Dr. Phil - AM818
AM818
00:00:00 Dr. Phil
I think it's a great time out and I have confidence in Dr. Manion and West Wind Recovery and Anger Management 818 is a great addition to this. I think you're wise to involve them.

AAMS - Compassion Fatigue, Burnout in Healthcare & Domestic Hardships in the Era of COVID 08.24

00:00:12 Vicken Sepilian
All right, here we go. We're starting our program at 07:00 p.m. And this is a continuation of the AMS's, CME and CDE Webinar educational series. We started these things as we had to shift our activities to virtual meetings, virtual educational sessions. Of course, as a result of the global pandemic that we've all found ourselves into, it turned out that it is a very effective way for us to get together, to learn from each other, to communicate what the latest knowledge is, what the latest scientific aspects of this are. And of course, here we are, and we're continuing these sessions and diversifying not just from knowledge about COVID and the latest science about it, but also various aspects of other issues, including mental health that is a very important component of how we cope and how we deal with this new normal that we've found ourselves. In the past six months or so to date, we have produced 28 of these lecture series. We have granted 44 continuing medical education credits and we have granted 58 continuing dental education credits, which really is a remarkable accomplishment. And we really appreciate the feedback, the overwhelming positive feedback that we've received from our members and the participants tonight. We have two very accomplished and esteemed professionals in the mental health world. Truly, we're blessed to have them with us.

00:00:12 Vicken Sepilian
Many of you know both of the guests today, Dr. Irene Yaymajian and Anita Avedian, who are going to be addressing various aspects of mental health today. Anita Avedian, many of you know she is a licensed marriage and family therapist and she's been in the field since 1996. She's the executive director of Avedian Counseling Center and Anger Management 818 with offices throughout Los Angeles. Her specialties include working with relationships, anger, social anxiety, general anxiety and addictions. Anita is a certified anger Management specialist and a diplomat member of the National Anger Management Association. She's authored Anger Management Essentials, a workbook for aggression which has been translated into Spanish, Armenian and Hebrew, as well as Teens Workbook, which has been translated into Spanish. Anita is known to many of us. She has been very much involved in the community. She's also been a mentor to numerous therapists in the works. She's been a former guest of our television program and episodes, which received high praise for the risqué content and advice that it shared with our community, which was very, very important to hear, especially on the occasion of Valentine's Day. Today, Anita is going to talk about domestic violence and domestic difficulties that we find ourselves in as a result of the pandemic. And I'm really looking forward to hearing Anita on some of the latest science and what the numbers are. But when it comes to the Q and A session in addition to domestic difficulties, I'd like perhaps for us to shed on the positives of how relationships have been impacted, perhaps in the positive sense as well. With that, please Anita take over this platform. Go ahead and feel free to share your screen, and the rest of us will go ahead and mute and disengage.

00:05:01 Anita Avedian
Okay, so can you see the screen?

00:05:05 Vicken Sepilian
Yeah.

00:05:06 Irene Yaymadjian
Yes.

00:05:07 Anita Avedian
Okay, great. Thank you. Thank you for the warm welcome and the introduction. And I'm very happy to be here, even though we're talking about a little bit more of a serious topic today, I always enjoy trying to share information with our community here. So today, as Dr. Sepilian had mentioned, the discussion is going to be on domestic hardships in the era of COVID and let me just make sure my clicker works here. There we go. And this is just our disclaimer. Not to use the session as a therapy, any type of therapy treatment, but it's really for information only. And if there is anything that you're going through, we'll share some resources at the end, but to please contact a professional for additional services. And my disclosure if I don't have any financial disclosure or conflicts of interest with the presented material in this presentation. So, the objectives of what I'll be sharing about today, the prevalence of domestic violence. You're going to hear me say domestic violence or IPV, which is intimate partner violence. So, you'll hear me say both. But we'll take a look at the prevalence of DV and IPV during the COVID pandemic. We'll review the types of abuse, and we'll talk about the three phases of the cycle of violence, how to identify red flags if you're entering into relationships. I know there's a lot of questions on when people are dating, on what to look out for, the impact of domestic violence on victims. And the victims include both the partners and the children of the families.
We'll talk about contributing stressors to the increased incidences of IPV during quarantine and the considerations for IPV during the pandemic, how the stay-at-home orders impact victims of IPV. And in the end, we'll talk about screening and offering resources and support. But first, let's talk about domestic violence and or intimate partner violence. So, domestic violence and or domestic abuse is a pattern of behaviors used by one partner to maintain power and control over another partner in an intimate relationship. Domestic violence includes behaviors that physically harm, arouse, fear, prevent a partner from doing what they wish or force them to behave in ways that they don't want. It includes the use of physical and sexual violence, threats and intimidation, emotional abuse, and economic deprivation. So many of these different forms of domestic violence or abuse can be occurring at one time within the same intimate relationship. And let's just take a look at the prevalence. I know we like to talk a little bit about science and statistics.
What's going on in the United States, 24 people per minute, or 12 million people per year, are victims of rape, physical violence, or stalking within an intimate partner relationship. Nearly three in ten. So 29 women, so 29% and one in ten men. So 10% in the US. Have experienced rape, physical violence and or stalking by partner. And one in four women or 24.3%, and one in seven men 13.8% aged 18 and older have been victims of severe physical violence. So we could see that it has been a really major issue among relationships in the US. And it's really worldwide as well. And to continue, so nearly half of all women and men in the US. have experienced psychological aggression by an intimate partner in their lifetime. I know a lot of times we talk about domestic violence and the first thought or image one has is actual physical violence or breaking things, punching holes and walls. We'll talk a little bit about this later. But so much of it also is based on psychological abuse and, or threats to harm or kill and isolate. And so we'll get into that. But I just want you to know that when we talk about domestic violence, we're really talking about a lot of these different aspects of it. Females ages 18 to 24 and 25 to 34 generally experience the highest rates of IPV. And from 1994 to 2010, about four in five victims of IPV were female. And children and pets are at risk of suffering significant physical and emotional harm. In fact, these kids are 60 times more at risk in comparison to the general population of such harm. So let's just take a look at the different types of abuse. So obviously I'm talking about domestic violence, we're talking about physical abuse is one aspect of it. And when it's physical abuse, it doesn't just mean punching. Physical can be you're spitting on someone, you're choking them, you're pinning them, whether you're pinning them down to the bed or against the wall.
So physical contact can include a lot of those or even when you throw a bottle across the wall and not intending to hit the partner, but it misses, but it threatens them that you can hurt them with that. There's sexual abuse. So rape, having sex against one's will, being forced into doing certain sexual acts. And I do want to mention something about rape because we're talking about in relationships and unfortunately a lot of people, once they're married, they actually think that they have to have sex with their partners just because they're married or whenever the partner wants to. And it's really not the case. Rape does occur in marital relationships and in committed relationships. And I think a lot of people don't feel comfortable coming forward with that because there's shame associated with that.

00:11:18 Anita Avedian
There's also verbal abuse. So name calling, put downs, and then we have emotional psychological abuse. And in this you're going to see things about threats. Hey, if you don't do this with me, you'll see what I'm going to tell your family. Or if you ever leave me, you'll see what's going to happen. Right? So there's a threat and of course it gets pretty scary to try to leave. And that same person may have never done any physical harm to the person, but a threat in itself is very dangerous. And we also see gaslighting. So when we talk about gaslighting, it's a term where the abuser actually tries to get their partner to think that they're doing something. They plant seeds in their head, like doing something that they really didn't do. So questions like, hey, are you sure that I promised you that? I don't ever remember promising you that. Or hey, you normally don't have a good memory anyway, so you're probably not remembering that correctly. I didn't hit you, remember? I didn't hit you. Or you're just imagining that that never happened. It's all in your head. You do this quite often. So when one hears us enough, eventually we start buying into the possibility that something's wrong with me or I guess I don't have a great memory. So perhaps what my partner is saying about me is true. So gaslighting is really a huge factor in psychological abuse. There's also financial, and especially recently, but with financial, it's going to be something like the perpetrator may tell the partner, hey, why don't I manage our finances? I know you don't do too well with savings, so why don't you direct deposit or bring the check home to me or direct deposit into my account. And then what happens thereafter is that the perpetrator will then just put their partner on like a salary, giving them $5 a week. I mean, not enough for food or anything like that, but more so to kind of humiliate and to control the situation. So really a lot of what we're talking about when we talk about domestic violence is about having power or control over the partner. So it's not just about a one time incident that occurred where you're yelling or putting someone down. That's not what it's about. Domestic violence is about power and control over one's partner.

00:13:48 Anita Avedian
The other type of financial abuse can be, not everyone necessarily works. So again, it's just having full control over the finances and not providing enough finances to the partner to perhaps feed the children well enough or to even buy necessities. Now, Leonard Walker so she is the person who came up with the cycle of violence, and she described three phases. Some people talk about four phases of the cycle. So I want to briefly talk about this because it's so important to understand what takes place. It's really the dynamics of the relationship and some of you may be able to relate to the earlier part of what I'm about to describe.

00:14:35 Anita Avedian
So initially when you meet, you're kind of meeting someone in really a honeymoon phase. This is the part where chemistry is flying all over the place. And in your first three months every month, the chemistry kind of changes a little bit, but everything's really exciting and you pretty much fall in love or your brain thinks you're falling in love with this person who really fits the bill of what you've been fantasizing about as a partner. And of course, within some time that's going to become disappointing. But within the first few months there's this honeymoon period and everything's so exciting. You want to spend every day with this person and it feels so amazing. You want to introduce them to everybody. It's exciting. You've met someone who swept you off your feet, who fits the bills for the perfect wife or perfect husband or perfect partner. And what happens then is eventually we start to realize that there are some things a partner is doing that is creating distress.

00:15:38 Anita Avedian
Now in a domestic violent relationship, and the perpetrator may not really be in it trying intentionally wanting to be this person. By the way, some of this can be subconsciously driven. But in a domestic violence situation, what we're going to start seeing is that when that disappointment starts to come or the distress starts to arise, that the perpetrator is recognizing that there's some tension that's building. And perhaps the perpetrator is not directly stating anything and in fact maybe hoping or assuming that the person understands them. But within a short period of time, the tension building starts to get pretty bad. And during this period is where you see that gaslighting perhaps like some questions such as, hey, where are you going? Who are you going to go with? What are you wearing? What time do you plan to come back? You're not going to talk to anyone there or let's say it's a female there's. No one is going to be there with the opposite sex. Will there be? So this is what starts to happen, is that the questioning, the jealousy comes through and then eventually there's so much build up of it that they end up being able to get to this short phase, but a very intense one of the blow up phase. And this is what we call the blow up escalated phase or the acute abuse. And this can literally last a couple of minutes or it could last all day. For some people it lasts for days. And in that period, this is where the perpetrator may totally snap and yell, I can't believe you did that and cuss the person or how am I ever supposed to trust you? And just kind of psychological put down and potentially physically harm, maybe. So that kind of happens. And right after that incident, the perpetrator then realizes that, oh wait, I'm going to lose this person. I can't lose them, I need them around. And quickly goes into, I'm so sorry, I love you, I'll fix this. I won't yell again, I won't hit again. I don't know what came over me. This is unlike me. And so this is now the reconciliation phase. And now we're entering this honeymoon phase. And this is the phase where there's promises of going to therapy or anger management or there's the purchase of the diamond ring, let's get married. I promise maybe if we live together, I won't have to deal with my jealousy in that way. And then around then, the partner in the relationship realizes and or thinks how genuine the partner is and finds a partner that they originally met and falls in love again, or wants to make this work. And then the cycle continues from there, and then thereafter starts attention building after that. So this is a cycle of violence.

00:18:36 Anita Avedian
And this has been around, the theory of this has been around for at least 30 years. I want to get into some warning signs of domestic violence. So initially I shared with you guys about the dynamics in the relationship so much about power and control. So when we talk about domestic violence, I want to stress it's really not about a partner saying, I just lost control or I just lost it. I didn't mean to yell, I didn't mean to put down. It doesn't work that way.

00:19:08 Anita Avedian
Typically in these relationships, there's the intent to harm, intent to threaten, intent to do all this. And I will say that with most cases of domestic violence, if a police officer was there who was planning on arresting, they would not have done that behavior. Okay, so what that tells us is it's controlled. In fact, most of the time, this particular perpetrator and these relationships are very charming to the outside world, and no one would ever put any doubts across them that they would potentially harm their partner. So no one's going to believe this person, that they're an actual abusive person because they're so charming or successful and everyone loves them and they're really kind to other people except for the partner. So it's about power, control. So I wanted to put out these warning signs just in case anyone listening or knows anyone in terms of support systems and maybe going through this, that this is typically about a perpetrator trying to gain power and control over the relationship, that there will be extreme jealousy of the partner's time outside of the relationship.

00:20:20 Anita Avedian
And when I talk about jealousy, I mean, we're even talking about say, the partner wants to go visit their mom or their dad or their sibling. There's jealousy around that because it's time away from the actual person. And so it's almost like the person's time should be spent as much as possible within the relationship for the partner to feel secure and not to get upset. And I'm sharing all this because it's not all exact where the perpetrator has all of these symptoms, but this is just in general what we find, what we see. And also we see that the perpetrator will encourage dependency so that the partner doesn't leave.

00:21:04 Anita Avedian
So if you think about what this relationship is really about for the perpetrator, they need to know that their partner will stay with them. They're not going to leave. And any threat of the partner leaving will actually potentially trigger more upset. And so in this process, what starts to happen is a perpetrator may say something like, hey, if I was you, I wouldn't trust your best friend so much. She was kind of flirting with me the other day. I really don't think you should really trust her. Trust him. And they start kind of planting seeds in this way, which then pulls the partner away from a lot of their support system. And as they do that, guess who the partner has to rely on is the person, right?

00:21:51 Anita Avedian
The other is that they control who the partner sees. So perhaps you may hear the perpetrator say something like, listen, I'm really not okay with you having this best friend of yours anymore. Not a good fit, not a good friend to have for my partner. That person is still into socializing and flirting and not okay with that, right? Or they drink, and I don't want you to be around anyone who drinks. And or they prevent the partner from working or from going to school. So they don't want their partner to advance because if they're advanced, then they can leave them. There's a bigger threat of leaving them.

00:22:31 Anita Avedian
So if they're working, a lot of times there are places where they can potentially meet someone else. So that's a threat.

00:22:38 Anita Avedian
And or if they're working and they make enough money, then they have their resources to leave the relationship. There's also insults. They demean, they insult, they shame with put downs, hey, you're a really bad parent, or your cooking really sucks. Why didn't you ever learn how to cook? How am I supposed to eat food at home? Things like that.

00:23:02 Anita Avedian
And we talked about controlling finances, but also where money is spent. So there's a lot around if the partner wants something, they're excited about buying something. And then now that the power and control concept begins and the perpetrator will say, no, you don't deserve that. You're not going to spend money on that. And so there's a lot of control around that. And there's also intimidation used so we can have really strong, intimidating faces. I don't really have an intimidating face, I don't think. But, the partner will, the perpetrator, will look at the partner with certain facial expressions like, don't even think about doing that, and have a very cruel demeanor. And that gets pretty scary to be around because the partner also knows what that can mean.

00:23:51 Anita Avedian
Additional signs. So the partner may suggest moving in and getting married within a short period of time. So one of my favorite questions as a therapist to ask my clients is how long did you move in or marry your partner? How long did it take? And if I hear a response that's less than six months, to me, that's an immediate red flag. That there most likely is domestic violence. Now we're talking about the US.

00:24:22 Anita Avedian
So obviously there's countries with arranged marriages and things of that nature and there's cultural implications surrounding this. But in general, when someone jumps into a relationship and moves in really quickly, then there's impulsive behavior. And when there's impulsive behavior, we're also at higher risk for domestic violence. Why didn't this couple wait it out and maybe wait a year before they got married or before they moved in?

00:24:48 Anita Avedian
Now, if you're watching this and you have a healthy marriage and you guys moved in fast, ignore what I'm sharing. But I'm just saying, typically in general, this is how you look at that. But there's that impulsive behavior moving in, and then there's also threats to harm or take away the children.

00:25:05 Anita Avedian
Hey, I'm going to call DCFS on you. Tell them you're not feeding the kids or you're not tutoring them. There's destruction of property or they threaten to hurt or kill the house pets. I worked at a battered women's shelter for five years back in the day when I first started doing therapy.

00:25:23 Anita Avedian
And I can't tell you how many times the perpetrator threatened to harm the pets, even with the children present and or to their mom. Their moms used to be in the shelter. So they would threaten to harm the puppies or the kittens, or they would kill the pet and then buy, you know, when the kids would cry and the perpetrator realized that really harmed the child, they would go buy a new puppy to buy the love again. So it was really like a very sick approach to controlling the family.

00:26:00 Anita Avedian
And then there's a lot of intimidation with the use of guns, knives, or other weapons, and they pressure the partner to either have sex or withhold sex or have sex with others. Present just a variety of different scenarios around sex, by the way, and the other is drugs or alcohol.

00:26:21 Anita Avedian
So a lot of times, let's say, if the partner, the victim doesn't want to be using or drinking, there's a lot of pressure around, hey, no, why don't you drink with me? Come on, you know I'm going to get upset if you don't drink with me tonight. Why do you have to ruin my day that way?

00:26:36 Anita Avedian
And we hear that, and so we'll see some of that occur as well. Let's take a look at some effects of domestic violence on the victim. So we see that the partner who's being abused, they typically will lack confidence in their parenting, in their parenting skills due to their authority being undermined.

00:27:00 Anita Avedian
So think about it. If, let's say the kids are at home, it's bedtime, and the victim partner says, hey, kids, why don't you guys get ready for bed? And the perpetrator's parents may say, you guys, don't listen to your parents here. They don't know what they're talking about. You guys are fine. Don't worry. You just follow what I say, right?

00:27:22 Anita Avedian
So something like that will start undermining the authority of the other parent, and the kids start to look at that parent as the weaker parent. And the perpetrator is the dominant or the more powerful and the one that they would respect more. There's also the feelings of helplessness and powerlessness. So helplessness is going to be, there's nothing I can do to get me out of this situation. There's trauma. When I worked at the shelter, it was a huge component that we would see is post traumatic stress disorder and anxiety. We would see them go through depression. Trauma is really around. You'll see them being very hyper vigilant, where any noise, they just get very startled, constantly thinking that the perpetrator is around to harm them. There's isolation from their support systems, from friends and family and loved ones. There's the constant surveillance from the abuser. So sometimes the perpetrator will follow them. If they're like, going to work, they'll kind of go in and spy on them or have someone spy on them for them. There's issues around health problems.

00:28:32 Anita Avedian
So we see that victims of domestic violence will have acute traumatic injuries, especially if they're getting physically harmed. We're going to see more of this that they suffer with. And there's restrictions on behavior. Hey, why did you laugh like that at the dinner table? That was so embarrassing. Like, you should get a hold of yourself. Or, I can't believe you wore your shirt button down. That's not the type of woman I married or for the man. I don't know. They'll just make comments around the clothing or any restrictions on sanitary needs, support system, who they can see. Hey, no, I told you I don't want you to be around that friend anymore. I don't trust them. They're not good for you. Look at how much of a bad influence they are on you. And also privacy is limited. And then social media, especially these days on social media, they follow each other and then they take the other person's phone and look at all the messages and the likes, I can't believe you had a wink emoji, or you put a smiley emoji. You're flirting with this other person. Or they'll look at all the history on the Internet to see what's happening and go from there.

00:29:53 Anita Avedian
And then for kids, the effects of domestic violence on children. The children, they feel pretty anxious. They feel depressed and stressed. They also go through trauma because, again, they're going through this horrific state where they see one parent being abusive to the other, and they can't do much to help, especially when they're young. So they feel pretty powerless when they're supposed to be in a home that's loving that they take care of them, and they're not.

00:30:22 Anita Avedian
So when we worked at the shelter, what would happen is children, even at 8910, obviously they would have been potty trained, which they were, but then they come to the shelter and we would find a lot of incidences of Fed wedding. There's regressions in Caprices and incontinence. So all of a sudden they reverted back to a younger age and needed to feel safe in a nice environment where they felt protected and loved. And in that we would typically see them either take on the role of the abuser now that the other parent wasn't around and they started controlling or manipulating the mom as who was at the shelter, or they would be more clingy and try to be protective of the mom.

00:31:12 Anita Avedian
So you kind of saw both. We also saw a lot of separation anxiety. So if the mother stepped away from the child, even going from one room to the other, the child would actually go to follow the mom or go peek to see where the mom is going. So there's a lot of separation anxiety and that's not that uncommon. When parents divorce or separate, the child is oftentimes going to worry that what if my other parent leaves? Or what if my parents leave and never come back. And then there's also where the child becomes protective over the abused parent. There's also a lot of powerlessness surrounding the inability to help.

00:31:58 Anita Avedian
So many of these kids can't wait till they grow up so that they actually start fighting back the abusive parent, they want to protect the victimized parent. And there's also the feelings of being trapped with the perpetrator of abuse. And the children will either take the role of the abuser or the victim. So what would happen in the shelter?

00:32:20 Anita Avedian
What I would typically see is that the children would start bullying other kids and you see this being demonstrated. They would go to school and bully others or at the shelter they would bully each other because that's what they've learned, that's what they've seen. Or they're going to be very anxious and nervous and be quiet and reserved. So it kind of saw both kids acting both different ways. Also note that the parents increased stress level is a predictor of neglect and physical abuse of children. Parents may respond aggressively to their child's anxiety.

00:32:58 Anita Avedian
All right, so let's talk about domestic violence during lockdown. So we know that the lockdown is great for slowing the spread of COVID-19. However, it did become pretty unsafe for victims of IPV. A lot of historical data does reflect that during pandemics, intimate partner violence does increase and it increases during economic crises and it increases during holidays when families spend more time together.

00:33:28 Anita Avedian
So it's interesting in the therapy practice. Most of our practices kind of slow down during the holidays, let's say around Christmas, but starting early January, everyone's ready to come in to do family work and or ready to leave the family. Because that's what we kind of start to potentially see is enough time spent together. And if there's a lot around power and control and abuse that it becomes a pretty difficult scenario to continue in.

