undue pressure on new moms, emotionally, physically, spiritually. When we’re trying to understand how motherhood and losses affect us, it is imperative to remember that the transition into motherhood and assimilation of loss are multi-dimensional and encompass physical, social, emotional, spiritual aspects of humanity. Although we mostly associate motherhood with new beginnings and joy, the questions of loss and death and endings actually also come up. Becoming mothers is a definite end to our earlier self, our pre-motherhood bodies and relationships, and mothers must mourn how the idealized fantasy of motherhood is never matched with the reality of the day to day. This is all considered “normal” to go through unless it gets complicated with trauma or major stressors. But if the transition to motherhood coincides with a loss, mothers get all of this thrown at them at the speed of light. It’s like existential pressure overload. – Helena Vissing, M.S., Psy.D. Clinical Associate, Psychological Assistant

The mental health of mothers is a major public health concern. Research demonstrates that depression and anxiety in mothers impact their children. The exact ways children are impacted by their mothers’ mental health involves a complex interplay of factors. We always have to look at the unique combination of risk factors and protective factors for each mother-child couple. If you grew up with a mother who suffered from postpartum depression, you are not necessarily determined to suffer. But we know that on a large public health scale, there is a clear connection between mothers’ mental health and lifelong mental health of their children. The immediate effects of mothers’ depression is that babies become withdrawn and irritable. This is happening at a sensitive time when babies are beginning their lifelong development of emotion regulation. Development is layered and scaffolding throughout life, so a baby who is experiencing these challenges already during their first years will be What we often experience in the consulting room is adults who struggle with feelings of shame and inadequacy or “never being enough”, even when they are normally functioning. They might describe a vague sense of unworthiness that has always “haunted” them. Although it’s widely acknowledged now that our sense of ourselves is rooted in our earliest relationships, it is still overlooked how issues in this area can stem from the emotional pain the child of a depressed mother experienced. This pain does not just disappear as the child grows or if the mother’s mental health improves, as it has influences the very core of the child’s sense of self. Infants and children are developmentally unable to make sense of the intensity of their mother’s depression, but they still feel it. This is because our earliest sense of self is built from our early nonverbal and physical experiences of being cared for. The only way and infant can interpret the signals from a depressed mother is to internalize it, which manifest as a sense of never being enough. Even when the child grows up to be an adult who can rationally separate their mother’s emotions from their own self-worth, the early experiences can still linger and manifest as issues with unworthiness. For each person, it’s a unique story of with all the risk factors and the negative impact on one hand, and then all the mitigating factors and strengths on the other hand. The adult who describes feeling shame and unworthiness might struggle to pinpoint the root of their issues, especially if their mother’s emotional issues were hidden, denied in the family, or minimized. The mother’s emotional state during the crucial early years is often that missing piece to help an adult fully understand their development and life story. Often they are not in a position to communicate about sensitive material with their mothers. This is why it’s crucial that maternal mental health is addressed clearly at all levels of society. The taboo still surrounding motherhood and postpartum emotional issue has devasting consequences for the entire family. I know this is a lot. Feel free to use what makes sense, and let me know if I should clarify things? I tried to use language for laypeople. – Helena Vissing, M.S., Psy.D.