00:33:56 Anita Avedian
We've also seen that low Ses, low socioeconomic status and unemployment has also been linked to increased abuse. So we also look at stress and we know, I teach anger management, we know that stress, the higher levels of stress and the more stressors one has, that their chances of being more aggressive increases. So the increased stress hormones are associated with increased aggression. And because the pandemic has a lot of unknown. So think about anxiety. 00:34:28 Anita Avedian What if it's unknown? What if this happens? We don't know what's going to happen. We don't know when COVID is going to be done. We don't know if the vaccine will work or what the vaccine will do. So there's a lot of these unknowns, especially around work. Am I going to have enough money and family? How are we going to feed the kids? So during this, Cortisol is released often.

00:34:49 Anita Avedian
So we know Cortisol is a hormone that's released during stress and the body is in the constant state of stress. And when that happens, we can typically become more aggressive or more short with people more irritated. And then we also see, we talked about economic distress increases the likelihood of intimate partner violence. Alcohol consumption increased by 243% by some sales. So this was a statistic that came out in the last month or a couple of months ago. US Sales of alcohol rose 55% in the week of March 21, according to the market research from Nielsen. So, alcohol is another one of those stressors where when you drink a lot, chances are you may AI to blackout, say things you're going to regret, become more violent, be more aggressive.

00:35:43 Anita Avedian
So picture this, you have all these stressors, you're stressing and chances are that alone is going to increase aggressive behavior. And then now on top of it, you have alcohol and or increased drug use which couple together. We're becoming a little bit more violent as a society during the pandemic. But let's take a look at contributing stressors to domestic violence. During COVID-19, there was a shelter in place. So during the quarantine, people are under stress because what's going to happen? We can't go out. We don't have our normal coping mechanisms. Coping mechanisms. The gyms are closed in certain places, you can't even walk outside. And then there was social distancing. So the lack of connection or support that we had where we typically would use to help us through our stress level, and then we saw an increase in alcohol consumption and drug use. Then there was unemployment and the temporary layoff.

00:36:48 Anita Avedian
And of course, to add to it, we had the fear of contracting the virus and the fear of dying and our loved ones dying from the virus. And then we had childcare responsibilities, which increased. People are working from home. They're not only having to work from home, but now they're responsible for the child care and they're responsible for the house cleaning and they're responsible for the cooking, and they're responsible for everything else, including the children's schooling. So you can see how all these stressors just kind of piled up on so many people, and it blew up to a different level. The additional stressors heightened perpetrators' need and desire to control and further humiliate their victim. 00:37:38 Anita Avedian Now, with all of this included, we also have limited resources. The school's work is being closed, or we're closed. I think they're reopening now, and there have been less opportunities to detect child abuse. So if you think about where a lot of the reports were made in schools where the teachers would notice a bruise and would ask a child, how did you get that? What happened? Or the school counselor may ask questions. Well, when there's no school, who is observing? Who's looking out for the children?

00:38:11 Anita Avedian
The concern is now when there's going to be a return to school that the child abuse reports are going to flood the system upon returning. So this is going to become another pandemic in itself. Extended family was not going to be available during this time because we were quarantining, and not everyone was readily available.

00:38:34 Anita Avedian
Or typically, extended family may involve elderly, and they didn't want to place themselves at risk or in harm's way around this. Child care is limited. You can't just drop a child off at childcare anymore or at least spend. Now, I think maybe a few things have opened up religious gatherings, church, temple. A lot of those institutions are off limits. I think some may have opened up already, but when someone relies on that as part of their coping mechanism and then no longer has that, that's going to add to the stress of what's going on at home. And then DCFS, the Department of Children and Family Services have fewer workers available to make home visits. So now we have less resources available to even kind of follow through with some of this. The quarantine measures led to increased unemployment, reduced income, and limited resources. People's social support was limited because you weren't getting together. So you're at home stuck with a perpetrator who was under more stress than usual, who then was amplified into potentially exerting more power and control and abusing the family members and then access to health care.

00:39:51 Anita Avedian
A lot of people are too concerned with going to the doctor's office. Well, for those of you who are physicians, you're also reporting when you see a victim come into your office and see if they're bruised, you're going to ask questions around domestic violence or if they've been safe. Give me 1 second. So we saw a lot of increase of domestic violence during COVID-19 IPV increases because the victim has been unable to flee that dangerous environment. They weren't able to leave their house. It's locked down. There's nowhere to go. They were unable to get the momentary breaks of freedom that they would have normally gotten when the partner would leave home to go to work.

00:40:35 Anita Avedian
So perhaps the tension was around for a few hours a day, but at least eight to 10 hours of the day, there was no tension at home. Right. And also, they weren't able to file a protective order because the police filed a protective order via the police due to the stay at home order. And then women in various parts of the world couldn't escape because of limited resources during the Pandemic, Italy's lockdown began in early March and the domestic violence reports were on a rise over there. And the shelter system in most of these places is communal living. And because of that, that was a big concern around the spread of COVID So what Italy finally realized is that they're going to open up hotels. At least people had their own units. So if people were in a domestic violence situation, for the victim and kids to get support by staying at a hotel room, that felt more secure.

00:41:35 Anita Avedian
In Spain and France, the abuse reports soared two weeks following the lockdown orders. In England, domestic abuse reports were up by 20%. And then, in the UN article, the data there showed that helplines in Singapore and Cyprus had more than 30% increase in calls. In Australia, 40% of frontline workers in New South Wales requested help with violence. In France, the DV cases increased by 30% since the lockdown on March 17. And in Argentina, emergency calls for domestic violence have increased by 25% since the lockdown on March 20. In the UK, reports the following contact information to respect their national DV charity. Their calls increased by 97%, the emails increased by 185%, the website traffic increased by 581%. And then during the first two weeks of quarantine, unfortunately, 14 women and two children were murdered in the UK. Now, out here in the US, physicians found evidence of physical abuse.

00:42:44 Anita Avedian
So there's a whole study done and what they did is they compared the number of victims who went through the hospital or who sought for medical treatment between March 11 and May 3 of this year, and they compared it to another group of women who sought support in the last three years. So from 2017 through 2019, during the same month. And so what radiologists and physicians in the emergency were seeing was fractured bones and bruises and punctured organs.

00:43:18 Anita Avedian
So what I did want to state, though, is the number of calls actually decreased, I think, in the La area in the US overall, early on. So during the lockdown, there's something around people feeling intimidated by calling. Either they couldn't call or there's nowhere to go for them, or there was fear around where to go. They went to the shelter, they would get potentially sick with COVID. So the idea was that a lot of the victims did not seek support because of those fears, but instead, they waited some time until it was really bad, and then they would go to visit the doctor. And at which point, through X rays or other means CT scans, they had found that there were all these fractured bones and bruises, and this is what this research was surrounding them, what was happening. All of a sudden the calls were left, but all of a sudden, there were so many injuries. The idea is that They sought support at the later stages, but overall, there was 1.8 times greater this year of severe abuse than the groups from the last three years for the IPV. And that the incidence of physical abuse and severe injuries were greater.

00:44:43 Anita Avedian
So 42% in 2020 versus 12% in those three years between 2017 and 2019. 10.2% increase in domestic violence calls during the pandemic was in the 14 metropolitan areas in the United States, including Los Angeles. And physical abuse increased and escalated despite decreased reports by the victim. The proportion of physical abuse was 80% higher in 2020 than the previous years. And in Boston, they had found that the domestic violence cases doubled during the coronavirus pandemic. This is just added information I wanted to share with you guys today because I wanted it to focus more about domestic violence and what changes we've seen during the pandemic. So what we realize is abusive partners may actually use COVID-19 as a new attempt to psychologically abuse their partners. So they would do things such as forbidding hand washing to help increase fears of contracting COVID, or they would threaten to forbid medical treatment, especially if a person had symptoms.

00:45:55 Anita Avedian
They would withhold necessary items such as hand sanitizers or disinfectants. I mean, what I'm trying to say is a perpetrator is literally looking at their partner having increased anxiety and fear and actually gaining excitement over having that type of power and control over their partner. So it gets pretty sick. They would share misinformation about the pandemic to control or frighten the survivors. They would prevent partners from seeking appropriate medical attention even if they had symptoms. They withhold insurance cards or threaten to cancel insurance. Or they would prevent survivors from seeking medical attention if they need it, and they feel more justified and escalate their isolation tactics, like pulling them away from their support system.

00:46:40 Vicken Sepilian
So how did COVID-19 how it could impact domestic violence? Survivors programs such as shelters were impacted because of communal living. Survivors may fear entering shelter during that time because of COVID And then survivors who are older or have chronic heart or lung conditions may be at increased risk in public places where they would typically get support, like shelters or counseling centers or courthouses. So you're seeing that the resources are less, so all the stressors have gone up, and the resources are less. And then there were travel restrictions that impacted a survivor's escape or safety plan. It may not be safe for them to use public transportation or to fly. And the victims of domestic violence may experience agitation, anxiety and chronic apprehension.

00:47:31 Anita Avedian
The constant state of alertness that makes it difficult for them to relax or sleep. There's constant worry about what tomorrow is going to bring? Is my partner going to be? I notice the tension that they're going through. Are they going to be more aggressive tomorrow?

00:47:47 Anita Avedian
And there's also the sense of hopelessness and hopelessness, of despair or despair. And they believe that they won't escape the control of their abuser. So literally they're thinking they're stuck for life and they fear that others can't truly protect them or their children. I mean, if you think about it, there's so many people who try to help some of these victims and then the person who's helping is the one who gets hurt in the process as well. So they start turning down assistance from their relatives, their friends and or professionals.

00:48:22 Anita Avedian
And I will say that sometimes these victims leave, many times they leave. They realize they can't do things on their own or they feel too dependent on the partner, so they return. And so there's this back and forth and eventually what happens is they start exhausting their support system. Because if, for example, you have a friend who you constantly try to help them leave their abusive relationship or you just offer support to them and they come, they talk to you about the problems, they finally leave and you're grateful that they're now safe. But then they return. And in fact, their kids get taken away from them because they return to their partner.

00:49:02 Anita Avedian
So a lot of the back and forth starts to exhaust some of the support system and then the victim starts to feel that they can't really rely on others. And then their symptoms experience. They feel paralyzed by the fear to make decisions or protect oneself. A belief that one deserves the abuse and is responsible for it. Flashbacks, recurrent thoughts and memories of the violence and nightmares of the violence. Nightmares are huge for both the children and the victims, the partner. So that becomes a huge symptom for them. And then there's emotional reactions to reminders of domestic violence. So if this person is watching a movie around a person getting physically harmed, a lot of flashbacks will come back and they'll start feeling like they're re-experiencing the event all over again.

00:49:58 Anita Avedian
And then there's hyper vigilance. So they'll hear something, they'll get startled or they see something, or they see a person that looks like their abuser and then they almost re-experience the feeling again.

00:50:13 Anita Avedian
And then there's some common physical symptoms. So victims of domestic violence can also have physical symptoms due to constant stress and fear of living in an abusive relationship. These include headaches, asthma, gastrointestinal symptoms, chronic pain, restlessness, sleep or inability to sleep, genital soreness, pelvic pain and back pain, and some screening questions that would be helpful to incorporate. So for medical professionals some of these are also okay to ask for friends and or family members. Is anyone in your home being hurt, threatened, or neglected? Do you feel safe in your relationship? I noticed you have some bruises or marks. Could you share with me what happened? You seem frightened of your partner. Do they hurt you? When you argue? Does it lead to a physical altercation? Your partner seems nervous. Any chance they're responsible for your injuries? And be sure that if you're offering telehealth services as a professional to gauge whether or not this person is in a private setting.

00:51:21 Anita Avedian
When I do therapy and we're doing telehealth, I always want to make sure, and I always ask, and then I text them as well, that, are you alone in the room? And you'll kind of get the gist of it if they're not because the information they're providing is very limited and different. But these are some of the questions. Now, I know in some of the medical centers you come up with at least one or two questions that offer the basic screening. And if someone's not in that type of situation, oftentimes they're just going to laugh it off or say, oh, yeah, no, thanks for asking though, and they'll leave it at that. But it's worth asking because you never know who you're helping and who you can protect. And we never know how bad the situation is for the person, and this is their one opportunity to get support.

00:52:07 Anita Avedian
Now, an additional concern, as if we didn't have enough concern, gun sales have increased during the pandemic. And that being said, we may start to see an increase in domestic homicide. Already that was an issue, but now that the gun sales have increased, that may become more of a situation we're going to foresee in the near future. The risk of homicide increases by 500% with the presence of a gun at home in a domestic violent situation.

00:52:40 Anita Avedian
20% of intimate partner homicide victims were actually found to be family members, friends, neighbors, persons who intervened, law enforcement, responders, or bystanders. And 72% of all murder suicides involve an intimate partner. That is huge.

00:52:59 Anita Avedian
And in 94% of these IPV murder suicides, the victims are female. What can you do to support yourself? Check in with a person frequently if it's a friend you have or an acquaintance. If you're in a position to support or offer housing, be sure to share that information so that the person feels like they have a place that they can go if they really need to, help them create a safety plan. When we did safety plans at the shelter, I would do that because I knew there's a high chance that they were going to return to their partner.

00:53:32 Anita Avedian
What we would do is have them make sure that they had a copy of their ID, a credit card, bank account information, their birth certificates, their passport, having anything with important identification, certain medication that if they're going to leave the house, they have just if they need it for at least a few days. Keys to their car or an extra copy of a key to the car. Believe it or not, we experienced a lot of stories where the partner would actually burn all the IDs just to keep the partner at home so they can't leave.

00:54:05 Anita Avedian
So it's nice to just create a safety plan, run to the neighbor's home or see what neighbors in the area will be understanding, and we'll let them in in case of an emergency. And of course, nowadays you can text the police at 911 and they can come out to support you. Share resources, including support groups, therapy, shelter, or legal support. The courts play a huge role in helping with creating the protective orders or anything that may feel supportive to them. Here are some resources. So there's a national domestic violence hotline. There's a hotline.org or text Love Is to 22522 and they'll support you. There's a link I shared for shelters in Los Angeles. I used to work at Jewish Family Services. Family Balance project. So that's their website and their number that you can call, especially if you're wanting shelter. And then these are some of the references I use for my talk today and my contact information. So that's the end of my talk, and I want to hand this over back to Dr. Sapilian and Dr. Barkoudarian.

00:55:21 Vicken Sepilian
Thank you, Anita. Really, that was a very informative presentation, and in fact, I have several questions, but we're going to hold the questions and the discussion for the end, please. If anybody else has questions, there's a number of ways that questions can be placed. Feel free to put them in the chats. You may also put them in the Q and A session and we'll address them at the end. Our next speaker is Dr. Irene.

00:56:02 Vicken Sepilian
Dr. Yimejan is a licensed marriage and family therapist and has a doctorate in Psychology in Clinical Psychology from the Chicago School of Professional Psychology. Dr. Yamajan is trained in Jung Yin psychodynamic. Psychotherapy. In her private practice, Dr. Yarmaijan works primarily with women suffering from postpartum depression, self esteem issues, and individuals struggling with addiction and trauma related disorders. Dr. Yamagian's dissertation focused on the possible relationship between Jungian personality types and burnout risk levels amongst psychotherapists. From this, she developed a self care prevention workshop where she volunteers her time and conducts training for medical health professionals across the country.

00:56:56 Vicken Sepilian
Dr. Yamajian is the founder of Hillside Wellness Center, a nonprofit organization in Sherman Oaks dedicated to providing affordable mental health services to individuals and families in need. She completed her internship at the Maple Counseling Center in Beverly Hills and continued her studies at various residential treatment centers while building Hillside Community Hillside for the community. She's passionate about helping her community, especially working with mothers and new parents who are in need of support and guidance.

00:57:32 Vicken Sepilian
In addition, she's an adjunct professor at Pepperdine University and Pacific Oaks College, where she teaches addiction and Substance Abuse law and ethics, diagnostic Skills, theories and Practicum ready courses to masters and doctoral students. We're very honored to have Irene Dr. Yamajian joined us today. She's a relatively new member of the organization. She's going to talk about compassion and physician burnout, and we look forward to hearing her presentation.

00:58:09 Vicken Sepilian
Dr. Yamajan, please go ahead and take over the platform and feel free to share your screen.

00:58:16 Irene Yaymadjian
Thank you. Thank you. Hello, everyone, and welcome. I'm going to share my screen right now. There we go. Perfect. So I actually do this presentation typically in training with one of my colleagues, Dr. Dane Cloner. And so that's why you will see his name on some of the slides. We put it together. We put it together. So I wanted to do this presentation because I found that it's very important, especially for caregivers and all the mental health professionals and physicians that are doing a lot of working with other people and taking care of them.

00:58:56 Irene Yaymadjian
And mothers, of course, because parents and mothers, they're home and they're taking care of kids and they're teachers these days as well, including housekeepers and babysitters. So I thought it was important to really just kind of learn the red flags and move forward from there in preventing burnout. So, again, the disclaimer as Anita went ahead and did as well, it's important to know that this video and this training is not taken out of context in any way.

00:59:26 Irene Yaymadjian
You don't use it to diagnose anyone or yourself or treat if you find yourself having any kind of burnout symptoms or anything like that, it's still important to go forward and see a therapist. I think a lot of times we tend to Google and look at things online. We diagnose ourselves and then we try to treat ourselves, and it sometimes makes things worse. So please talk to your therapist, talk to your doctors. Any questions you might have, feel free to go ahead and write it in the box and I'll go ahead and answer it for you.

00:59:59 Irene Yaymadjian
So today we're going to go ahead and I wanted to welcome you all. I want to discuss burnout? What is compassion fatigue? Because they are two different things. Self care techniques, activities. I do have two activities. Let's go ahead and move this back. My PowerPoint tends to do its own thing. So I do have two activities that I would love for you guys to do. I'll share the screen and then you will go ahead and do them on your own. And then of course, thank you. So the first thing I want to share is, as Dr. Sepillian noted that I did my dissertation on burnout. I don't know why, I apologize. 1 second. I do not know why. My stuff is just changing. Give me 1 second. There we go. Okay.

01:00:53 Irene Yaymadjian
As Dr. Sepilian was notting, I did my dissertation on burnout and I developed a self care program because I wanted to see the personality types that were prone to more burnout. And then it just kind of became a bigger thing. Okay, all right, so this is one of my favorite quotes. The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet. So you kind of take whatever you can from that.

01:01:33 Irene Yaymadjian
The difference between burnout and oh, goodness. Hold on 1 second. I'm having a little bit of trouble here. Hold on 1 second. There we go. I apologize. I don't know why my okay, there we go. Let's do one more.

01:01:57 Irene Yaymadjian
Okay, so the difference between burnout and compassion fatigue is that compassion fatigue is trauma specific , specifically trauma occurs and then compassion fatigue comes into play, whereas burnout is related to the workplace. So this is why we always say, oh, I'm burned out of working. So whenever we're diagnosing as therapists, whenever we diagnose burnout, it is an occupational diagnosis rather than a mood disorder of some sort.

01:02:31 Irene Yaymadjian
So according to the research, burnout appears to affect individuals as a result of organizational issues. So having an unsustainable workload, feeling competition in the workplace, lacking a supportive environment, feeling deprived of what one deserves. So if you feel like you're getting paid too little for the work that you do, that's going to contribute to you burning out. If you feel like there's a lot of competition and you're not good enough, that will eventually lead you to burn out. 01:03:01 Irene Yaymadjian That's why it's so important to have or be a boss or a supervisor that makes sure that you evaluate your workers and your staff and you make sure that they know what their growth areas are, what their strengths are, so that they feel valued and appreciated. And this will prevent burnout, and we'll get more into that. So burnout is related to chronic tedium in the workplace rather than exposure to specific kinds of client problems such as trauma.
So if you are exposed to specific kinds of trauma, working with clients or patients, that would be more compassion fatigue. It is a little bit of a self-explanatory phrase, compassion fatigue, having compassion for the ones that you work with, but you are burning out. You stop having compassion for yourself, and eventually you start to feel like you can't have compassion for other people, which becomes the problem. Okay, let's hope this cooperates with me.

01:04:00 Irene Yaymadjian
So burnout, burnout is a term first coined by Freudenberger in 1975. So burnout, it's important to understand what burnout is. It has three components. The first one is emotional exhaustion. The second one is depersonalization. And what that means is a loss of one's empathy, caring and compassion for others, and a decreased sense of accomplishment. For example, emotional exhaustion is when you emotionally are not feeling more depressed, you're feeling more anxious within yourself, depersonalization. When we look at that as caregivers or as parents or as we are speaking as physicians, whether it's in a mental health or not, whenever we are caring for another patient, we have to have some sort of empathy and compassion for that patient.

01:04:53 Irene Yaymadjian
When you're burning out, you get desensitized to the point where it's hard for you to feel compassionate towards another person and their problems. So actually you start to get more irritable, you start to zone out, you start to kind of think about other things and not be able to treat the person in front of you in an appropriate way. So a decreased sense of accomplishment. This is the third category in burnout where it feels like no matter what you do, it's just not good enough for you. You don't feel good enough and you lose hope in life and you lose hope in the work that you're doing. Now if you're losing hope in life, that goes more into suicidal ideation.

01:05:40 Irene Yaymadjian
If you're losing hope in the work that you're doing, that's really something that you should look at because that's one of the most significant things when it comes to burnout, is that if you don't find, if you don't see a future in the work that you're doing, you're very prone to not doing your best. So the burnout prevalence statistics from several states, I pulled this straight for my dissertation. I think it was very straightforward. So, a national study of burnout with a sample of 27,276 US. Physicians. 45% of the physicians reported symptoms of burnout.

01:06:23 Irene Yaymadjian
I'm pretty sure right now in the COVID pandemic, this number is probably higher. 71% of the therapists and 43% of the psychiatrists. So 71% of the therapists, MFT psychologists, school therapists, exhibited symptoms of burnout and 43% of psychiatrists. Some would say that. And of course, adding from my dissertation, looking at a lot of the stats, psychiatrists don't tend to sit with too many patients and talk to them and listen to their issues unless they have a practice where they do so. And so a lot of the interaction is much, the duration is much shorter. And so that's one hypothesis that we might have. That's maybe why they don't tend to burn out as much as regular therapists. So private practice clinicians are more prone to burnout.

01:07:16 Irene Yaymadjian
Now, this was a very interesting thing because looking at it from a Jungian perspective, and I'm not going to go too much into that, but you guys have probably heard of the Myers Briggs. And the Myers Briggs basically gives you, if you were to you can do it online, you can go on to Myers Briggs Personality Inventory and you take it as about 100 questions or so and it gives you certain personality traits that you might have, two of them which you all have heard of, extrovert and introverts. And so one of the things that we looked at when I was doing the research and I. Was doing the study because I thought that extroverts would actually be more prone to burnout. As a matter of fact, I was wrong. Introverts are more prone to burnout. Introverts are more prone or are more into private practice doing their own thing. And one of the reasons why they're more prone to burnout is because they're isolated.

01:08:13 Irene Yaymadjian
So when you're able to be around other people, you feed off of their energy. And even though sometimes that might be exhausting just by being around people, as we have learned right now, when it comes to COVID and us being separated and isolated from our friends and family, we tend to become after a while, we tend to feel symptoms of depression and then anxiety and loneliness. And so as humans, we want to be connected to people. And when we're not, it can affect us in a negative way.

01:08:43 Irene Yaymadjian
And so in private practice, if you're constantly alone and you're isolated and the only people that you're seeing are patients who come in and are talking about trauma, rape, depression, anxiety, and so forth, it tends to wear off on you. It's important to note the red flags.

01:09:05 Irene Yaymadjian
These are a few of the red flags that I wanted you guys to really keep in mind. There aren't many more. I just really want to pull the main ones. Loss of motivation and commitment. Again, feeling like you have loss of hope manifested into a wide range of medical and somatic symptoms. Remember, our psyche is a very, very important part of our life. And so if you don't take care of yourself psychologically, the next thing that gets affected is your body. And so physiologically, you start to feel depressed, anxious.

01:09:38 Irene Yaymadjian
If you're stressed out in your mind, it starts to affect your body. Remember, your mind controls your body. And so if you don't take care of it, it's going to manifest itself with different things, such as insomnia, poor appetite, depression, anxiety, and so forth. So increased cynicism. If you feel like your cynicism is more increased, you're more irritable and so forth, you can't see the hope in people, and that's one of the red flags. Lack of empathy or ability to relate to patients. This is a really big one, especially when it comes to mental health professionals. I think it goes across the board.

01:10:18 Irene Yaymadjian
But it's really important for us that no matter what we hear, we're able to actually empathize with the person in front of us. Whether it's something that we agree with or not agree with, whether it's politics, whether it's sexual orientation, whether it's depression, whether it's anxiety, whether it's trauma, whatever it is that the person is saying in front of us, it's important for us to feel empathy towards them. And when you're burning out, your empathy starts to decrease.

01:10:52 Irene Yaymadjian
So negative thoughts about self burnout and vicarious trauma. So vicarious trauma is a term used to it's basically something where if a person is in front of you and they're telling you about their trauma, you start to feel some of the similar symptoms as the person who's talking about it. So you start to actually live through that trauma in your psyche and your body starts to respond. It's something that a lot of therapists actually go through when it comes to the Diagnostic Statistical Manual DSM Five. And this would be the revised one.

01:11:29 Irene Yaymadjian
This is an old picture. The diagnosis for burnout would be occupational problems related to employment labeled under occupational problems, it's a VCode.

01:11:40 Irene Yaymadjian
However, whenever we have patients come in, typically what ends up happening is that this is kind of partnered with some sort of anxiety or depression. So there are comorbid diagnoses underneath it as well. Now, it's important to measure burnout. I would actually encourage every single person who is watching this to go online and do some sort of burnout inventory.

01:12:13 Irene Yaymadjian
The best one is the Maslach Burnout Inventory. That's also the one that I used when I was doing my research study. And it has three different components that measure your burnout levels. One of them is emotional exhaustion. Second one is depersonalization. And the third is reduced personal accomplishment. So those three components that we talked about about two minutes ago, those are the three things that Maslach Burnout Inventory, which is one of the best burnout inventories out there, measures. And if you can't find this online, I'm more than happy to send it to you. That way you can do it on yourself. So that's how you would go ahead and measure it to kind of see get a baseline of what your burnout level is or your patients.

01:12:59 Irene Yaymadjian
Now, there is a process aspect of burnout, and I like to break this down into four stages. The first stage is high workload, high levels of job stress, high job expectations. This is a great example of all of my team, all of my therapists right now. They have very high workloads. Their stress is super high. They're not only seeing patients, but they're also in school and doctorate programs and master's programs, and I expect a lot out of them.

01:13:30 Irene Yaymadjian
However, because I know about burnout, I make sure that I'm really flexible with them. When they need a break, I encourage them to take a break. And I'm always watching out for red flags to see if any of my therapists are burning out and of course, myself as well. So the stage one would be high workload, high job stress, high job expectations. Stage two would be physical and emotional exhaustion. Physical exhaustion. It would be like you're tired, you don't want to get out of bed. You're just not motivated to do much emotionally. You're just exhausted. Sometimes you're zoning out, you have a loss of words at times. You'll be talking to someone and you'll forget what you're saying. And stage three is depersonalization, cynicism and indifference. You just feel kind of detached from people. And so when you're burning out, it's hard for you to connect to others because you're actually disconnected from yourself.

01:14:26 Irene Yaymadjian
And stage four would be despair, helplessness, and aversion. This is a very chronic stage of burnout. This is a stage where a person actually stops going to work and most often ends up in therapy or ends up taking some sort of medication. If we can get them into therapy. Because lack of sleep, lack of nurturing their body with food, lack of exercise and lack of self care can eventually lead you to feeling helpless and sometimes even hopeless. So this is the process aspect of burnout.
There's also the medical aspect of burnout. So the persistent and distressing complaints of feelings of exhaustion after minor mental effort, or persistent and distressing complaints of feelings of fatigue and bodily weakness after minimal physical effort.

01:15:21 Irene Yaymadjian
So if you are a medical doctor out there, or if you're a dentist, or if you're a chiropractor, anyone, and you have a patient who's coming in and just telling you, I get so tired so fast. I can do the smallest thing, and I'm just exhausted. You might want to kind of point out they might be burning out. I know you're not a psychologist, and maybe you don't know how to assess the burnout, but you kind of know some of the symptoms. You might want to tell them, speak to a therapist and see what your burnout level is right now. Are you working too much? Are you sleeping enough? And so forth. So at least two out of the following six distress symptoms, such as muscular aches and pains, dizziness, tension headaches, sleep disturbance, inability to relax or irritability. This also actually goes into a lack of sex drive.

01:16:13 Irene Yaymadjian
If people are in a relationship, they tend to not want to have sex. They don't want to connect with the other person. It's just exhausting because their body is not able to kind of pull through with many activities that they would typically be able to do very easily. And so, as I mentioned before, whenever you have someone who's burning out, or if you're burning out mentally, if we don't take care of ourselves, our body reacts like that. And so you might be having muscle tension and feeling dizzy and having headaches, not even thinking that you might actually be burning out. So the patient is unable to recover from the symptoms by means of rest, relaxation, or entertainment. This is really, really important. So most of the time, whenever I talk to my colleagues or friends, I would say, oh, I'm so tired. I've been working so much, I kind of feel like I'm burning out. This week was really hard, and they would say, we'll go take a vacation. So I'll take a week off after about not even a week, I'll take like two, three days off after about two, three days. During those two, three days, I'll exercise, I'll eat, I'll take care of myself. I'll kind of catch up on my rest.

01:17:23 Irene Yaymadjian
Even though research shows that you actually can't catch up on rest, I still like to call it that after just a little bit of a few days of doing that, I'm okay, I have my energy back up, I'm feeling good. This patient who's severely burnt out or is burning out, actually, they can do that for an entire two weeks, and they still don't feel energized. If they sleep all night, they might actually sleep all day as well. And when they wake up, they're still super tired. So the duration of the disorder is at least three months. So you have to be feeling at least two of these six symptoms of muscular aches, pains, dizziness, tension headache, sleep disturbance, inability to relax, and irritability, at least two of those. You have to be feeling at least two of those for at least three months in order to be diagnosed with burnout. The criteria for any more specific disorders does not apply.

01:18:24 Irene Yaymadjian
The number one thing that we therapists do is when someone comes into therapy, the very first session when we're doing their assessment is we always ask them, when was the last time you went to the doctor? And typically people will say, oh, about three months ago, a year ago. I haven't been there for ten years. And the number one thing we say is, go to the doctor. I'm going to give you a month to go and get a full physical. Why we do this is because we want to rule out any medical conditions that this patient might have, because if they have any kind of medical conditions that are underlying and we're trying to do therapy with them psychologically, we're not going to be able to help them. We have to make sure that anything that's medically related, that's taken care of first, and then we can take care of the psyche. You want to kind of think of burnout as when you light a candle, your flame is gone. And so no matter how much you light it with the lighter, it just doesn't turn on. There's no more wax or there's no more fuel to the fire, we could say.

01:19:30 Irene Yaymadjian
So the role of balance and self care in avoiding therapist burnout I know I wrote this relating to therapist burnout, but this could be burnout for any physician, for anybody who's working in any field, really, and can also now definitely be applied to caregivers and parents. So another thing I want to kind of go back to is the word balance. I typically don't like to use the word balance, and the reason why is because balance means that it's 50 50, it's equal. Nothing is ever equal in our life, and no matter how much we make it, it's not going to be equal. And so what I like to substitute that word with is integrating. So we need to learn how to integrate our love life, our sex life, our home life, our work life, our social life together, it's never going to be equal, it's never going to be fully balanced.

01:20:24 Irene Yaymadjian
However, if we can integrate it in a healthy way, that's when we can have a much happier life, actually. So work related factors, these are specifically to work. These are specific factors that are work related. So setting client type, lack of progress, chronic conditions and relapses on call schedules, emergencies and crises, suicide attempts, violent and aggressive clients, anita professional isolation, fear of malpractice claims, ethics complaints and licensure board complaints. So, difficulties collecting fees, et cetera. Focusing on others' needs often neglects your own being on call, long work hours, the unknown, inability to make plans, and administrative responsibilities. So I'm going to stop at administrative responsibilities. The first part is really telling us that the lack of progress and the types of patients we see can lead to us burning out if we don't take care of ourselves, if we're stressed about complaints, if we're constantly seeing patients with trauma and DV cases and depression and bipolar syndrome.

01:21:38 Irene Yaymadjian
All of that is going to eventually affect us if we do not have some sort of healthy way to take care of ourselves during the process. So if we're focusing on others and on others' needs, we are often neglecting our own. And that's just the normal, natural thing. So if right now you were to sit down and if there was a person in front of you, and if you're focused on what they're saying, you are going to not pay attention to what you're thinking unless you're not focused on what they're saying. So in order for you to actually be fully hearing what they're saying, you have to kind of shut down your mind for a second and the voice in your head. And that's how neglecting your own feelings is when you're taking care of someone else. If you're physically taking care of someone else or mentally taking care of someone else and you're neglecting your own, you're not paying attention to yourself. That's going to lead you to burnout.

01:22:31 Irene Yaymadjian
So if you're on call and you're constantly working, this is one of the things that I always tell my patients, especially the new moms that I work with. I have moms who I work with who are doctors, lawyers, and teachers, and I tell them, your work is going to be there, but if you don't take care of yourself, you're not going to be able to be there for either your work or your child. So you have to take care of yourself first. And I know it's such a cliche thing to say, like, take care of yourself first. Real so you can't take care of others, but it's absolutely true. It's the same concept whenever you go to a therapist and they say if you're flying on a plane and

01:23:13 Irene Yaymadjian
something happens and your little air thing comes down. You put it on yourself first to give yourself air and then other people. Because if you don't take care of yourself, you can't take care of other people. So look at yourself and allow yourself and teach your patients to really kind of step back and help them have some sort of structure in their life which includes time off and time on. I'll talk about that a little later. So administrative responsibilities like paperwork, insurance, managed care, low reimbursements, utilization review, staff cutbacks, lack of resources, this is what is happening right now during the pandemic in the majority of workplaces, this is something that can affect anyone.

01:24:01 Irene Yaymadjian
But especially right now, if people are losing their jobs, they're going to feel a bit burnt out if they're trying to apply to others. I mean, I understand there's edd going on, but once we start going back to our normal, a lot of people are going to start to fall into a little bit of anxious distress, kind of looking for things and trying to get a job and so forth. So if they have a lack of resources, it's eventually going to burn them out. So, lack of immediate feedback. So this is something that during the workplace receiving negative feedback, not feeling appreciated. Again, in the beginning when I mentioned make sure if you are a supervisor, if you're a mentor, or if you are running a practice, it's important that as a physician, even though we are doctors and we're therapists and we're healers, we have to also remember to take care of the ones that work for us. And so making sure that they get the feedback, that's important.

01:25:00 Irene Yaymadjian
Of course we have to give sometimes we have to give some negative feedback. But a three to one ratio is really nice. For every three positives, there can be one negative and I like to call them growth areas. So if you're not feeling appreciated and this can also play a very big role in your relationship if you're not feeling appreciated, if you're constantly getting negative feedback, you can definitely be burning out. And time demands and pressure is not enough time to get everything done. 01:25:31 Irene Yaymadjian Sometimes we need more time in the day, but I always say we need to make more time in the day. These are personal factors. Now those were work factors and these are personal factors. So personal factors meaning family health, financial relationships, mental health, substance abuse and related issues. Related issues.

01:25:53 Irene Yaymadjian
There's substance abuse, there's alcohol abuse and so forth, like gambling, shopping, all of that. So examples include caring for an ill family member, getting married, going through a separation or divorce, having a child, experiencing depression. So there are a few things that can happen in our life that can significantly increase the anxiety and depression in ourselves. And these are some of the examples. Yes, getting married can actually lead you to burnout. It's not always happy and dandy, sadly. So if you are constantly giving, giving.

01:26:31 Irene Yaymadjian
You are not saving enough energy for yourself. You're going to burn out if you don't catch yourself. I always like to tell my patients, you wake up in the morning with a jar of energy. You have to be careful of where your energy goes, and you also have to save some for yourself. You can look at it this way. If you had a plate of food and you just gave all your food away to everyone, there's not going to be any food left for you.

01:27:00 Irene Yaymadjian
And you're going to then neglect yourself and you're going to feel irritated, and then eventually you're going to start to struggle. So think of your life if you have a certain amount of energy, you have to be picky about where you're giving it to because eventually you will burn out and you won't be able to give it to anyone. So these are some of the very important personal factors in our life.

01:27:20 Irene Yaymadjian
So if you move, if there's any kind of move, any kind of job change, any kind of job loss, any kind of pandemic, what we're going through right now. In the beginning of this pandemic, the one thing that was very prominent was adjustment disorder after about a couple of months. Why? Because everybody needs to adjust and everyone adjusts in a different way. And so we as therapists have to step forward. And as physicians, we step forward.

01:27:50 Irene Yaymadjian
And somehow, even though we're also trying to adjust, we are all of a sudden becoming this person for the people in front of us, the patients, where they can look to us and go, oh, well, my doctor seemed like he or she was having a good day and, oh, they seemed so happy and they were smiling. Okay, maybe it's okay to smile.

01:28:08 Irene Yaymadjian
So it's like little things like that that we can incorporate into our sessions with our patients to make them feel better. But at the same time, if we're not taking care of ourselves, we're not going to be able to do that for them. I'm going to say that often so you can always remember it. So challenges throughout your career. This is another one.

01:28:29 Irene Yaymadjian
I like this picture of the thinking cap because we don't realize how much stress is incorporated into our daily activities. Even if it's something we've been doing for 30 years, we are still constantly thinking, thinking. So graduate students when we were graduate students, if you are a graduate student right now, the impossible situation, practicing good self care, but do a great job on every assignment, turn them in on time, do research, see clients, make money, have a life. Like, these are all the challenges that a grad student feels. Someone in their early career starting a practice or a career, starting a family, expectations and time pressures. A lot of the majority of the patients that I'm working with are in their early to mid career and a lot of them are complaining about not having enough time or running out of time.

01:29:22 Irene Yaymadjian
So if you're constantly thinking about your running out of time, that is going to eventually lead you to become very anxious and distressed, eventually irritable, maybe sometimes resentful, which is going to then lead you to burnout as well. So be careful. Mid career, raising a family, finances, running a practice, seeking tenure, so divorce, remarriage blended families, et cetera. And the last challenge is later career, so, raising a family, caring for aging parents, retirement planning, declining health, all of these things are challenges throughout your career that if you don't pay attention to, can lead to you burning out. The reason why I put this here is because it's important to know that it's not just you who's going through all this and that it's normal that you're going through this or your patients are going through this.

01:30:16 Irene Yaymadjian
One of the things that happens is that a lot of patients come in and they feel like they're alone. They feel like they're alone, feeling like, oh, I'm running out of time, I should be married or I should be doing this, I'm taking care of my family, they're not taking care of themselves. And then eventually they feel like they're burning out and then they feel guilty for burning out. So when you have a patient in front of you and you see that guilt within them, please refer them to a therapist.

01:30:43 Irene Yaymadjian
It's going to be the best thing that you do for them because they're going to be able to step back, learn about their risks and their burnout levels, and then we can help them through this. But all of these things that are listed here are very normal and typical things that patients go through that everyone goes through, especially ones who have gone to higher education and who have higher degrees and so forth. So that's cool, but how do we go from that little green thing to unicorns and cute kittens? So how do we manage and reduce the impact of compassion fatigue and burnout? This is one of the biggest questions. It's really, really important.

01:31:34 Irene Yaymadjian
So knowledge and awareness of the symptoms, you have to understand and you have to be aware of what are the symptoms. Then you have to know how to talk about it and how to ask for help. It does not make you weak to ask for help. If you're feeling like you're burning out, you don't have to be able to take care of yourself all the time. So be aware of your own limitations. You have to know what your limits are. If you're constantly surpassing your limits, you're going to burn out and then you're going to feel like you're not good enough. So maintaining discipline and daily responsibilities, meaning setting boundaries, take small breaks throughout the day.

01:32:17 Irene Yaymadjian
One of my favorite things to do, I do two things throughout the day. I take a walk and I have coffee with no one interrupting me. I don't care what is happening. I take about 20 minutes out of my day. It's not a lot, but I take 20 minutes out of my day and I just have coffee. I just had coffee. And it has significantly changed the way my day is because I've learned how to slow down and take a walk. I was reading an article, and this was a couple of years ago, actually, it must change now, but in one of the articles it stated that taking a simple 20 to 30 minutes walk a day reduces your chances of heart disease by like 20%. That's huge.

01:33:04 Irene Yaymadjian
Now, when we look at psychologically how it affects us, especially, we're kind of constantly thinking it's important to move forward physically because it helps us to go forward. If you're physically moving forward, you can't be thinking backwards. Try it next time. So taking small breaks is number one. Understand that some things are outside of your control. So we are high achievers.

01:33:29 Irene Yaymadjian
We always need to have control over everything, or we like to think we have control over everything, which is one of the major contributors to Burnout, is we thinking we have control over things and when we realize we don't, we feel like a failure. Then we start to move back. Eat lunch anywhere but at your desk. Move from your chair. Move from your office. Leave your office if you can step outside. If you have a balcony. If you can't leave the office, step outside of your office and go out into the waiting room.

01:34:05 Irene Yaymadjian
Not the waiting room or anywhere you want, outside. And wherever your center is, move away from where you're working and have lunch elsewhere. Why? Because you have to remove yourself. Because if you're in the same place where you're working, you're going to automatically work. Get outside, get fresh air. We do live in La. So we have beautiful air until it's like 115 degrees outside and then we can't breathe. But most of the time we have good air. Know your peak times of alertness. This is a very, very important thing to learn about yourself. Know when you have the most energy.

01:34:42 Irene Yaymadjian
For instance, I am not a morning person. I can't stand waking up early in the morning. I am the worst person to talk to in the morning. So I know that I'm not going to schedule patients in the morning. As a matter of fact, I'm not going to schedule patients until about 12:00 in the afternoon, and that's fine. I would much rather see patients in the afternoon and the early evening. Not late at night, not early in the morning. And that is when my best time is, where I can be a therapist and I can feel like I'm my best self. It took me about eight years to learn that. All throughout grad school, I scheduled all everywhere and this and that, and then I just had to admit to myself that I'm not a morning person and it just made my life a lot easier. So assess within yourself what your peak times are for alertness. So acknowledge and embrace difficulties you are having.

01:35:31 Irene Yaymadjian
It's okay to have difficulties. You don't constantly have to be this perfect person. This really is an important thing, especially for new medical students and trainees and associates and psych assistants.

01:35:47 Irene Yaymadjian
Untie the knot. The work will always be there. Our patients are always going to be there. You have to know when to stop. You have to know to leave your work home. I know we have a lot of work to do, but it's not going anywhere. That's the beauty. Our work isn't going anywhere. It's still going to be there. If we took a break and went to sleep and woke up in the morning and continued to do it. Seek supervision and pure support. Again, this is a really important thing because if you can talk to like minded people, you'll realize that you're not alone in the world feeling the way you do.

01:36:23 Irene Yaymadjian
And it also contributes to you being able to think about things from different perspectives instead of being stuck in your own way, which can lead you to burn out. Because if you're not able to activate the different brainwaves and think in different ways, you're going to burn out because you're going to get stuck in your head or you're going to get stuck in your own way. Continuing education. This is exactly what you guys are doing right now. Good job. Ongoing training for greater foundation. It's such a wonderful thing, especially for, I mean, not especially licensed and unlicensed professionals. It's really important to take continuing education units to educate. It's mandatory for us. I'm sure it's mandatory for the medical society as well. There's a reason for that is because again, we're learning new things. We feel like we're moving forward and we're also building a stronger foundation within ourselves and keeping up with the times. Take many vacations. Make time for them.

01:37:21 Irene Yaymadjian
You don't have to go to Europe for a month out of the year in order to relax. And then you work eleven months out of the year. Just stressed out. You can take many vacations. You can just take a two day vacation. You could take one day and just go do whatever you want and turn everything off and just focus on yourself for that one day. So don't think that you have to take a huge chunk out of your day or out of your year or out of the month. I'm sorry, not a day out of the month in order for it to work. You can take small vacations and it can actually make the same effect. So the bottom line is self care, boundaries, training and supervision. Again, it's self care, boundaries, training and supervision. If you have those four, you're going to be less. Prone to burning out. This is a positive coping checklist. If you guys want to take a picture of it, you could, and then you can kind of check off the things that you do. So taking regularly scheduled breaks.

01:38:25 Irene Yaymadjian
I take vacations periodically. Don't bring work home with me. I have friends, hobbies and interests unrelated to work. This is a very big one. Having friends that are not in your field is a very important thing because again, they allow you to see the world in a different way. You don't get stuck. If you're stuck, you're going to start to get burnt out. You got to open your horizon. Exercising regularly, eating healthy, having a good diet, maintaining an appropriate weight. Wherever you feel comfortable, limiting your work hours and your caseload, your work is always going to be there.

01:39:06 Irene Yaymadjian
Participating in peer support, clinical supervision, personal psychotherapy, or journaling. I know a lot of people that love to journal. I love to journal. I've been journaling since I was like eight years old. I still have the journals. It's incredible how much I've grown, thank God. But basically what journaling provides for you is we tend to keep all of our thoughts in our head. And so if it's being overwhelmed with all these different thoughts and stuff, we gotta put it somewhere. So when we put it somewhere, it now opens up some more space to think about other things, which is really nice. I attend to my religious and spiritual side. Religion and spirituality is a very important thing. This doesn't have to be something like a god or anything like that.

01:39:58 Irene Yaymadjian
Whenever we look at human nature, it's important for us to have some sort of faith, something that's higher than us. Whether it's the universe, whether it's whatever your religious background is, whether it's spirituality, whether it's meditation, mindfulness, whatever it is, something like that in your life will bring some sort of relief. And it's shown to really help a lot and prevent you from burnout because now you have faith. I regularly participate in relaxing activities such as meditation, yoga, reading and music. This is an interesting one because I know a lot of people like myself who cannot do yoga. I am not a yoga person. I can't sit there and just breathe. I'm a very hyperactive person. And so I would like to go boxing. So boxing, hiking, that would do the same thing for me as it would do for a person who likes to go to yoga and reading and listening to music and meditation. Whatever it is that floats your boat, whatever gets your energy out and brings you to the ground, you do that and regularly do that.

01:41:04 Irene Yaymadjian
I regularly participate in activities that I enjoy and look forward to. If you find yourself or if you find your patients stating that they don't have the motivation to do things that they like to do or they usually liked to do, that's actually a symptom of depression and you want to kind of keep an eye out on that. I'm going to have you guys take a picture of this, please, and do it on your time off. So this is a forgiveness exercise. The one thing you want to remember is that when we forgive, we do it for ourselves. Forgiveness is a very selfish act. If we're holding on to resentment and if we are holding on to things within us that other people have done to us, we are only hurting ourselves, which then leads us to kind of be like a teapot.

01:42:04 Irene Yaymadjian
We boil, boil, boil, boil, and then eventually we kind of burst and scream and which leads to burnout emotionally. And when we're emotionally burnt out, especially right now, if a lot of you are home and stuck with your family members, if a lot of stuff happens within our family and we don't know how to forgive them for our own sake, so we can move forward. We're going to burn out. We're going to be resentful, and we're not going to be able to be there for our own family members. So this is an important concept in compassion fatigue, actually, and in the work that we do is helping professionals. So this is because sometimes we're limited to how much we can help someone else and that's a difficult burden for us to carry as caregivers. What this means is that we have to admit to ourselves that there are going to be some people that we cannot help and we have to forgive ourselves for that. We have to do the best we can and we cannot burn ourselves out thinking we could have done better.

01:43:12 Irene Yaymadjian
So burnout. Forgiveness is important because forgiveness is also helpful and effective in reducing traumatic reactions, stress, anxiety, anger and depression. And it also helps increase hope, peace, positive emotional feelings, self esteem and self confidence. And this is the little activity I would like for you guys to do on your time away. So you would write down one person that you want to forgive and in one word why you want to forgive them. Why do you want forgiveness? I'm sorry. And write down one person that you would like to forgive and in one word why you want to forgive them. So you're going to read it out loud to yourself or silently. You're going to take a deep breath and you're going to burn or crumble the paper and throw it away.

01:44:04 Irene Yaymadjian
It's a very symbolic exercise and it's helping you let go because you're literally doing the action. You're writing it down, you're thinking it through and then you're getting rid of it. This is a good example, or these are good examples of maladaptive coping.

01:44:24 Irene Yaymadjian
A lot of this is actually coming up right now with a lot of our patients, especially in the beginning of the pandemic when a lot of patients were just burned out on news and media and politics and the Coronavirus and so forth. I self medicate with alcohol drugs, including over the counter and prescription. And food. Yes, food could be like a drug because your body gets addicted to sugar or whatever it is. And so you think you're nurturing yourself, you think you're taking care of yourself, but actually you might be harming yourself. So, for instance, sometimes we have patients that we're working with and they would say, oh, when I'm stressed out. Or I was so stressed out last night that I went home and I had a whole box of muffins and I ate an entire bag of chips, and then I had an entire pizza and I felt so good. But then I felt so bad after an hour, I ended up having to throw up or something.

01:45:25 Irene Yaymadjian
So in the beginning what happens is that you don't know how to take care of yourself, you don't know how to cope. So what happens naturally is that we think to ourselves that oh, we can feed ourselves, we can nurture ourselves with all the vitamins and minerals and everything that has to go with it and the sugar especially. And then what happens is that and yes, sometimes it can also be ice cream and all these wonderful things that are yummy and good, but at the same time if you constantly find yourself doing it whenever you're stressed, it can be a problem. So you want to watch out for that. That could be a maladaptive. Coping so I seek emotional support and nurturance from clients. This is a no no. This is a no no.

01:46:13 Irene Yaymadjian
As a physician, you have to really check in with yourself. When you find yourself looking for nurturance from your own patients because you're there to take care of them, they shouldn't be taking care of you. So if you find this, you have to really reach out for help. I keep taking on more and just try to work my way through things. This does not work. This is not a good coping mechanism. This is something that's actually going to definitely get you to burn out. If you keep taking on more and thinking that if you keep your mind busy and you just move forward with every day and you're just not thinking about it, that it's just going to disappear. Actually what happens is that your mind just kind of throws it in the back burner and then it starts coming out subconsciously, it starts coming out physiologically and then eventually behaviorally. And so you really, really want to look out for that.

01:47:05 Irene Yaymadjian
I try to squeeze more into the day, get more done, measure success by how many tasks I completed and by how much I can accomplish in a day. This is something that a lot of us might be guilty of, but all you're trying to do is basically show yourself that you're good enough and that you're progressing in your life. But this is very maladaptive, because eventually what happens is that we are very hard on ourselves, and most of the time, humans don't know when to stop. Most of the time, humans can't really tell them, and don't really know what's good enough for them. This is why we have our supervisors, our spouses, our parents tell us, you're doing such a good job, and so forth. And we reach out to them to see if we are doing a good job. That's a great way. Don't do it with your patients.

01:47:54 Irene Yaymadjian
But if you think that you're going to feel good about yourself by setting tasks and checking them off, eventually what's going to happen is you're going to set more tasks for yourself, which then leads to you feeling like you're a failure. Because what ends up happening is you don't have enough time in the day and then you don't get things done, which then makes you feel like you're not good enough and so forth. It's just a domino effect. I isolate, avoid colleagues and minimize the significance of stress in my life. If you find yourself isolating and not talking to people, this is a red flag, especially for a lot of us who are high achievers. We're a little embarrassed to ask for help as a therapist, a lot of therapists sometimes feel embarrassed to ask for help. I have a psychologist I go to. I don't know what I would do without her.

01:48:46 Irene Yaymadjian
And so it's really important to reach out for help and know that it actually takes strength to reach out for help. When you feel like you're burning out rather than not reaching out for help, it does not mean that you're stronger because you're not reaching out for help. So I know that distress and impairment are for others and don't take seriously the warning signs I experienced. This is a very big one. Oh, no, I'm going to be okay. You take care of yourself. Let me do this for you or not. Oh, that's sad for them, but you're not realizing that it's actually happening to you and you're doing the same thing. And I believe that everything will turn out fine just because I say so.

01:49:24 Irene Yaymadjian
Well, that's a very wonderful optimistic way of looking at things. But sometimes it doesn't turn out fine. Sometimes we have to do things differently in order for things to turn out fine or not. So those are some maladaptive coping skills. Self care is my favorite thing and something that is the hardest thing to do for most people, no matter how much education we have, no matter what our grades were in school, no matter what we have accomplished in our lives, it seems like the one thing we just have a really hard time with is self care. And eventually what I found is after talking to several therapists, I talked to about 350 therapists when I was in grad school. What I found is that the more seasoned therapists were the best at taking care of themselves. The age group was, like, above 60. That's one of the things they said, is that when I was younger, I was not able to take care of myself until I got to about 55, 56. And then I realized I have to take care of myself. Why? Because I need to take care of my health.

01:50:37 Irene Yaymadjian
And I couldn't actually work if I didn't take care of myself. So it was kind of like they were forced to. So make an adequate time for yourself. Schedule breaks. As I said, throughout the day, this is all self care. Do things you enjoy. Engage in hobbies. Please find a hobby, whatever it is. Drawing, watching a reality TV show, knitting, I don't know, playing with your dogs, cooking, anything like that. Just find a hobby that just takes your mind off of things. Take care of yourself physically and spiritually. Take care of your relationships in your life.

01:51:16 Irene Yaymadjian
Don't neglect your relationships. Say no. This is a big one. Say no. That was something very big for me to learn as a therapist, saying no. I always said yes. Yes, of course, of course. Because I want it to be, I want to show that I can do everything. However, I realized that it's okay if I don't do everything. I could say no to things, and the things that I do say yes to, I give it my best. And don't isolate yourself. One of the things that I can also add to this is substitute I'm sorry with thank you.
We tend to feel smaller, and it's a self care technique, actually, because we're taking care of our feelings when we learn how to thank people. So thank you for waiting for me. Thank you for being patient with me. Thank you for doing that for me instead of, I'm so sorry I'm late. I'm so sorry, I made a mistake, I'm so sorry that happened, and so forth. When you say I'm sorry, you feel smaller.
You can take care of yourself by saying thank you instead. Try it. All right, so the other ones keep in mind that self care is a good thing. It doesn't mean that you're selfish and you don't care about your patients. No, self care is a good thing. You have to schedule your lunch. You have to eat lunch. It's important. I know patients need to be seen, but you have to eat. You have to be seen and heard and nurtured as well.

01:52:43 Irene Yaymadjian
Watch out for warning signs such as violating boundaries, self medicating, wishing patients would not show up, finding it difficult to focus on a task at hand. Boredom, fatigue, or missing appointments. Watch out for distress, burnout, and competence problems in your colleagues. So one of the other things that happens in burnout that we really have to pay attention to is that we start to see other people burning out. We can see it in them, but we ignore it in ourselves. Just like I kind of mentioned previously, this is another exercise that I would like for you guys to do. This is a wonderful one. How do you cope and take care of yourself?

01:53:28 Irene Yaymadjian
You would just write down three ways you can change to take better care of yourself. And so when you write these things down, whenever you're sitting at home and you're like, well, how can I take care of myself right now? Pull out your little list and see the different ways that you wrote that you can take care of yourself. You can write three things you can do and do one each day. So conduct periodic distress and competence, self assessment and seek help when it's needed. This sounds very fancy. It's basically just checking in with yourself on a one to ten scale. How much do I feel like I'm burning out? How tired am I? How excited am I for the day? And so forth. And if you feel like you're just on the very high end of burnout or you're on the very low end of motivation, seeking help, maybe that day scheduling a little coffee, chat, zoom zoom chat with one of your colleagues or friends just for about 1015 minutes to just sit down and talk about something.

01:54:31 Irene Yaymadjian
Another thing is very important is planning things for the week or at the end of the day, if you have something to look forward to, it automatically gives you a little bit of a boost in energy so that you can actually go through the day. You want to focus on prevention. Don't tell yourself to stop doing things. Tell yourself to change the way you do things or to I'm going to basically say the same thing or do things differently. So sometimes we have to say it in a different way for us, whichever one we grasp. And what I mean by that is, I'm not saying this doesn't go back to the saying no to things so that you're not overburdening yourself. What I mean is that when you're focused on prevention, it automatically helps you focus forward rather than when you tell yourself you're not going to do something. Typically most humans, when they tell themselves they're not going to do something, they want to do it more. And so you want to focus on prevention. You want to focus on moving forward.

01:55:40 Irene Yaymadjian
You want to focus on the change rather than what you don't want to do and so forth because you know what you don't want to do, but you have to pay attention to more of what you do want to do. So instead of seeing ten patients in a row, maybe you would like to see seven patients and then take a break and then go take a walk. So really focusing on that is going to be much more helpful than the alternative. Make time for self care. You have time. You absolutely have time. It's not true when we tell ourselves that we don't have time, we don't make time and we don't make time for ourselves. And that's the sad part, because we make time for everyone else except for ourselves at times, and then we start to resent ourselves.

01:56:30 Irene Yaymadjian
So the next time you find yourself saying, I don't have time, or somebody else says, I don't have time, tell them, make it. Well, it's impossible. No, it's not impossible. We have time. We all made time right now out of our crazy schedules to sit here for a three hour webinar. We made that time. So if it's important to you, you'll make the time. If not, you'll make an excuse. So seek out personal psychotherapy. Guys, psychotherapy is an amazing thing. You don't have to be in it for many years. You can have a therapist, which you can go to as needed. It's a place where you can get support. You can learn about yourself. You can gain some strength and knowledge, develop skills, and just move forward with your life. You don't need to be severely depressed or anxious to go. You can just find someone that you feel safe with so you can have that outlet. Use colleague and assistance programs.

01:57:24 Irene Yaymadjian
So actually, a lot of workplaces I don't know if you guys know, but they have employment assistance programs, EAPs through health insurance programs. You can use that to go see a therapist. And they pay for your sessions. They pay for like five or six sessions, and then your therapist can ask for an extension. So if you don't want to, or if you don't want to, if you can't pay for therapy out of your pocket, ask your insurance company and see if you have an EAP program so you can help yourself if you need to get the help. Participate in peer support groups again. This is really important. Why? Because this is going to help you build a network, a community, and a support group so that you don't feel alone.

01:58:08 Irene Yaymadjian
Accept that you're human, in need of assistance and a work in progress. Guys, we are always a work in progress. No one is perfect. And no matter how perfect they seem on the outside, they're not. And that's okay. You're always growing and you're always changing. So in psychology, some therapists might disagree with me and they might tell me that, no, people don't change. However, because I'm very Jungian, Carl Jung always stated that change is on a continuum, which actually shows that humans are always changing. So you can argue with me about it later, but know that you're always changing. And don't try to be perfect. Don't try to have it all. Don't try to do it all. Know your limits and please be realistic.

01:59:00 Irene Yaymadjian
This is the last exercise that I want you guys to do. This is a wonderful exercise. This is Dr. Cloner's exercise that he always has our patients and our students do. And it's very, very close to the one that I always brag about on my Instagram page, which are the three G's, the Good, Grateful, and goal. And so mine is, name one thing you're grateful for. Name one thing that's going good in your life and name one goal, a selfish goal for today. It can't be work related, it can't be home related. None of that has to be something selfish. 01:59:38 Irene Yaymadjian Like, for instance, my goal today was that after I'm done with all of this, I'm going to sit down and watch my favorite show. I'm going to watch two episodes. That's because I haven't been able to watch it for the past week. So that's my goal for today. It's going to make me feel good, and I'm going to have ice cream, just a little bit of it. So the gratitude exercise again, go ahead and take a picture of it. You would write down one thing that made you feel good today. Just one thing that really made you feel good today.

02:00:06 Irene Yaymadjian
You want to write down one thing that makes you smile. When you think of it, what makes you smile? For instance, what makes me smile is my dog. Every time I feel down or I'm feeling like I'm burning out or I feel like I'm just not in the right, I think of Chloe. And then when I think of her, I just smile. And it just makes my day, or at least makes my moment. So write down the name of one person who supports you. It's important to think about the people who support you so that you don't feel alone.

02:00:34 Irene Yaymadjian
Write down the name of a person that you adore. You don't have to love them, just adore them when you think about them. You adore them. You take a deep breath, you soak it in, and then you just smile. It's very, very simple elementary exercise, and it's one of the smallest things that you can do every day. It just literally takes you 30 seconds to do every day. You can do this, and it changes.
02:00:58 Irene Yaymadjian
If you do this consistently, it will make a shift in your mind because you're basically telling yourself, and you're making yourself smile, and you're thinking about the positive without being unrealistic.
You're not saying these random things, that life is so positive. You're actually thinking about what is good in your life, which then can also, if you practice that every day, it allows you to be hopeful. It allows you to have faith in yourself, and it also allows you to see the future and be motivated, and it gives you a little bit of energy.

02:01:33 Irene Yaymadjian
Thank you. I really appreciate everyone's time today, and I will go ahead and put my information in the chat box. And thank you very much.

02:01:47 Vicken Sepilian
Thank you, Dr. Yaymadjian and Anita Avedian, for really these great and very, very informative presentations. I'm going to ask Dr. Barkoudarian, who is a board member of the Armenian American Medical Society, joined me to help moderate the Q and A session. I'd also like to say, if you have Instagram, you can follow both of our presenters on their pages. Dr. Irene Yay is the instagram handle for Dr. Yaymadjian and Anita Avedian LMFT is Anita's instagram page.
02:02:29 Vicken Sepilian
And also Hillside Therapy, which is the nonprofit center that Irene spoke about, also has its Instagram page. And both of our panelists, esteemed panelists, are very active in putting out great advice and great resources on Instagram stories and on the posts. I follow both of them, they come up with my stories at the top, and some of their suggestions are very meaningful. I have to say that I have really benefited from some of the information that both of you have shared, so I commend you. And if anybody here who's watching on Zoom or on Facebook Live, I encourage you to also go ahead and follow some of these resources that they share. With that, we're going to ask some questions.

02:03:25 Vicken Sepilian
Garney, if I could ask for you to open up the Q and A session?

02:03:31 Garni Barkhoudarian
Yes, absolutely. Well, first of all, I have to echo your words and thank our two excellent presenters today. I mean, lots of content and just important topics that deserve a lot of attention and have clearly been heightened in today's current pandemic situation. We find ourselves and many of us are struggling with these types of issues now, and it's always good to hear how we can address them as caregivers as well as taking care of our patients who may have these.

02:04:09 Garni Barkhoudarian
Irene, one question came to mind. I was trying to relate to some of your points that you were pointing out. For example, don't take your work home with you and try to limit your casework. And here we are at 09:00 on a Monday. I'm actually still in my office, but I work. But propose what's going on with COVID and a lot of virtual visits, a lot of Zoom sessions, basically we are working from home and the offices come home, and the home has come to the office from time to time.

02:04:50 Garni Barkhoudarian
What do you recommend in terms of setting boundaries so that we can still have some of that separation, where we're able to still have this zone where we can deal with some of the stresses and not deal with the work, although it's still kind of at the kitchen table or somewhere nearby. Any advice for us dealing with these issues?

02:05:12 Irene Yaymadjian
Yeah, Garni. That's a really good question. That's actually something that even I'm sure we've struggled with as therapists, I have at least when you're home and everything is just right there, I've actually found myself to work more. Right. But what happens is that we just have to step back for a moment and again, think of setting boundaries and structuring our day. So we can look at it this way. Since you're home, you probably don't have to. You could be more comfortable in your clothes, for instance, right? So that means that you can also eat instead of not eating, you can have a lunch break because your refrigerator is right there. So the excuse of "I didn't eat the whole day today because I was working" kind of goes out the door. Right. And then also just making time in your structured schedule to incorporate whatever it is, whether it's taking a walk, whether it's talking to a friend, having your coffee in the morning, having a coffee break.

02:06:07 Irene Yaymadjian
So setting your boundaries and knowing, okay, for instance, I don't work past a certain time, like I don't work past 04:00. Let's say that's my schedule, no matter what happens, I have tried not to work past 04:00, meaning seeing patients. Of course, I have to respond to a text here and there, but I don't fully go into work mode. However, there are certain days throughout the week, like this week, today I needed to work in the evening, and that's fine, but that's not a consistent thing that I want to do. And so I've catered my schedule so that it can work for me. So I guess what I'm trying to say is make sure to set boundaries and have a time where you can stop. Know when you need to stop and when you stop, you stop. You have to, because you could just keep going. It's three in the morning, you still have your laptop in front of you doing work. I've done it, I've been there. It's not healthy. The work will still be there. Tell yourself, oh, this is great. I can actually eat when I need to. I can wear more comfortable clothes. As long as you look good in the top. Sometimes that's all that matters when you're home. Not that I'm wearing sweats or if I ever but again, setting the boundaries and knowing to structure yourself and also knowing when you work best. You know what I mentioned before? So knowing when you work best and when you stop, you stop. Like, if it's 09:00 that you're done at 09:00, you're done at 09:00.

02:07:41 Garni Barkhoudarian
That's really helpful. And that's important, I must say, as ambitious caregivers and practitioners are often violating some of that. But I think it's important to keep that in mind as a follow up question to that. Many of us are in relationships, have spouses that are also professionals, and also tend to have some of the stresses from work that trickle over, and some of that affects the ability to find some balance with these issues.

02:08:23 Garni Barkhoudarian
Do you have any advice for two professional type relationships and how that can be addressed both by behavioral changes and also maybe a conversation with each other? Any help with that?

02:08:39 Irene Yaymadjian
Absolutely. And Anita, you can chime in when you'd like to. I think. That we have to go back to. You don't want to find balance. You want to find integration. So you have to both learn how to integrate your work, your social, your sex life, your exercise time, and your family life in your daily routine. Okay?

02:08:59 Irene Yaymadjian
So if you can become a team and have a plan of some sort that is also flexible because it has to be as physicians and as therapists, we don't know. Like, one day I can plan to go to the beach, then one of my patients ends up in the hospital because they attempted suicide. You know what I mean? That can happen. But that's not a usual thing every day for it to happen. And so I could still have that plan. So maybe sitting down with your spouse or your significant other, your partner and talking to each other, how can we integrate the many different things that we need to do during the day into our day?

02:09:37 Irene Yaymadjian
And the different components, the different roles that we play in our life? How can we integrate those different roles so that we don't feel like we're neglecting each other? Because if you're not connected with your partner, you're not going to be happy at work, no matter how much money you will make. And if you're not connected at work, you're not going to be really that happy at home because you're going to feel like you're not being the best. So again, take out the word balance and put in, integrate and come up with a plan together that is flexible enough to change if it needs to, however, but is realistic enough to actually pull through. Do you want to add to that?

02:10:15 Anita Avedian
I thought you responded so well to that question.

02:10:20 Vicken Sepilian
That really is very great advice and I hope that it's something that is challenging and with all the changes. Yesterday I spent the afternoon with a friend of mine who is a busy surgeon and I hadn't seen them for a while and their two children and really some of these very challenges that you hit on Garni and that I witnessed right in front of me, and this is advice that really everybody can use.

02:10:56 Vicken Sepilian
Anita, I have a question for you. Now, I know that the discussion topic that you presented was on domestic difficulties and touching on domestic violence, but I'd like to sort of flip to the opposite side of it and perhaps if you can chime in on what have been some of the positive impacts on relationships as a result of the lockdown and as a result of the pandemic. Is there any data or any information? And this question actually goes to both of you. You work within the family and relationship setting. I wonder if there are some positive impacts that have been felt or experienced as a result of the lockdown or the pandemic.

02:11:46 Anita Avedian
So I'm so glad you brought that up because it's so interesting within the pandemic or during the pandemic. I work with a lot of couples, and let me just put this out there, that typically when there's domestic violence, I would not work with that couple as a couple unit in therapy because it wouldn't be safe to. But to answer your question, and it was really surprising, most of my clients, the couples I work with, their relationship drastically improved during the pandemic because they spent a lot of quality time together. It slowed down.

02:12:24 Anita Avedian
They didn't have their separate outings, they didn't have the added stress of drive time going to work and returning home, even though a lot of people, when they're working from home, there's still as much stress because of the work. But a lot of people felt like they were able to enjoy the quality time that they had, not just with one another, but even with their children and other family members. We saw this deeper connection occur, more valuable time spent together. And it was interesting because I was preparing the domestic violence talk for tonight, and most of what I had seen and witnessed was how great the pandemic has been for a lot of people in terms of their I shouldn't say mental health, but really within their relationship.

02:13:13 Anita Avedian
So then when I did this research, I realized, oh, wait, there's a whole other side to this. And that's what I kind of brought forward. But yeah, I have seen it. I don't know about statistics, but I've certainly seen it help improve a lot of relationships. Irene, I don't know if you want to chime in on

02:13:34 Irene Yaymadjian
I've seen both. I think in the beginning I saw a lot of anxiety and especially when I had two parents who were full time, they had careers and they were working. And so I agree with you. Actually. Anita, what I saw is that in the beginning, it was really hard, at least for me, to see them and just kind of like, how do they, quote, balance working and taking care of the baby? Or if they have a little one who needs to go to school, who's going to be the teacher and who's going to be cooking and well, by now, I'm actually seeing a really positive outcome within my couples and my families, and I'm so grateful for that because they've all of a sudden become a team now.

02:14:19 Irene Yaymadjian
Monday, Wednesday, Friday, dad's doing zoom meetings with the five year old and the teacher and teaching and mom's while she's cooking and the other one's running to the store.

02:14:27 Irene Yaymadjian
And it's like all of a sudden they've become a team where when they were separated constantly, they were unable to work together and it actually brought them closer. However, I have seen a dramatic, which actually my other friends as a therapist said, no, I've seen an increase, I've seen a dramatic decrease in the sex life. They're so exhausted from doing everything at home and the kids can't go anywhere, so they can't have a babysitter. They just can't send off the kids, so they just don't have privacy. That's one of the things that couples have been saying. We don't have enough privacy.

02:15:08 Irene Yaymadjian
Our sex life is kind of out the door, whereas the couples that don't have any kids, a lot of them actually have gotten pregnant. That's true.

02:15:20 Vicken Sepilian
Wait and see. If there's a mini baby boom, a pandemic baby boom probably will be as a result of the lockdown.

02:15:33 Garni Barkhoudarian
I have to agree with what you guys are saying. My wife and I, we're both professionals, and we lead really busy lives, and there's been a lot of positive things that have come out of the pandemic.
We've been able to spend more time with each other, more time with the kids, and that's been very helpful, and it actually has allowed us to kind of reflect on should we be traveling as much and how better to divide our time, especially when all of this ends. So this is a good way to kind of take a look in the mirror and see where you want to be.

02:16:08 Garni Barkhoudarian
So, Anita, I did have two questions for you. One is pretty serious, and the other is somewhat light hearted, and I was wondering if you can address these again, going back to the whole zoom and teleconferencing, and we're not seeing as many of our patients in person. And also, for example, teachers aren't seeing their students in person. Are there any signs to look out for through the camera, through the screen that you can say, hey, I think there's something going on. Maybe there's some domestic violence or child abuse or something going on that we need to pay attention? What should we be looking for? What should our teachers be looking for when they're educating these kids digitally?

02:17:00 Anita Avedian
I'll separate the two. So I think as professionals or healthcare professionals, when talking to the patients, I know for me, I'll notice that they're about to say something. They stop, and then they kind of look in a direction where you know someone else is there, and then they come back. And oftentimes I'll just type a message to them in that moment or text them to just say, is there someone else in the room? Or Is it okay to talk right now? But even then, that could be dangerous because typically if the abuser is there, they may check up on any text messages or messaging.
So you want to be very careful around it and or have them contact you at a separate time, briefly of some sort.

02:17:45 Anita Avedian
I think it's nice to have certain questions in place, like basic screening questions, if they maybe report any type of injury or headaches, to just kind of ask around things that have occurred for children, for example, if they're not being fed or if they've lost weight or gained weight. Just anything where there's this change that you can kind of just point out and ask them about would be helpful. Just again, a lot of this becomes tough because if the person who's abusing is in the household, they're probably checking and reading a lot of this. It just puts them in a difficult position.

02:18:31 Anita Avedian
I think my recommendation would be to just figure out if there's a way for them to contact you separately or privately at a different time or following up with them at a different time. If someone is in the room. If someone's not in the room and sometimes we have our clients call us from their car because that's the only private place they have in the household is going to the car and contacting us from there, then they will more likely speak a little bit more freely. But the reality is they may be too scared to report. I mean, a lot of times what's going to happen is during a time like this, they're not going to go to a shelter setting and if they leave, they're not sure where to go at this point. So it gets pretty tricky at this point.

02:19:18 Anita Avedian
But we are going to see a big surge once school is back and I think VCFs are going to be on overload at that point.

02:19:28 Garni Barkhoudarian
Interesting. Thank you. Okay, so switching to a lighter topic, so we've been talking about relationships and how to deal with issues within a relationship. But this may be just a curiosity for me, but I remember how hard it was to date when there was no coronavirus. What have you guys been seeing with just the ability to go out on dates and meet new people? How are people socializing these days? What is going on out there?

02:20:00 Anita Avedian
Do you want to start first or do you want me to start?

02:20:02 Irene Yaymadjian

You can go ahead. 02:20:03 Anita Avedian
Okay. I'm going to answer this in two different ways because I focus on domestic violence and I'll come back to the light hearted aspect. This is such a great formula for people to move in very quickly. So in the quarantine, whether people realize that it's not fun being all alone and that it was not a comfortable feeling, you start seeing them trying to meet someone more quickly. Online dating, that's like one of the main ways of meeting people nowadays, I think.

02:20:33 Anita Avedian
But they would meet and then they would jump into a relationship and because of the quarantine, they would just say, why don't you just come live with me? Or they would go live with the partner. So I would see clients who within two weeks they've already kind of moved in, they're sleeping over every night and you see them jumping into it.

02:20:53 Vicken Sepilian
Red flag for domestic violence.

02:20:56 Anita Avedian
Yes, it is.

02:21:01 Anita Avedian
But they're using an excuse now. I'm like, okay, so this is kind of a tricky situation, but in general I have seen a lot more online dating people talking via Zoom. I don't think this has really stopped people from getting together one on one that much. They are getting together one on one. They are going to restaurants. I think the real lockdown occurred.

02:21:22 Anita Avedian
I mean, it was really more of a curfew than anything, so I think they're not meeting at bars or anything, but that wasn't happening as much anyway before. It was mostly online dating. Right. Irene, what have you noticed?

02:21:38 Irene Yaymadjian
Kind of similar, but everyone's having Zoom meetings. Yeah. Set up their nice background. They dress up. They have dinner together, because it's like, I have a split clientele, so a few of my patients are, like, terrified of the coronavirus, and they just will not refuse to do anything with another person. And the other half of my patients are like, oh, my God, let's go out. Let's go to lunch. Let's go to dinner. Let's go do this.

02:22:09 Irene Yaymadjian
But I tell them, okay, well, let's slow down for a second. Why don't you guys kind of meet via Zoom instead of the telephone? So you see each other after three Zoom meetings, then you could because I want them to kind of assess, you know what I mean? Especially if you know that there's some sort of, like, a virus out there. Hopefully within the three sessions of talking to each other, something would click if something was off. I don't think it stopped people from dating. I think in the beginning, as you said, Anita, you're absolutely right. In the beginning, it was like and everybody was like, oh, my God, how am I going to date? And now in the past three months, two months, they're going out, they're dating. Actually, I find people who I used to have sessions with who were a little flaky on their commitment area in their life are actually much more focused now because they realized how fast their life can change, and they realize how much of the excuse me for my French the BS they've been thinking about in their life.

02:23:13 Irene Yaymadjian
And so this actually has kind of shook people and some people into a place where they've actually thought about their future more and realized, wow, this is sad. I never thought about a pandemic happening, and I'm totally alone in my house, and no one would visit me because I feel like I'm an infested person. But now I didn't really see a dramatic change. Only in the beginning.

02:23:37 Anita Avedian
Yeah.

02:23:40 Irene Yaymadjian
How about you guys? Have you guys heard anything from your friends or patients?

02:23:47 Vicken Sepilian
Yeah, I think that what I've noticed amongst colleagues is that nothing has changed. Perhaps the whole dating or meeting experience was enhanced. Some of the points that Anita hit on were spot on. We all got to unplug a little bit and perhaps tend to some things in our lives that had been neglected or perhaps we were too busy for, and maybe romance being one of those things. And there's a plethora of platforms that people can participate and use in addition to the online platforms, just your everyday social media, whether it be Facebook, Instagram, even some of the online dating platforms had set up virtual dating activities and ways to go about it.

02:24:54 Vicken Sepilian
I can tell from my staff that several of them were young women who are single but have subsequently found love during the pandemic and now are dating and are in serious relationships. So, go figure. For several years they were single, but for somehow romance was found amidst a global pandemic. So there you have it.

02:25:32 Vicken Sepilian
I think there's a question. Someone had their hands raised. Varouj had their hands raised. Varouj, if you're there, please go ahead and ask your question.

02:25:54 Anita Avedian
Do you want to start first, Irene?

02:25:56 Irene Yaymadjian
I don't see the question, but I do see a question from Sophia, which I think is one of my interns for you.

02:26:03 Anita Avedian
So I see a question that reads, what inspired you to do your specialties in anger management? DV, burnout, self care? What made them intriguing to you personally?

02:26:12 Irene Yaymadjian
Yeah, you can go first.

02:26:15 Anita Avedian
So for anger management, well, domestic violence, that was my literally, it was my first internship I did. So it was my second year of graduate school, and I needed hours. I started working at a shelter, and I started working there. And I absolutely loved helping the victims of domestic violence. So I did that for five years, and that got me involved more with not only helping with domestic violence, but also working with anger management. I literally went from helping the victim to helping the perpetrators. But anger management, it's just more general skills that we teach, and it just unfolded into a whole business as a specialty for me, where I author the books and I offer anger management certification training to counselors.

02:27:09 Anita Avedian
But the reason why I love it is when we do therapy, therapy gets a lot more involved and insight oriented and more in depth. Versus anger management is more skill based. So I'll see a lot of male and female executives coming through for anger management, and they like it because it's just very skill based. They can incorporate it within the day and see a change and see an improvement in how their relationships unfold. So it's kind of quicker, I guess. It's more surface level and quick, and you see changes occur pretty quickly versus in. Therapy could take a few years or it could take a few months. It's a longer process, but a lot more of a rich and in depth process which has its own benefit to it as well.

02:27:59 Anita Avedian
But I look at anger management as the gateway of people entering into the therapy field. So most people come to anger management, have never done therapy and would never go to therapy. And when they realize what that's about, they actually are more open to them later, getting into therapy. So that's what I enjoy about it. And you're really helping people make a change in their day to day lives at the workplace, at home with their friends. I really think among Armenians, especially in the older generation, anger is just in every family. I don't mean domestic violence, but just yelling and being loud. And so I guess part of me was drawn to that for that reason, to better understand how to help people around, try to keep their cool, I guess.

02:28:49 Anita Avedian
Irene, how about for you?

02:28:52 Irene Yaymadjian
So when I was in grad school, I had this bright idea because I wanted to find what made people happy. That was my first part in my dissertation. My mentor came to me, and she said, yeah, so that's too broad. And when you're doing your dissertation, you're just going to make a dent. And I wanted to make an entire explosion. I'm like, I'm going to solve this.

02:29:19 Irene Yaymadjian
Well, what ended up happening is I realized that I ended up kind of like dropping my entire dissertation halfway through, and I got severely burnt out, and I fell into a really bad depression, and I had a lot of anxiety, and I didn't know that was burnout. And so I started just kind of like saying I was saying, like, oh, I feel burnt out. I feel tired, this and that. And then I realized, well, how can I energize myself?

02:29:48 Irene Yaymadjian
How can I live a life where I feel like I'm happy with everything that I'm doing, and I enjoy doing what I'm doing, and I don't ever get to a place in my life where I'm like, oh, I have to go to work tomorrow. That's the one thing I didn't want to do. And so I just started to read up on Burnout, and all of a sudden I saw that Carl Young and all these different theorists already had written several articles on burnout, and I'm very fascinated with personality types. And so I wanted to make that dent in helping therapists because I wanted to actually help myself. I was very selfish.

02:30:25 Irene Yaymadjian
I was doing my whole dissertation just to help myself, and I expanded, and I was then able to help others also. I guess it really is. I practice what I preach. I started off helping myself, but now I can help others. And so I burned out myself, and I never, ever wanted to feel like that ever again. And I also wanted to know what about myself led me to burnout and how I can better myself so that in the future, I don't ever reach this depression and anxiety ever again. And that's when my journey began. And then, of course, I couldn't just leave it there because none of us doctors could just leave something as we get enough information. I had to expand it and make a program to help everybody else. So that's a very short and concrete way of saying it. I experienced it. I wanted to learn more about it to help myself. And then I was able to do a lot of research on it. I talked to about 350 therapists. I gave them the Myers Briggs inventory.

02:31:28 Irene Yaymadjian
I analyzed them, I saw their burnout levels, and then I incorporated it and made a self care program. That's basically it. I'm happy I did that. It helped me become happier, actually. There we go. I found happiness. Yeah.

02:31:43 Irene Yaymadjian
I think we had another question, Samantha, with such a stigma on the concept of domestic violence, Anita, what is your approach in communicating to a client that they are experiencing domestic violence or emotional abuse?

02:32:00 Anita Avedian
And then you can read the rest of his, yeah, and I'll continue. So I have a client who I reflect with and rephrase the way he is being treated, but he is struggling to wrap his head around his girlfriend's behaviors. What adjunct resources can I introduce him to? I'm sure there's a lot of great books out there. I typically have handouts that I give to clients, and instead of straight out labeling, hey, your relationship sounds like it's violent or controlling. I rather use the words controlling or describe what's really happening in this particular situation.

02:32:40 Anita Avedian
I may not say, hey, you're in an abusive relationship, but I may ask more questions around it and ask them how safe they feel in there. Typically, sometimes people don't necessarily feel unsafe, but it becomes very toxic, and they start questioning themselves as an individual, and they start questioning how they're actually thinking and whether what they're doing is really inappropriate. So what you start seeing is some of the most confident people getting destroyed with their level of confidence. So if this particular person is going through that emotional abuse, I may check in with them about what their thoughts are about how to be treated, what their beliefs are about, what's okay, what's not okay in a relationship.

02:33:28 Anita Avedian
And if something is okay, has this person tried setting boundaries with their partner? And if they have, is the partner accommodating or respecting the boundaries, or is the partner ignoring it based on what the partner's needs are?

02:33:42 Anita Avedian
And so all of this becomes a discussion rather than going straight into a label of the relationship, because not everyone's open to seeing themselves as a victim. That becomes very difficult for a lot of people to process. So I'd rather describe the specific behaviors and what's okay, what feels okay, what doesn't feel okay, and if it doesn't feel okay, are they communicating that to the other person?

02:34:05 Anita Avedian
If they request for space, does their partner give them the space, or are they not able to handle it and try to violate their space? So that's kind of how I would go about that. Hopefully I answered the question. 02:34:19 Irene Yaymadjian There's another question. In a post COVID world, do you think remote therapy will become normalized? And do you believe telehealth has affected burnout levels due to increased therapist availability throughout the day.

02:34:34 Irene Yaymadjian
Yeah, the BBS and the American Psychological Association, I hope they can allow this to kind of go and move forward because I feel like people are more comfortable in their own area to do therapy and I hope this will continue. It's always been a thing, but we're trained in therapy that the person needs to be in front of you and be more analytically based.

02:34:59 Irene Yaymadjian
I do believe that there's an exchange of energy that happens in therapy. When the person is with you in the room, you pick up certain subconscious things and it's really important to feel that literally as a therapist and work through the countertransference and the transference for the patient to work through.

02:35:18 Irene Yaymadjian
I don't think that it's really healthy to go full blown just zoom and FaceTime therapy. I'm more old fashioned. I prefer the patient to come in. I think there's such a process that goes on that we are definitely missing via Zoom or FaceTime. But yeah, I think therapists are going to be burnt out. I think that yes, this is one of my interns and the poor thing is trying to tell me that she's burning out. I hear you. I told you to take a week off.

02:35:48 Vicken Sepilian
It definitely is a paradigm shift on doing some of these things from a face to face visit, there's many cues just like you hit on where the patient or the client sort of gives us some understanding or some hints of their level of comfort or their level of comprehension.

02:36:14 Vicken Sepilian
Nevertheless, as providers, as healthcare professionals, we still have to make ourselves available through all channels that are available on all platforms to make sure that we're best handling the needs of our patients.

02:36:39 Vicken Sepilian
This has been a very informative session. We have gone way over the allotted time. It's evidenced by the very interesting questions and discussions that we had that there is a very strong demand for these types of conversations. And I think that it just behooves us to continue these types of programs and perhaps have a follow up to this series of mental health lectures.

02:37:11 Vicken Sepilian
And we hope to have both of you back. Part of our discussions and ongoing continuing professional education series as well as our community education series that we do on the television program. And I hope to see both of you on our program soon.

02:37:34 Vicken Sepilian
I'd like to remind everybody who's watching and participating that if you are claiming CME credits, you can go to our website, aamsc.org. There is a post activity quiz and questionnaire that you have to fill out and then claim your CME credits. The whole year worth of CME activities you can participate in even after the fact. It doesn't have to be live.

02:38:03 Vicken Sepilian
We do want to point out though, at the end of October, these questionnaires will expire. So if you do plan on going and taking the quiz and answering the questions to claim the credits, please do so and claim your credits before the end of October. October 31 is when it's going to expire.

02:38:26 Vicken Sepilian
With that, Garni, I'm going to ask you to have the last words. Make the closing comments.

02:38:31 Vicken Sepilian
I'd like to thank both of our speakers, really, for the extremely informative lectures. And once Garni is done, I'm going to ask all of us to look at the camera and smile. In fact, why don't we do that now? If all of you can look at the camera and smile so that we can take a group photo.

02:38:56 Vicken Sepilian
All right, Garney, it's all yours.

02:39:00 Garni Barkhoudarian
Well, I will also just thank our fantastic faculty for a great session. You guys are dealing with really challenging conditions that many of us can barely even think about how to approach. And it's really been eye opening from both the caregiver and just the human perspective. Thank you guys so much.

02:39:23 Garni Barkhoudarian
Thanks for spending your Monday evening with us and educating our membership. And we look forward to having another session, hopefully in the near future. Thanks and have a good night.

02:39:32 Anita Avedian
Thank you for having us.

02:39:35 Irene Yaymadjian
Bye. That was so nice.

[James Kennedy and Anita Avedian sit down for a therapy session at Anita's office.]
00:00:14 Anita Avedian
Hi, James.

00:00:15 James Kennedy
How are you? Good to see you.

00:00:16 Anita Avedian
I'm good. How are you? You too, how is it going?

00:00:20 James Kennedy
Things are going good. Things are going good.

00:00:22 Anita Avedian

Yeah?

00:00:23 James Kennedy
I've been really trying my best to keep my temper at controlled levels, but we were meant to all go on a vacation as a group to Mexico, and I didn't exactly take the news well that I wasn't invited, and I kind of blew up on the hosts of the trip.

00:00:42 Anita Avedian
Okay.

00:00:44 Flashback
[A 5 second flashback from the show Vanderpump Rules is shown. James is arguing with Tom Shwartz about Tom's wife Katie Maloney. Tom Sandoval and Lisa Vanderpump are standing alongside them in a restaurant.]

00:00:48 James Kennedy
I was really angry, you know, and I just don't understand the mentality of people that are really angry and just don't do anything about it.

00:00:55 Anita Avedian
Yeah. How's the drinking?

00:00:59 James Kennedy
I've had, like, couple beers at my friend's birthday party once and stuff like that, but never gotten drunk.

00:01:06 Anita Avedian
Was it two beers at the most?

00:01:09 James Kennedy
Two beers at the most. I'm more comfortable with that than just, like, trying to go to a party and be, like, the sober guy there. I hate that. I don't know what made me have that first beer. I kind of didn't even think about it, like, to be more James Kennedy, be more charismatic, I guess.

00:01:23 Anita Avedian
Let me ask you this. You don't think you would have been able to be that person without it?

00:01:27 James Kennedy
You know, sometimes I don't. Lisa always tells me that I don't need that, but I got self doubts. I'm human. It's just like I'm just like, what's one beer?

00:01:36 Anita Avedian
You tell me. What is one beer? How can one beer harm you?

00:01:39 James Kennedy
I don't know. Am I going to go cold turkey sober? Not right now. I feel like I'm just thinking so much when I'm sober, but, like, after a couple beers or a couple shots, you put yourself in the moment. I'm 26. I can make decisions for myself.

00:01:56 Anita Avedian
Try to focus more on what you do for you than trying to prove it to others.

00:02:01 James Kennedy
So, like, not worry about what they think too much.

00:02:03 Anita Avedian
Yeah.

00:02:04 James Kennedy
That's impossible to me.

00:02:06 Anita Avedian
The more power you give to someone else with how they look at you, the worse you start to feel like, is what I did not good enough?

00:02:15 James Kennedy
Just wish I could go back in time and said different things in different moments, and life would have been very different right now.

[James Kennedy and Anita Avedian sit down for a therapy session at Anita's office.]

00:00:00 James Kennedy
Hi.

00:00:00 Receptionist
Hi. [The receptionist directs James to the correct office down the hall.]

00:00:04 James Kennedy
Hi. How are you?

00:00:05 Anita Avedian
I'm good. How are you?

00:00:07 James Kennedy
Good to see you.

00:00:07 Anita Avedian
How have you been?

00:00:09 James Kennedy
Good, how have you been ?

00:00:10 Anita Avedian
Good. Thank you.

00:00:11 James Kennedy
I'm going to therapy because, you know, Lisa thinks it's gonna be a good idea for me to start talking to somebody.

00:00:16 Lisa Vanderpump
[Flashback of James Kennedy speaking with Lisa Vanderpump.] You need to be in some kind of therapy.

00:00:20 James Kennedy
I promise you I will. [End of flashback.]

00:00:21 James Kennedy
[James is speaking in a confessional/interview segment of the show.] In order for me to get back into Sur, I need to show Lisa that I really want this to show her that I'm trying.

00:00:26 James Kennedy
[James is now talking directly with Anita]
I'm kind of dealing with something right now with my parents. My mom called me saying, like, oh, your dad owes me this much, and blah, blah, blah. Puts it on me pretty much. My dad tells me he is looking for a job, but there is still a responsibility, like the car insurance and [censored] like that. And it's not for much, 200 here or there, which I'm sending to my mum every other day at this point.

00:00:50 Anita Avedian
So you're really supporting her.

00:00:51 James Kennedy
Yeah.

00:00:52 James Kennedy
[James is speaking in a confessional/interview segment of the show.]
Back in the day, when my dad was happily managing with George Michael and before my mum stopped modeling, they were living a very lavish lifestyle. And as I got older, the nice cars were going, the nice houses were going. And then before you know it, they are fighting about money twenty four seven.

00:01:09 James Kennedy
[James is now talking directly with Anita]
You know, it's like, in my normal head, like, a family is, like two incomes. A mum and dad, that was my life. And now it's just completely flip turned opposite. Right. And I'm the guy, like, making the only income. It's just like, for God's sakes.

00:01:25 Anita Avedian
James, that's too much. James, the expectations I'm hearing from you, you've put it upon yourself. I'm the one who's making the money, so it's on me.

00:01:34 Speaker 6
Sounds so stupid. When they're happy or we're having a good day. I mean, it's just, like, so good. And it's just, like, it turns so quickly.

00:01:44 Anita Avedian
Your mom, she has a lot of resentment towards your dad.

00:01:48 James Kennedy
A [censored] ton. She's still very angry. Very angry.

00:01:51 Anita Avedian
Set the boundary. Mom, you can't take it out on me.

00:01:54 James Kennedy
I'll say that. I'll tell her. I'll try that,

00:01:56 Anita Avedian
You know.

00:01:58 James Kennedy
Right.

00:02:00 James Kennedy
[James is speaking in the show's confessional/interview segment.]
It really is frustrating when I am financially helping my mom and my dad, and then I still get caught in the crossfire between them. I still get treated like a [censored] child when I'm the man of the family right now, keeping this whole thing together.

How Anita Avedian Collaborates with Amen Clinics to Level Up Her Practice 00:00:00 Fallon
Hi, Anita. Hi, Lisa.

00:00:03 Anita
Hi, Fallon. Hi, Lisa.

00:00:07 Fallon
Hi nice to meet you, Anita. I've heard so much about you, not just from Lisa, but from also Katie and some of the other people on the West Coast, and it sounds like you're doing some amazing work.

00:00:17 Anita
Thank you. Thank you. It's nice to meet you too. And thank you for having me here.

00:00:21 Fallon
Absolutely. So if you wouldn't mind sharing a little bit more about yourself, your practice, and then kind of where you first learned of Dr. Amen and then kind of your journey to where you are today with your practice.

00:00:34 Anita
Sure. So my name is Anita Avedian. I'm a licensed marriage and family therapist, and I've been practicing for more than 22 years. So hopefully it doesn't give my age away, but does with my experience. And I am a Certified Anger Management Specialist for so what I do is both. I have a therapy practice, and I have an anger management practice. And I think you asked, what else was it, how we met and how I got into this. So at every Evolution of Psychotherapy, we try to go have a booth and participate with my agency. And the last evolution of psychotherapy, where we had a booth, we had Amen clinics right next to us. And so we chatted it up and stayed connected with Katie. Amazing woman. And so it was really nice to not only get to know her better. I mean, obviously we knew about Dr. Daniel Amen and have watched a lot about him, but I know during that conference, my staff and myself, we all attended a lot of his talks and was really impressed by the material he has and the records of how many brain

00:01:47 Anita
scans he has. I think he has the most in the world. And just one thing really stood out about what he had shared, which is how come, of all physicians, of all doctors, why is it that psychiatrist is the one doctor who does not look at the organ that they're treating? And I thought, wow, of course, Right

00:02:10 Anita
I mean, that would totally make sense.

00:02:12 Fallon
Right

00:02:12 Anita
And how we were still using old school system of diagnostics of symptoms and experiences rather than also taking a look at what's happening. But that was a moment where I thought, he's really onto something and just being able to share a lot of the brain specs that they talked about whether someone was under the influence of marijuana or what a brain. Looks like when it's dehydrated versus under the influence of or having been damaged through so much drug use or alcohol use and so forth. And so just having seen all that, I was extremely inspired to learn more and was impressed by him and the clinic and what everyone had to offer. And so I think after

00:02:58 Anita
that Evolution of Psychotherapy, I was at a state CAMP Conference exhibiting again, and there was Katie exhibiting for Amen clinics, and I noticed that they had the brain health coaching certification. I said, oh, let me look into this. And so I started the process, I purchased it, and again, extremely impressive and was very intrigued by the material shared. And so since then, I've collaborated care with Amen clinics, quite often trying to refer clients to your center because I have a lot of clients who prefer not to be on medication but want to know what they can do, just doing things with the natural course and taking supplements. And so Dr. J. Faber is someone I work closely with in terms of making a lot of referrals to him and Dr. Melissa Quinn, both very great psychiatrists. And so that's kind of my history with them. I did also because I'm on the board for the California Association of Anger Management Providers, I thought it would be an excellent idea to bring Dr. J. Faber on to

00:04:06 Anita
provide a continuing education program. And so the board was very excited about that. So we invited him on and it was a great hit. He talked about the raging brain, and I thought that was a great training and a workshop, again, wonderful material that he shared about what happens to the brain when one is angrier and or one is raging. So I think I may have shared more than you asked, but that's kind.

00:04:31 Fallon
No like, oh, that's exactly what we want to know. And I love that Dr. Faber has been working with you so closely. He really does have a wonderful heart for helping the community and just opening people's perspective again, looking at the organ that you're having problems with and then real simple solutions that don't necessarily have to go straight to medication. So it's really cool.

00:04:54 Anita
Right, Definitely.

00:04:55 Lisa
And thank you so much, Anita, for being such a trusted partner and for doing that for us. Dr. Faber and Dr. Quinn appreciate you so much and we all appreciate you so much at the LA Clinic. You have been such a great asset to us and have sent so many professionals our way, and we really appreciate it.

00:05:14 Anita
Thank you. I'm happy to do that. It's really a two way street. You guys have helped me, and I've had a wonderful place to be able to collaborate with and send my clients to. And I will say, usually they're seen pretty quickly. They have a full report that gets to be shared with me, of course, upon the client's request and just that collaborative work to be able to connect with the two psychiatrists as needed with what else is needed and making sure the clients are following through with the recommendations. So all that has been really helpful for me and loving sending people your way too for that support. Yeah.

00:05:54 Fallon
That's awesome. Is there any patient or type of patient that you see where the scans really showed why they were having anger issues and why it was a biomedical issue and how much that helps with their healing.

00:06:07 Anita
There's been so many that I referred. I think one did the hyperbaric chamber. I think a few have done that. A few has really helped a lot. Some didn't need as much of treatment. Some are still using actively. So there's not much that can be done right now until they sober up. So it just really depends on each person what they're going through. But for the clients who are ready to do the work, it's just been absolutely amazing. And hopefully the other clients who will do the work later, that the resource is there and they know that even if they prefer not to take medicine, that there's an option, there's an alternative that whether it's the supplements or the hyperbaric chamber hyperbaric am I saying that right?

00:06:57 Fallon
Yeah.

00:06:57 Lisa
Yeah

00:06:59 Anita
Okay. For some reason it sounded wrong for a split second, but the hyperbaric chamber treatments have had, like their reports back about it have been really positive and wonderful. So I think through this past year or so with all these referrals and the positive feedback, I

00:07:18 Anita
think it's really been helpful. And of course, the ones, as mentioned, they're still using, so it's not going to and they know it, so it's not going to really be as helpful until they make lifestyle changes.

00:07:31 Fallon
That's why I love talking to counselors about the work that we do, because you really have to at least be a little bit open to getting information and then doing the work, like you said. So I think that's really cool that you have that healthy perspective, that you do so much for them, but you can't do everything for them.

00:07:49 Anita
And I will say what I also love, I think I've worked more with Dr. J. Faber, but they both do this, the psychiatrist, is that there's this full lengthy report with the recommendations on there and even recommendations of what books they would recommend for the client to read exercises, brain exercises. So as a therapist, to have that type of feedback from a psychiatrist so specific really helps me be better able to integrate some of that work with the client. And really to have it more like there's just more resources where I can help motivate the client to do some of that reading or I personally can be involved with some of that treatment too. I will say that that actually plays a huge role of support for therapists, because if you're just working with a client alone, there's only so much we can do. But when we have that second opinion and the recommendation from a psychiatrist and you're seeing the brain specs and what's happening and gaining a better understanding of how the brain is

00:08:58 Anita
involved in what areas of the brain is impacted and what to do to support that. So much of that collaborative work, really, I think helps me as a therapist to do a better job with my clients and to know that I have that extra support with. Collaborating with a psychiatrist is really golden. I think that really helps us do the job we really need to be doing.

00:09:18 Fallon
I love that. Yeah.

00:09:21 Fallon
Dr. Faber has always been so wonderful and very exceptional at making really personalized book recommendations. When he was in Atlanta helping us open for the first two years, I got to work with him, so I'm used to reading his reports between three and ten a day and going over him. Loved how he recommended things. And honestly, half the books on my bookshelf are things that he's told the patient. And I'm like, I kind of resonate with some of this patient has going on. I might read this book and I just always have found his information really helpful.

00:09:55 Anita
Yeah, definitely. Me too. I love seeing those.

00:09:58 Lisa
Fallon and I were saying that we think you and Dr. Faber ought to do a video together too.

00:10:03 Anita
I'd be happy to.

00:10:05 Lisa
Yeah, we'll put you all in touch. I think it would be a very powerful video since you guys collaborate so well together.

00:10:13 Anita
I'd love to. I'd be happy to.

00:10:16 Fallon
He comes alive on camera too.

00:10:19 Anita
And he was really well received with our California Association of Anger Management Providers. So when he did the talk, it was wonderful. Too. Yeah, I love that.

00:10:29 Fallon
That's so cool.

00:10:30 Anita
Yeah.

00:10:33 Lisa
Going for you too. Are you doing a lot of your services telehealth now, too?

00:10:37 Anita
Anita I went all telehealth for the last few months just because of everything that was going on. And this past week, literally two days ago was my first time back in the office. I decided to just with very select clients to meet with them at my office. My office is large enough to allow us to sit 9ft apart, so I think that's pretty safe. I think, of course, with coming in with masks and so forth and making sure we're taking proper measures, but with select few clients, I'm meeting them in person. I did this week. I'll continue to doing that, but most of my practice is still telehealth, just to keep it safer for now, until things feel better. But yeah, so I'm available for both. I have a whole staff at Avedian Counseling Center. We have a staff, I think about 15 of us. So twelve of who are therapists. So most of them are still doing telehealth, and a select few of my therapists are comfortable with meeting with some clients in person. But yeah, I think across board a lot of therapists

00:11:48 Anita
are trying to focus on telehealth right now. It's not the same for me. I really prefer in person. The connection, reading every queue is very different in person than it is doing telehealth. I mean, it's a good alternative instead of putting everyone at risk. But I think I'm more of an in person therapist and thrive more doing that, seeing clients in person. But both work just my own preference. Yeah.

00:12:20 Lisa
Wonderful. Well, you want to tell us a little bit about your business and give your information too? So when we do, put it on our website that you get some feedback and some people reaching out to you.

00:12:33 Anita
I'd love to. So Avedian counseling center is our group practice. We are a number of therapists who focus and specialize in different areas. I personally work a lot with couples, a lot of relationship work. I work a lot with mood disorders, anxiety, and anger. And I'll talk about my anger management practice in a minute. And so we have a group of us, everyone has their own specialty. I also work a lot with addictions, and I think it's most of my addiction clients. I've been referring to Amen clinics, if I'm not mistaken.

00:13:08 Anita
Those are who I would normally work with. My personal clientele usually are either executives or in the entertainment industry or health industry. So a lot of physicians and surgeons. And then with our Anger Management 818 Center, we work a lot with court order clients and those who come in voluntarily. Normally we have over 20 groups a week in person, but now it's all on Zoom Telehealth. So we want to keep it safe for everybody. So we still do have those groups. And we also offer one on one anger management. I have authored my own program, so we have a book titled Anger Management Essentials. It's published on Amazon. We have a book for adults. The second edition is about to come out, and we also have a teens version, Anger Management Essentials for teens. And then the adult book has been translated into Armenian, Spanish, and Hebrew. And the teens book has been translated into Spanish. And we're currently finishing up the second edition. And we'll be focusing on the facilitator

00:14:11 Anita
manual. Hopefully that will be out in a few months as well. And then my other businesses, I offer a monthly anger management certification training for those interested in offering anger management services to help the community better deal with their aggressive regression. That's my other side gig that I do. So I do offer CES for those, which is what kind of got me into wanting to take the Brain Health Coaching certification, because I'm all about certification trainings and become specialized in areas and the websites. In case anyone's interested, for Avedian Counselingcenter, it is www.avediancounselingcenter.com. For angermanagement 818, it's angermanagement818.com. And then for the certification training, it's angermanagementessentials.com. So those are the three websites I have, and for anyone who would like to contact me directly, the number is 818-426-2495. I'd be happy to talk to anyone about any of our services.

00:15:21 Fallon
That's incredible. You're like superwoman.

00:15:24 Anita
Thank you. It's been 22 plus years, remember?

00:15:27 Fallon
I know. But still, 20 classes and a private practice, and you just wrote books.

00:15:35 Anita
Thank you.

00:15:35 Lisa
Also, how amazing she was.

00:15:37 Lisa
Fallon.

00:15:37 Lisa
And you're really plugged in with the Armenian community, right? Too.

00:15:41 Anita
Absolutely. Which I think I tried to speak to you about this. I'm a member and have been a member for some time of the Armenian American Medical Society and also of the Armenian American Mental Health Association. And so I know the Armenian American Medical Society, especially during these times, they were holding two to four webinars a week worldwide to help disseminate information about medical concerns, or we would have specialists come on to do talks to educate those who were interested in learning more about medical issues that were coming up, especially around COVID. And so they're a very supportive group, so I'm very involved with them.

00:16:25 Lisa
Love that. Now, what can we do to help? Is there anything that we could do to help give back to you? Because you've given us so much.

00:16:36 Anita
Yeah, I mean, this is amazing. What you guys are offering right now is this interview. And for me to be able to also share this with my contacts as well, literally, I'm not exaggerating, but just existing with the services you guys offer and to have that platform, for me to be able to be able to send my clients to as a resource so that they can get the proper support has been absolutely, very, very helpful. If you know of anyone who wants to be trained in anger management, feel free to send them my way. And absolutely anything with services around anger management or therapy, we offer those.

00:17:15 Fallon
Can you do that across state lines or virtually?

00:17:19 Anita
So the anger management certification training is actually international.

00:17:24 Fallon
What

00:17:28 Anita
I've done the training in Armenia. The last several trainings had people from Canada.

00:17:33 Fallon
Oh my gosh

00:17:33 Anita
Yeah, we have people from all over who attend because it's a NAMA approved program. So National Anger Management Association is really international, even though they're called national. But I'm an approved supervisor and trainer, and the program is approved. So anyone who goes to my training, they'll get the CE's for California and or if they're NASW nationwide, but whoever takes it can then be part of NAMA and receive their certification as well. So it's kind of a nice program in that way to be able to offer that. It is a three day training, and it is a live training, but on Zoom, and so it's kind of nice. Yeah.

00:18:15 Lisa
Awesome.

00:18:16 Fallon
Wow.

00:18:16 Lisa
I would love to do it.

00:18:18 Fallon
I know. Me too. Just sounds fun.

00:18:20 Anita
Yea

00:18:24 Lisa
Well, Fallon asks a great question at the end because I've watched all her videos. She's made some great videos with professionals. What's the question you ask Fallon?

00:18:33 Fallon
What else we can do to support you? I know that I'll be helping you with the course.

00:18:39 Anita
You got it. Thank you. You guys are really doing a lot of great for the community, and I really do appreciate that a lot.

00:18:50 Fallon
Of course. That's what we're here for.

00:18:52 Lisa
And is there anything else that you want the folks that are watching to know about you?

00:18:58 Anita
Let's see. I'm of Armenian descent. I can kind of speak Armenian. I can speak Armenian, but I cannot do therapy in Armenian. I think there's a difference between the two, but I am I'm passionate about cultures. I love traveling, mostly because I love to learn about the culture of the country. And in fact, right before COVID I was at the safari in Kenya and absolutely loved it.

00:19:25 Lisa
Wow.

00:19:26 Anita
Came back, I think it was early March, and I'm like, what's going on here? I was lucky. I was fortunate to have that experience. But I do love traveling and very proud of my background. Let's see. I started doing therapy at a younger age. I've been doing it for some time, and I think that's really it. I love working with couples, and anger management has been a big passion of mine, especially more recently, and I love to mentor. I think that's something to note. That the day I was allowed to have interns and supervise, I had interns. So I've always had several interns to supervise in my practice, and it's something that I just enjoy doing. It's giving back, mentoring and helping people know that there's someone there that can be supportive towards them. Just like you guys are asking me how you guys could be supportive. It feels good to give back. It feels good to guide. It feels good to be there for others as well, because I know a lot of people have been there for me.

00:20:30 Lisa
I bet you're an amazing mentor. I can imagine that you've helped a lot of people get into this industry and do wonderfully. You're a wonderful woman, and I feel so grateful that you spent some time with us today.

00:20:43 Anita
Thank you. Likewise. I appreciate this time spent and that you chose to highlight me as a therapist. I do appreciate that a lot.

00:20:52 Fallon
Easy choice to make.

00:20:54 Anita
Thank you.

00:20:56 Lisa
Thank you so much Anita.

00:20:58 Fallon
Thank you so much for everything that you're doing for the community and your clients, and I'm so grateful that we have this partnership together. And there's anything else that you need from me as a coach, let me know.

00:21:13 Anita
I will. Thank you so much, you guys.

00:21:15 Fallon
You're welcome.

00:21:16 Anita
Have a great one.

00:21:17 Fallon
You too. Bye

00:21:17 Anita
Bye

Interview with Dr. Sepilian - Anger Management
The interview is held at a recording studio, with Dr. Vicken Sepilian wearing black scrubs sitting on the left and Anita Avedian, LMFT, wearing a navy dress and sitting to the right. Both Dr. Sepilian and Ms. Avedian are sitting behind a gold-colored table with the television centered behind them.

00:00:02 Dr. Vicken Sepilian
Good day, ladies and gentlemen, and welcome to Stay Healthy TV. I'm Dr. Vicken Sepilian, your host. Today in the studio, we're going to focus on some mental health issues. We have a very special guest, Ms. Anita Avedian, who is a licensed marriage and family therapist. Anita practices in Southern California. She has multiple locations, including Sherman Oaks, Tarzana, Glendale, and Hollywood, and she's the director of Anger Management 818. Anita, welcome to our program.

00:00:35 Anita Avedian
Thank you so much, Dr. Sepilian.

00:00:37 Dr. Vicken Sepilian
So mental health is a very, very you know, important topic that I think oftentimes gets overlooked in health educational programs. And before we start and we're going to talk about anger management today, I want you to tell us a little bit about your field. I mean, you're a licensed marriage and family therapist. What is a licensed marriage and family therapist? What are some of the common things or common conditions that you work with? And tell us a little bit about your typical day for you.

00:01:15 Anita Avedian
So the licensed marriage and family therapist is a license which allows us to provide psychotherapy services, individually, to couples, to groups, to adults, to children. We can specialize in different areas. So most therapists have certain specialties they like to focus on. Several of my specialties include anger management, social anxiety, and couples therapy; so , relationship issues. With your other question around this was my typical day, what my typical day would look like?

00:01:47 Dr. Vicken Sepilian
I know one of your specialties is actually anger management. So I mean typically, what are the type of conditions or issues that you work with that you specifically specialize?

00:02:00 Anita Avedian
So with anger management, you're asking or just in general? In general. So my personal client load is going to be half my practice; I actually work individually with clients who are struggling with anger, some of those are court ordered, some of them are coming in. They're executives at the workplace, and they want to improve, realizing that they keep experiencing loss of work or setbacks, and they're getting into trouble. And the other half come in voluntarily. So some are ordered by the workplace or court, some are coming in voluntarily. And then in terms of my clinical practice and I say clinical, I try to separate the therapy and the anger management because in the clinical aspect, I'm going to work more providing therapy services to either couples or the individuals who come to me either have social anxiety or some form of anxiety, and I also work a lot with mood disorders such as bipolar.

00:02:56 Dr. Vicken Sepilian
Right. So that's great to know. And today, in this episode at least, we're going to focus on anger management. And this is one of your specialties. As we said, Anita is the director of Anger Management 818 throughout Southern California. So what is anger?

00:03:14 Anita Avedian
Anger is the feeling. It's the emotion that we experience. And I know a lot of people aren't realizing this, but when you experience anger, a lot of times there's another feeling that comes up right before it. So we call anger, we treat anger as a secondary emotion because a lot of times we're going to be hurt and it's difficult to stay in that hurt place. So instead, we quickly get into the anger place to give us some energy and control of doing something about it. And so anger is a secondary emotion according to one school of thought, which is a school of thought I prefer to belong to. And so it's something that it's a protective emotion. So you'll see this especially in parents, their child gets hurt and they go into the school and they start yelling at the school principal. So it's a protective emotion. Don't harm my kids, and of course, of ourselves. But it's a signal to us when we start getting upset. How wonderful is it that there's something that signals to us that, you know what, something's wrong with this situation.. trust my instincts, trust whatever comes up for you. And using that signal, we get to channel through and properly deal with situations that arise one on one or in a group setting at the workplace you get to communicate what's really bothering you.

00:04:35 Dr. Vicken Sepilian
Right. That's an important aspect. Now, what's the difference between anger, aggression and rage?

00:04:44 Anita Avedian
Great Question.

00:04:45 Dr. Vicken Sepilian
You know, like you said, anger is a secondary emotion. What's the difference between aggression and rage?

00:04:52 Anita Avedian
So what's interesting is our program, anger management, should really be called aggression management, because aggression is the actual behavior, it's the act. So if I'm yelling, if I'm hitting, that's the aggression. But if I'm just feeling the anger, I haven't done anything wrong. I have not violated anybody. I haven't broken any rules or laws. So it's okay to be angry, not to be scared of that, but what do I do with my anger? So some people, if they're not channeling it properly, like we just discussed, that signal, we communicate. That's a proper way of dealing with it. But for those people who have trouble with channeling it properly, sometimes can aggressively take it out on people. Either put someone down, the road rage we'll see, office rage we'll see, and so that's the aggression. Now, rage, rage is really this tough concept to really pull together. But the way I look at rage is someone is aggressive, but ten times as much, it's out of control. They cannot control it. I usually like to ask my clients, if the cop was there, if the policeman was there and you knew you were going to get arrested for what you were doing, would you have stopped? Now, the person who has control over that and they knew, they would have stopped. There's aggression, there's an intention. The person who's raging, there's no control. So those are the people who you see, they're fighting back with the police or there's still the physical fighting going on. It's too much has passed. So we're going to see people who rage in the prison system, mostly because they've really gone out of their way, they've violated. Right. And with people who rage, we see more shame associated because it's not what they want to be doing. They get triggered and they act out like really badly. And then there's a lot of regret and shame. Not always.

00:06:47 Dr. Vicken Sepilian
Eventually.

00:06:47 Anita Avedian
Usually, yeah. Versus someone who's aggressive, you're going to see the aggressive person, they have an intention to harm. They have the intention to "I'll show him, I'll show her." And they have a plan on what they're going to do. So it's not an out of control behavior. They know what they're doing. Makes sense. And there is a fine line. Some people say, well, at what point would you call that rage?

00:07:12 Dr. Vicken Sepilian
Right.

00:07:12 Anita Avedian
And there's not enough research on that necessarily, but in all honesty, our program should be called aggression management and then I'd let people know. I ask, do you know why it's called anger management? Because the anger is okay. They say, well, what are people going to Google search, anger management or aggression management? Leave it to anger management.

00:07:32 Dr. Vicken Sepilian
You should start to correct the terminology and eventually have the search engines catch up.

00:07:39 Anita Avedian
That's right.

00:07:40 Dr. Vicken Sepilian
Batter's intervention. How is that different from anger management? Or perhaps I should use the correct lingo and say aggression management.

00:07:49 Anita Avedian
Oh, there we go. So great question, because a lot of people confuse what domestic violence is, which would involve batters intervention versus why people come to anger management. And the best way of knowing this is if there's domestic violence, think of domestic as a home. The violence that occurs within the home, husband to wife, partner to partner, partner to child, that's all considered domestic violence. And there's a different dynamic that occurs there that's not necessarily occurring with someone who has issues around anger. For example, we're going to see people come home and there's like the cycle of violence that reoccurs at the home, but that same person, the perpetrator at the home, is not an angry person at the workplace necessarily. They're holding it together there. They're very charming to society and their surroundings. But at home, you see all the anger come out there. Vice versa, if I have people who are coming to our program for anger management, these are not people who have necessarily ever been aggressive at the home place it's more at road rage or office rage or bar fight or things of that nature and not necessarily what goes on at home. So your biggest difference with domestic violence or batter's intervention (that's the treatment for domestic violence) and the anger management, is that one is at the home, one is outside the home. Some people need both, that does happen, but typically in our anger management program we don't see as many perpetrators or people who need batter's intervention and you also have judges who sometimes will court order someone to take anger management instead of batter's intervention. I don't know if it's because they're not sure of the difference, but if I had to guess if someone's ordered to do batter's intervention, it's an automatic 52-week program. Versus anger management, since there's no legislation, they can have just one session or ten sessions and not the rest. But that's your main difference. There's a whole different thing.

00:09:50 Dr. Vicken Sepilian
So what are some with anger, with chronic anger, what are some potential deleterious health effects?

00:10:00 Anita Avedian
I love that you're asking this question, and especially for men. I think what helps to know is that, and research has reflected this, after two hours of having an explosion, angry/anger episode, let's call it, a person is eight and a half more times likely to have a heart attack and three times more likely to have a stroke. And when people get to hear this, and this is really more you'll see this occurring with chronic anger. What happens is if you think about it, when we're getting angry, yeah, our blood is boiling, we're getting heated, there's chemicals getting released to the body, but how does the body pick up that energy? It takes the energy from the glucose getting released. So it needs the sugar, it needs the fat, and eventually when it keeps using all that sugar and fat, it starts to clog up the arteries and there you have your risk increasing with heart attacks and strokes,

00:10:52 Dr. Vicken Sepilian
Right. Indeed. In fact, spasm vasospasm, where the blood vessels may go into a spasm, could occur as well and these are all things that could ultimately contribute to a heart attack or a stroke, which have a similar mechanism at the end of the day. When a person is angry, what are some things that you would recommend to sort of calm themselves down? What are some tips?

00:11:21 Anita Avedian
Great. I usually love focusing on preventive tips, what they can do. Most of the clients who come through our program, we really focus on prevention such as communicating, which we'll talk about soon. But clients say just tell me what to do Anita, I'm about to blow up just tell me what to do and so here are my go-to suggestions in these situations. First, get out of that situation. If you're in the same room and you can't leave the home, try to leave that room, at the very least to another room because if that person who is upsetting you is still in front of you you're still activated, the chemicals are still being released in your body and you need that break away from that person. My preferred element around this is go outside, take a walk, because not only are you leaving the situation, you're walking and we know with walking you're in nature. You have the right left movement, which relaxes us, you have the breathing, which is relaxing us, you have endorphins being released if you're walking fast enough to relax us. There's a lot more benefit to be able to do something like that, but I get it not everyone's in the type of neighborhood that they were going to want to that's easily accessible to do and so at the very least, to be able to excuse yourself to be in another room. The other suggestion we typically will have is count, I know it's been said so many times, but count one to ten. And the reason for this is, if you think about it, we have our right hemisphere which regulates the emotion so when you're angry you're predominantly in your right hemisphere, and when you're counting you're predominantly in your left hemisphere. So you're almost distracting the left hemisphere to not be as angry. When you stop counting, the anger is going to come back, but temporarily, you're kind of calming yourself down as much as you can. The breathing exercises, I know a lot of people will say, take some deep breaths. I'll caution people around how to do the breathing because we have certain breathing we can do that will activate the sympathetic nervous system. Which is not what we're wanting, because anger is going to be in that in that sympathetic nervous system. What we do want is how do you relax the body with breathing so that you're activating the parasympathetic nervous system? And that is, you count in, if we had to count, count in 4 seconds, hold 4 seconds and then exhale 4 seconds. Or inhale 4 seconds, exhale 8 seconds.

00:13:45 Dr. Vicken Sepilian
(Takes deep breathe)

00:13:46 Anita Avedian
Is it only counting for us? No. (Laughs)

00:13:53 Anita Avedian
This is how easily this works.

00:13:54 Dr. Vicken Sepilian
I wasn't angry to begin with.

00:13:58 Anita Avedian
But yeah, that's an important one to know.

00:14:00 Dr. Vicken Sepilian
We're going to take a short break. We'll be back with Anita Avedian, who's a licensed marriage and family therapist, stay with us. [There is a 30-second advertisement in Armenian for Dr. Vicken Sepilian's fertility practice.]

00:14:46 Dr. Vicken Sepilian
Welcome back ladies and gentlemen to Stay Healthy TV, our guest today is Anita Avedian and we're talking about anger management. Anita, again, welcome to the program.

00:14:50 Anita Avedian
Thank you.

00:14:51 Dr. Vicken Sepilian
And now, understanding and setting boundaries is an important aspect of anger management. What can you say about that?

00:15:01 Anita Avedian
Good. Great. So with boundaries, we have so many different types of boundaries. We have the physical boundaries, emotional boundaries. So if someone is in my physical space, of course I'm going to start getting a little aggravated. And the reason why we want to set boundaries is not only to let people know, here's my comfort level and at this point I'm not that comfortable anymore. So we're trying to communicate to people what's comfortable for me and what's not comfortable for me. What we find in people who typically get angry are they're pretty generous people. They give a lot. People ask them for favors, they'll say, sure, no problem. People ask for money, they'll say, sure, no problem, but what happens is now there's some sort of expectation built where they've been there for this other person. And so that moment where they're asking you for the favor and you say no and they feel taken advantage of at that point or they've been wronged at that point, they may turn and blow up at the person. And so what we try to teach clients is, first of all identify what are your boundaries? Physical, emotional? Meaning if I share something with you and I ask you, please don't share with anybody else, otherwise you're not going to know not to share. Perhaps my financial boundaries. If I lend you money, my expectation is you're going to pay back. Well, not everyone agrees with that. Some people just say if you lend money, that means you've given it. And so we're just trying to communicate on what the understanding is and where my comfort zone is. And so I really try to get my clients to start to see that it's okay to say no. It's okay to not give them, not give others whatever they're asking for, or give, but don't expect anything in return. Just make the assumption that they may not be there for you when you're needing them.

00:16:51 Dr. Vicken Sepilian
Right. And that's important, I guess, to communicate what your boundaries are because it removes any type of a preconceived notion or an expectation that if and when not met, then could be a source of anger.

00:17:06 Anita Avedian
And I think what we start seeing, culturally speaking, is you know in different cultures, boundaries mean different things. If you and I grew up in a culture where it was okay for me to take food off your plate without asking you because that was our closeness growing up as siblings, let's say, then now I'm dating someone who that's a huge no no, but I'm feeling close and I tried to grab it. So now we're going to be in a conflict, so that's where it's important. Culturally, we have very different upbringings and it's important to let people in and let people know, here's my comfort level and here's not and please respect this.

00:17:42 Dr. Vicken Sepilian
Of course. Now, drinking and drugs, of course, oftentimes do play a role. You know. How does that impact anger?

00:17:52 Anita Avedian
When someone first comes to our anger management program, during our intake, we try to rule out if their anger is existing primarily when they're drinking or using. What I notice is if someone is passive and they don't typically express themselves and what's bothering them that same person, when they're drinking, this is when they start either getting into a rage fit almost, or they get aggressive and start yelling and taking everything out on that person. It's because they haven't been able to share much. So under the influence, their inhibitions are lowered and they're more impulsive, so they're more likely to speak up and how they're speaking up isn't in the best way possible. So what we start seeing is, okay, drinking or the drug use has become a problem because they're holding things in and then when they're using, they're letting everything out at that point. If there's a drinking or drug use problem, I tell them, you can learn all the skills here you want, but unless you start treating the alcohol consumption or the drug use, this is not going to be helpful because it's a skill based program. And so we try to rule that out and we try to get them into the right programs necessary. If they're court order, there's not much we can do outside of making recommendations to the courts that this is what we're also recommending.

00:19:12 Dr. Vicken Sepilian
But if you do see that where issues of anger or the emotions of anger begin to manifest themselves, whether if it's expressing, or aggression, or rage, then I suppose in one sense it at least gives you some information that you can work with.

00:19:37 Anita Avedian
Absolutely, and a good point that you're bringing up. So if that same person is able to start asserting themselves during times when they're sober and they're not under the influence, that may actually help them during the times when, let's say now they are drunk because they've kind of let it out in a healthy way, but they're still using. We kind of hope that that helps if a person is deciding to continue to drink and we'll see that sometimes happening. The other relationship I see with this is with marijuana use. I've noticed that the day after, if someone is a chronic marijuana user and the day that they're not using, sometimes they're like the angriest people I've seen when they're not using. And I don't mean social using and the next day, that's not what I'm talking about. And so I realized that sometimes these drugs or alcohol is what they're relying on to calm themselves down. So when you remove that substance and a person doesn't have the skill set to really identify and know what to do differently to calm themselves down, you'll start seeing them get into rage fits or become aggressive.

00:20:41 Dr. Vicken Sepilian
More aggressive, yeah. Now, how are some ways we could improve our communication when we are angry? You touched on they don't have the skill set or whatever, have you, but what are some of these skill sets?

00:20:57 Anita Avedian
One of my favorite worksheets that we talk about is assertive communication skills. For one, there's so many words, trigger words and phrases we have. For example, if I start saying you did this, you did that, I'm attacking you. Of course you're going to attack me back and of course that's going to become a conflict and it's going to escalate. We also ask why questions. Why did you do this? Why did you do that? Well, that's accusatory. Whoever I'm asking is going to attack me back and blame me or the conflict gets worse. And so what we recommend is when you do something specific, when you don't put away the glasses after you're done with them, right. It's very specific. It's not an attack on your character, but it's talking about a specific behavior that you're doing and how that impacts me. So, you know, I can get into that I feel bothered or I feel alone in this in the household chores, right. So I'm expressing how it's affecting me when you don't do a specific piece rather than attack on the character, so it's so important not to get into attacking on the character. You're lazy. No. it's to try and stay away from the judging and such. And we have an entire skill set, I won't go through all the details, but I think it's just as important to be aware of what not to use. Such as words such as "always", "never" those absolute words that we just try to make our statement more powerful when really what it's doing, it's negating what we're trying to say and so just be very specific. I would like for you to do this more, I don't like it when you do this, rather than you always do that or you never do that. So those are the big tips when it comes to certain communication.

00:22:37 Dr. Vicken Sepilian
And that's very very important. Now let me ask you, if somebody, if or when somebody is seeking for an anger management provider, what should they know? What questions should they ask? If you can give us some tips on that.

00:22:51 Anita Avedian
Of course, currently there is no legislation actually in any state in the United States, so my focus is trying to get legislation in California. But right now, anybody can teach anger management. So you don't need to go through any course, you don't need a degree. So it's a little bit scary of what's going on out there. So what I would ask, highly recommend for you to ask, is one, are they a clinician? Even though they don't have to be a clinician to offer the services, but if they are a clinician, it's an added benefit if they're also certified in anger management. So they have the skill set of what they're teaching you to help improve what you're there to work towards. Some people go to a certified anger management counselor and they're not necessarily clinician and they're great. So kind of look for both if you can, but at least go to someone who is at least certified and hopefully has been doing it for some time so they have some experience under their belt.

00:23:47 Dr. Vicken Sepilian
Right, of course, experience is always a plus. Now, when it comes to programs, I mean, we did touch on batter's intervention where it's a 52 week program. What's the typical anger management program and at least what do you recommend?

00:24:07 Anita Avedian
26 weeks, six months is my recommendation, and I'll say why. It takes three months for people to normally have that behavioral change. So all of a sudden they're incorporating all the skills we've been teaching and now it's become more natural, and we say six months because that's the amount of time it takes normally after trying to practice all the skills, that you're actually going to maintain it. Otherwise, if someone comes through a three-month program, there's a great chance a year later they're court ordered again or they're coming back again. And so we see that six month as a magic number, 1 hour once a week not to rush through it, because you need time to practice those skills. Is such a great number in terms of the term to incorporate the skill set and to learn. We also notice in that second or third month, a lot of times, clients will come to us and will say, "you know what, Anita? I was about to do dot dot dot, but I didn't I stopped myself." And really, part of this program is to have that cognitive behavioral approach to get people to have their prefrontal cortex to connect to the amygdala more quickly to stop themselves from otherwise acting out as to why they even got to the program.

00:25:17 Dr. Vicken Sepilian
Right, but that's great tips. Six month program. It takes about three months for us to even begin to change our habits and any other three months to maintain. Unfortunately, we're out of time. We have to close the program. But I also wanted to mention that Anita is a published author, has a book on anger management. If we can just show that, fundamentals.

00:25:45 Anita Avedian
This one's the teens book, I co-authored with Ingrid Caswell. This is the adult version and then we also have it translated in Armenian and it's called Anger Management Essentials. It's also been translated and published in Spanish, and the Hebrew version will be out in a few weeks from now.

00:26:03 Dr. Vicken Sepilian
Great. Thank you very much, Anita, and we'll have you back on our program very soon.

00:26:07 Anita Avedian
Thank you.

00:26:08 Dr. Vicken Sepilian
Thank you very much, ladies and gentlemen. We'll see you on the next episode. Until then, stay healthy.

Interview with Dr. Sepilian - Social Anxiety
The interview is held at a recording studio, with Dr. Vicken Sepilian wearing black scrubs sitting on the left and Anita Avedian, LMFT, wearing a navy dress and sitting to the right. Both Dr. Sepilian and Ms. Avedian are sitting behind a gold-colored table with the television centered behind them.

00:00:34 Dr. Vicken Sepilian
[There is a 34-second advertisement in Armenian for Dr. Vicken Sepilian's fertility practice.] Welcome to Stay Healthy TV. I'm Dr. Vicken Sepilian, your host. Today we have in the studio Ms. Anita Avedian, who's a licensed marriage and family therapist. Anita, welcome to our program.

00:00:48 Anita Avedian
Thank you very much, Dr. Sepilian.

00:00:50 Dr. Vicken Sepilian
So Anita specializes in anger management, and one of her specialties as well is social anxiety and disorders related to that. Previously on this program, we've had Anita talk about anger management. She does practice here in Southern California, and is the director of Anger Management 818, with multiple locations throughout the area. But today we wanted to focus on social anxiety. Now, what is social anxiety?

00:01:23 Anita Avedian
Social anxiety disorder is when a person really fears going into social situations. They worry about someone judging them, perhaps judging them that they're stupid or not good enough or what they're saying is very boring. So there's a lot of fears around social situations. It can involve performance. It can involve eating in front of people. Are they judging with how I'm eating or how I'm chewing? So there's a lot of fear of judgment or being humiliated or embarrassing themselves. And so it keeps them, even though they're interested in making friends and having a support system, so they definitely have the interest in going out there, but they have so much fear around what can go wrong in those interactions. And therefore it keeps them from making friends. It keeps them from a lot of things, which we'll get into. But it's, it's a pretty serious you know, it's a pretty serious disorder when it comes to support systems and having people around you.

00:02:22 Dr. Vicken Sepilian
Now, let me ask you, how prevalent is it?

00:02:26 Anita Avedian
Currently in the United States statistically it's about 8%, or sorry, 6.8% of people right now in this year have it. But in someone's lifespan, there's a 13% chance people will have it. It's the third-highest mental health disorder. I once read fourth, but most of the statistics read as the third-highest. So the leading causes of mental health are depression and the alcohol addiction. But this is your third highest prevalent in the United States. It's a pretty serious and common.

00:03:04 Dr. Vicken Sepilian
And is there any differences in the genders?

00:03:09 Anita Avedian
So we see that there are twice as many women as men who experience social anxiety, but there are actually twice as many men than women who actually seek treatment. And it makes sense because you have men who are wanting to be promoted at the workplace and they're realizing why they're not able to speak up. And so it's impacting them getting promoted at the workplace. It's impacting them asking for women out or men out. So it keeps them from dating and speaking up, and so they realize how badly it's impacting them. And so in my social anxiety group that I hold weekly, we have mostly men, even though there's twice as many women who suffer from it.

00:03:52 Dr. Vicken Sepilian
That's true and those are great points that you brought up. A man may be less assertive in asking for a promotion they deserve or a raise. Or dating, asking somebody a woman out on a date or a man out on a date. So essentially, these are ways that social anxiety can truly interfere in one's ability to grow as a person,

00:04:20 Anita Avedian
Right.

00:04:21 Dr. Vicken Sepilian
Yeah. So what's the difference between someone being shy versus them having social anxiety?

00:04:30 Anita Avedian
I think it's so interesting where a lot of people end up confusing or mixing shyness with social anxiety. Shyness is a personality trait. People could be shy, but not have social anxiety. Versus social anxiety is an actual disorder, it's keeping someone from going to that social function, from making friends, from interacting. But someone who's shy can go to those parties they're just a little bit shy. It doesn't keep them from doing those things, and so the main thing to know is if you take all the shy people, only 12% of those people will say, yeah, I suffer with social anxiety. So you see that some people who have shyness also have social anxiety, and then you see some people with social anxiety who don't have shyness. So I've seen both where you see shyness, no social anxiety, social anxiety, no shyness. And then those who have both, who suffer with both. But really, one's a personality trait and the other is an actual disorder that we can treat and work with tourists.

00:05:30 Dr. Vicken Sepilian
Now, in terms of, you know, the actual symptoms, when does it typically present?

00:05:36 Anita Avedian
The median is at age 13. So for 75% of the people, it can start around age eight, all the way to 15. That's 75% of your population. Some children will experience it when they're younger and some in the adulthood. What's interesting is I end up seeing the clients who come to me, for example, for this social anxiety group I have during the intakes, I realize either they stopped drinking, they stopped using, and then all of a sudden they realize, wait a minute, I don't know how to talk to people. I'm actually very uncomfortable. And there's all this fear of judgment occurring. And that's when they realize they have social anxiety. So they've had it this whole time, but they didn't know it because they're at these parties drinking constantly, not realizing.

00:06:22 Dr. Vicken Sepilian
It got unmasked somehow.

00:06:24 Anita Avedian
Exactly. There's also ones where just during those college years, they went from high school with having a group of friends, and now they're in college. Well, wait a minute, they have to make new friends now. And that's when they start realizing, how do you approach someone? How do you make new friends? And that fear starts to kick in about the being judged, the rejection. There's a huge fear of rejection. What happens then? And so I see a lot of people coming to treatment in their early 20s, sometimes in their forty s and fifty s. And I've noticed the people who come in later in life is because they still haven't dated or they're struggling with the dating life and because they stopped using and all of a sudden they're realizing..

00:07:05 Dr. Vicken Sepilian
It's unmasked.

00:07:05 Anita Avedian
..it's unmasked right.

00:07:07 Dr. Vicken Sepilian
Now, is there a genetic component to this?

00:07:10 Anita Avedian
There definitely is. So there is a genetic component in that, I think, one third of the underlying causes of social anxiety is genetic. They haven't found the actual chromosome, as they have in panic disorder and agoraphobia. But that's to be coming, I would imagine, because they have very similar symptoms. But they have found that those who have a first degree family member, mom, dad, sibling, who also has social anxiety, that person is two or three times more likely to have social anxiety. So they're more prone to it. It's in the genes, but they haven't found the details yet. But that seemed to be coming.

00:07:47 Dr. Vicken Sepilian
That contributes to it. Now, in terms of other than genetics. Gender, we talked about the onset of age and the various clustering within age groups. What else contributes to social anxiety?

00:08:03 Anita Avedian
So there's several different things and we'll try to cover the different elements. So the family history we kind of talked about, part of it has to do with the genes. The other component is that they have negative experiences. So think about all the bullying that goes on, that child who gets bullied or teased or humiliated and there are people laughing at them. That's going to contribute to the social anxiety. Even if there's a lot of moving around as a child. So for those people who move schools and move cities and locations and the family kind of has to move around, let's say. That person is more prone to having social anxiety because they're constantly having to get into a new circle, loss of friends, making new friends, and it's not always easy to do that. And at some point, a person starts to feel more uncomfortable and trying to figure out how to get through in that scenario. So those are the negative experiences. We also want to look at temperament. So we see that children, when the temperament is, for example, shy or timid or withdrawn, especially when they're meeting new people, there's new situations. That person may be more prone to having social anxiety later in life. New social or work demands. All of a sudden you're hired at this workplace and this company is saying, Dr. Sepilian, we would like for you to make all these presentations. Now, you would have no problem with this at all. We know this. But there are a lot of people who they may not show up to work the next day because they're not going to love to do that, and so that becomes a big threat. So that same person didn't realize they ever had social anxiety, and they may have never had it, but all of a sudden there's these requests. We want you to go and speak in front of all these people or sell this thing to these people, and they start to realize, oh, boy, this is getting really uncomfortable. And so much so, they can't sleep. The anxiety is so strong, they can't function properly, and they want to avoid going back to work and eventually lose their work.

00:10:04 Dr. Vicken Sepilian
Right.

00:10:05 Anita Avedian
There's one more that I do want to cover, and that is for those who have a health condition that draws people's attention to them. So for someone who, let's say, may have skin burns on their face, something that's very visible of facial disfiguration of the face, someone who stutters, where they get embarrassed of, are people judging me? Can they understand what I'm saying? So it can be someone who didn't have social anxiety, but all of a sudden..

00:10:34 Dr. Vicken Sepilian
Acquires it.

00:10:35 Anita Avedian
Yeah, they can acquire that because of that. And so we want to just notice if there's anything around that that may be happening. Because, of course, there's also the fear of being judged. And even when we talk about the public speaking, the fear of people noticing that they're anxious. A person who blushes easily, not everyone blushes, but the person who blushes easily, that's a huge fear for them because it's an obvious everyone's going to know, right? And so the more obvious that becomes, the scary that feels for them.

00:11:08 Dr. Vicken Sepilian
I think I'm blushing [Dr. Vicken Sepilian and Anita Avedian laugh briefly] ..and environment as well.

00:11:16 Anita Avedian
Yeah. So environment. Thank you for that. Environment also definitely plays a role for some, we say it's a learned behavior. So if we have a parent who has social anxiety or someone is modeling like the peers are modeling for them, that there's social anxiety, they're scared to approach people. All of a sudden you start thinking, oh, maybe it's scary to approach people. I shouldn't approach them. And so you kind of start learning that same behavior from peers that otherwise you wouldn't have had. And so some part of it can be learned among the Armenian [Anita Avedian says a word in Armenian that translates to shameful]. It's shameful, it's shameful. Don't do this, don't do that. And eventually it's, oh, wait, people are going to think, this is embarrassing. This is shameful, I shouldn't do this.

00:11:56 Dr. Vicken Sepilian
So essentially, that was something that was imprinted on that individual by their surroundings, whether it be friends or family members or whatever have you.

00:12:08 Anita Avedian
And I think there's also one more point around this is sometimes when we see parents be controlling over their children or being overly protective. We start seeing that those same kids who've had those overly protective parents, end up developing social anxiety because the parents have kind of done the work for them.

00:12:26 Dr. Vicken Sepilian
Right.

00:12:26 Anita Avedian
Think about it again. Something happens at school, someone teased them. The parent comes in, does all the work. Well, now, this child hasn't learned.

00:12:34 Dr. Vicken Sepilian
Didn't learn the skills that it's necessary for them to actually do that. That's a great point. Ladies and gentlemen, please stay with us. We're going to take a short break, and we'll be back with Anita Avedian.

00:12:49 Advertisement in Armenian
[There is a 30-second advertisement in Armenian for Dr. Vicken Sepilian's fertility practice.]

00:13:16 Dr. Vicken Sepilian
Welcome back to our program, Stay Healthy TV. I'm Dr. Sepilian, your host. Today with us is Anita Avedian, who's a licensed marriage and family therapist. Anita, welcome back. We are talking about social anxiety, and we had talked about some of the causes. Some of it can be genetic, environmental, and whatever have you. Can this disorder go away by itself or does it go away by itself?

00:13:52 Anita Avedian
It's rare, it can but it's really rare. Because when you say, does it go away by itself.. if a person is exposing themselves to situations, chances are they'll probably work through it pretty well. Most of what we see is when someone has social anxiety, they start avoiding they'll avoid the situation to not experience the anxiety. And then the more you avoid it, the more fearful you become of it and the less you're able to go and seek support or have a support system. And so we highly recommend to get some form of help. There's self-help programs as well. There's one on one therapy. My preferred approach is a group therapy because how much better can that be where you have a group of people, you can work through, its exposure therapy, where you can work through some of your discomfort and share in common with other people what you are concerned with and your fears. So you don't feel alone in this disorder that so many people experience.

00:14:49 Dr. Vicken Sepilian
Right, now if it goes untreated, what are some of the consequences?

00:14:56 Anita Avedian
What we start seeing? I mean, at worst at worst, people do attempt or commit suicide, and that's when it gets pretty bad because they feel hopeless and helpless, that they're not going to get a job or they're not ever going to be able to date. But generally we'll start seeing that there's low self esteem. They may have trouble being assertive, so they're not approaching people, or they're not asking for a promotion at the workplace. There's a lot of negative self-talk which eventually can then get into not just anxiety, but then depression. Hypersensitivity to criticism. They personalize what is being said to them because it's so difficult to hear something negative about them. Poor social skills. Isolation in difficult social relationships. And a main one for students to know is a lot of times we'll see the grades. They suffer in grades because even going to school, they're too scared to ask a question to the professor or to the teacher. And then they're not really understanding what the school lesson plan is, and we see that they start suffering with the grades because of it. Or projects that involve a group of people, team projects or public speaking projects, forget it. They'll probably avoid that. And so we start seeing them suffer in those areas.

00:16:18 Dr. Vicken Sepilian
I see. Now, we touched on this earlier, but when do you see people come and seek help?

00:16:26 Anita Avedian
So usually when a person just transitions into college, or they leave college and now there's no place for them to start making friends unless they really put themselves out there. So a lot of times I'll see people around ages 18 to 23, 24, seeking for help. So most of my clients who seek for my help are in that age range. Or someone who's been using and all of a sudden they stopped using and they realize they're having difficulty in social situations. So they start realizing, I'm not comfortable talking to people. I don't even know what to talk about. What do you talk about where it's not going to be boring? Anita, I don't know what I can share that would be even of interest. And so there's a lot of that self-doubt. So what we start seeing is people realizing they're at home every day watching TV after work. When they're at the workplace, by the way, and there's a meeting, they'll do their best to show up exactly on time because if they come a few minutes early, that means they have to talk to people. If they come a few minutes late, that means everyone's going to stare at them. Right. So the people who show up, doesn't mean you have social anxiety because you show up on time, but the people who show up on time are usually trying to work around not being judged some way or another.

00:17:45 Dr. Vicken Sepilian
Right. Well, those are such cues that probably most people wouldn't recognize, but now I'll keep that in mind. Now, what's been found to be effective in the treatment of social anxiety? I know we touched on this, and I happen to know that you're the only group therapist where you do treatment for this in a group setting, in all of Los Angeles.

00:18:11 Anita Avedian
Yeah, in Los Angeles area. I have been facilitating social anxiety groups for over twelve years. I finally found a person out in Orange County who does a group out there and her and I met up, I forget, somewhere in the midpoint to kind of share notes on what works, what doesn't work, to improve. Because usually this type of specialty, yeah, people may work with them individually, but here's the oxymoron. How do you start a group for social anxiety for people who are too anxious to be around people?

00:18:41 Dr. Vicken Sepilian
Right.

00:18:41 Anita Avedian
It is the most challenging group to start, I will tell you. So I've noticed on the average, from when a person seeks out for help, which is usually ten years after experiencing symptoms, they'll seek out for help, on the average, that's 36% of people. They seek out for help, four months later they'll step foot into that office. And sometimes I've had it where we had to meet someone at the lobby to escort them up into the room because that was such a scary concept. So in Los Angeles, my preferred treatment is a group setup where you have the exposure in a comfortable and safe environment with a therapist who understands social anxiety and who can help through the skill building around it. And it's a place where you can practice through some of those learned skills. Now, one on one therapy will help as well, but I think that exposure to a group is what takes it to a next level. I think sometimes at UCLA, I've seen a group randomly kind of start and end, but really I seek for therapists who provide this service because it's so unserved, and I could see why because it is very tough to start a group. I'm fortunate enough because I've been doing it for some time where people make the referrals, but it's a very tough group to get started and to maintain.

00:20:02 Dr. Vicken Sepilian
Of course, I can just imagine.

00:20:05 Anita Avedian
You know, people are too scared to be around people.

00:20:07 Dr. Vicken Sepilian
Right.

00:20:08 Anita Avedian
But it's a beautiful thing to be in a group setting to provide cognitive behavioral skills. And the behavioral part, what I do once a month is we go out to a mall or an outing where there's a lot of people and I actually have clients try out, approaching people to try actually there's a thing called rejection therapy to ask for something that they know most likely they're going to get rejected for. And then we process what that was like for them, for them to realize, not a big deal, it's not as bad as I thought it was.

00:20:37 Dr. Vicken Sepilian
That's right.
00:20:37 Anita Avedian
And when they start realizing that, they start taking more steps and more steps. So I've seen clients join Toastmasters, which is very scary to do for somewhat social anxiety. And it's been great.

00:20:47 Dr. Vicken Sepilian
So cognitive behavioral therapy that's when you try to explain or have somebody understand the root of the process and then have them act on it.

00:20:58 Anita Avedian
The cognitive part is going to be, for example, if my thought is, they're going to laugh at me or I'm going to be boring, they're going to think I'm boring. So now the countering thought may be something like, wait a minute, I have things of interest to say. If they are bored of me, so what? Right? They'll just walk away. So it's dealing with the rejection. So it's what we tell ourselves to help us through that process, to push us to be able to start taking those risks. Because without taking those risks, you're still kind of stuck in that same outcome of staying at home and not really having the support system that we need. We need connection, we need to have friends, we need to have someone to talk to.

00:21:38 Dr. Vicken Sepilian
And there are medicines that can be used to treat this.

00:21:42 Anita Avedian
Yeah, because there's neurotransmitters that play a big role. So what happens with people with anxiety, especially with social anxiety, is that the amygdala is just it's hypersensitive, it's overly acting. So what you and I may perceive as it's okay, it's just a social situation and it's okay if someone doesn't like what I said; for a person with social anxiety, that is the biggest I can't handle if someone says they don't like something or look at me a certain way that they may not like it. And so they don't think as rationally, it's not proportionate to what the real, it's not really dangerous for us but for them it's a real danger. So that's where we start seeing the amygdala acting in ways that it's not going to be that way in other people. But so the neurotransmitters, the four neurotransmitters that play a role, which is why we look into medicine as an option, is Norepinephrine, Dopamine, Serotonin, and GABA. So typically when one is treated with, sometimes they'll prescribe Paxill or.. I don't want to talk about medicine, because I'm not a psychiatrist, but there's medicine that's provided to help out with those situations. And I think when a client is taking that medicine and they're trying out different behavioral things, then they start realizing this isn't as dangerous as I thought it was. So when they get off the medication, they're able to function.

00:23:06 Dr. Vicken Sepilian
To cope better and ultimately the result being better. Yeah. This is a very important thing. I'm glad that we had the opportunity to talk. As Anita said, social anxiety disorders is the third most prevalent mental health disorder after depression and alcoholism, affecting approximately 13% of the population at some point in their life.

00:23:33 Anita Avedian
Exactly.

00:23:33 Dr. Vicken Sepilian
And more prevalent in women by two to one, you said. However, men seek treatment at a rate of two to one, probably due to professional reasons. There are number of contributing factors. Part of it is genetic, environmental, and our surroundings that may impact this. Most of the time it does not go away. So some sort of an intervention is necessary. And those interventions, as we talked about, could be seeing a therapist, you're being an expert in the field, an authority in the field, you recommend group therapy.

00:24:15 Anita Avedian
My recommendation, but I will say this because I know it's a big deal. A lot of people are too scared to step out of their home. So Dr. Thomas Richards and I'll show his book, he actually has an entire I think it's an online group. So for those who are too scared to come in person with someone, he has a wonderful program online. He's created a lot of peer groups internationally for it's not necessarily therapy facilitated, therapist facilitated, but peer to peer. And there's an entire online program with videos and books. So I'm not trying to sell him, but this is something that I have found. A lot of my clients tell me that it is helpful.

00:24:56 Dr. Vicken Sepilian
That they have that is effective and that could be a self help approach as well. And the point being here is that regardless of the approach, that something should be done because in and by itself, it does not resolve and can lead to some pretty significant consequences, including suicide or suicide attempts.

00:25:18 Dr. Vicken Sepilian
Anita, thank you very much for coming. Anita Avedian, again, director of Anger Management Eight One Eight practices licensed marriage and family therapists and practices throughout California. You can look her up online. And again, thank you very much for being on our show.

00:25:38 Anita Avedian
Thank you for having me here Dr. Sepilian

00:25:39 Dr. Vicken Sepilian
We look forward for future episodes. All right, thank you very much. We'll see you soon. Until we see you, stay healthy.

00:00:00 Mishka Kimball
Hi, everyone. My name is Mishka Kimball. I'm an associate marriage and family therapist.

00:00:04 Anita Avedian
I am Anita Avedians, licensed marriage and family therapist.

00:00:07 Mishka Kimball
I'm going to be telling you a little bit about what men want in a relationship, and then Anita is going to tell you more about

00:00:13 Anita Avedian
what they don't want.

00:00:15 Mishka Kimball
Yes. So let me get started. So, ladies, it's very important to keep your beau or your bae, whatever you call it these days, or your person happy. So men want a couple of things from you. One of the most important things is men want you to be vulnerable. What does that mean? They want you to be real. They want you to be yourself and tell them what you feel. Don't hide your feelings, ladies. Tell them what you feel, what you think, what you want, what you want more of, what you want less of.

00:00:47 Mishka Kimball
It's really important. And tell them with grace instead of maybe getting cranky or not saying it and then later it comes out as you being really angry at them, and then umm that pushes them away. Men really want to be appreciated. They want our appreciation. So they want you to tell them, thank you so much for what you did. Thank you for cleaning the dishes, even the little things, right? Thank you for taking the dog out for a walk. You're such a good man. You're such a good hubby.

00:01:17 Anita Avedian
Ha ha ha

00:01:17 Mishka Kimball
They love that. Ladies, the third one that men really want from you is they want to know what you're passionate about, what lights you up, what makes you happy. It draws them more to you when they see you being your true self, when they see you being more authentic and just being your true selves. It makes you more attractive to them. Really want intimacy. And I know what you're thinking. You're thinking they want sex. That's all they want. And yes, men do want sex, but so do women. But intimacy is not only the physical aspect and the sex, it's also emotional. They want your affection. And that could mean many different things. There's different love languages. So Gary Chapman wrote a book about five different love languages. And that could be words of appreciation, it could be physical touch, it could be gifts. And it's important that you learn what your man wants. It's important that you learn what your man needs so you can show them that affection in that way. And that's going to help you connect with them on a deeper level.

00:02:25 Anita Avedian
And let me talk about what men don't want. We both do couples therapy, so we get to hear a lot of this. First, they don't want any drama. And when we say no drama, we mean it. They don't like the criticism. They don't like all the complaints we have. And I know we have a lot of complaints. There's a lot they're not doing. I'm not saying those points aren't valid, but we have to be careful with how we approach that. So we need to give them praise and slip in some effective criticism where they get to really hear it in a gentle way.

00:02:59 Anita Avedian
Don't tell them what to do. They're going to feel controlled. Men don't like that.

00:03:03 Mishka Kimball
They hate that.

00:03:03 Anita Avedian
They hate that.

00:03:04 Anita Avedian
So, again, we want to graciously ask for what it is we're wanting, what it is we may want some change about, but just don't be controlling, because that's how exactly they're going to hear it is you're trying to control me. And they want to know that they're coming up with these decisions.

00:03:17 Anita Avedian
Remember what you looked like, liked and how you were when you first started dating him. Well, let me tell you, don't let go of yourself. They want to see that you're still working out. You're still wearing the pretty dresses and the heels and the makeup, and you're taking care of yourself. Okay, We are going to age in time. We're not going to look like that. But you get my drift here, is just try to keep up with it a little bit, at least, because that's what they're drawn to.

Digital Marketing For Therapists

00:00:06 Anita Avedian
Welcome everyone. This is going to be a workshop or webinar per se on digital marketing for therapists, and today will be really an overview of the different things you can do that will help you with your practice to build that. To start, I just wanted to share real quick about Shrink Sync, since Shrink Sync is hosting this webinar. Shrinksync is a digital networking hub for therapists, and at the end of today's webinar, I will cover how to navigate through Shrinksync as a means of using it as digital networking for your practice. Rachel already wrote in the chat room that she will be available to answer any questions of technical questions that occur. And I did want to announce our upcoming webinars. So on February 10, Rachel Thomasian is going to offer part two of our marketing series and she's going to focus on SEO and websites. So after today's talk, if you wanted to learn more about those and get more details, not only has she written a recent blog post on Shrink Sync, but she will also do a webinar. It would be on Tuesday, February 10 at 09:00 A.M.. So tune in then if you're interested in learning more about that. Also, on February 17, that's one week after, Mercedes Samudio is going to present on 'Navigating Your Kids Digital Life.' So that will be very interesting. And in March, we're going to invite Melissa Hall to present on documentation made easy. So hopefully through these webinars, you guys could feel more confident about the use of social media and documentation and the marketing aspect of things. So, thanks, Susan. Let's get started, and you have our website there for Shrink Sync. Today the objectives: we're going to review the importance of having a good website, we'll explore popular ways to be found online, including SEO, understand the various online platforms for marketing, review paid and unpaid therapist search directories, understanding social media, some laws and ethics for therapists using social media, and also the benefit of using Shrinksync and navigating through it. And again, it's going to be an overview. We're not going to get too detailed into anything, but hopefully in our upcoming series we'll get more details in the specific areas that you have interest in.

00:02:31 Anita Avedian
Let's start with what is digital marketing? It's basically marketing through the use of electronic devices, including whether it's smartphones, tablets or computers. And it applies various platforms such as social networks, websites, apps, banner ads or emails. And digital marketing will also allow the marketers to track their return on investment, which is a good thing to have to know what's coming in through where in terms of referrals. Now, the main question is, do you market your practice online? And if you do, just obviously we're not answering these right now, but to think of how you do it and if not, why you're not. And we know there's a lot of discomfort that therapists have because of the legalities of confidentiality and not wanting to be known in certain ways. So there's a lot of concerns around that. And so hopefully I can shed some light to help bring some comfort in some of these for you today.

00:03:27 Anita Avedian
So let's take a look at how online marketing can help your practice. And I see Susan asking if we're going to get copies of the slides. We are recording this and so the recording will be available for you to view later. So let's look at various ways to use the internet for marketing your practice. Obviously, having a website is a great start and we'll talk a little bit more about the search engine optimization, which is also known as SEO. We'll touch up on marketing through the different platforms and we'll also take a look at online directories and the popular steps for those. Looking at a website, let's consider what should go onto a website. Obviously, there's so much that can go on, but to be selective and figure out how to make it most effective. Looking at what should go above the fold. The fold is really as soon as you open up a website, what you're seeing from the bottom of the screen to the top. If you ever notice the home pages of some of the websites can be extremely ongoing and you can just scroll down, scroll down, scroll down, but what's above the fold is literally what you see on the screen and above that bottom part of your computer screen.

00:04:38 Anita Avedian
It would be great for you to have a professional picture. It won't cost much to hire a professional photographer and have some nice indoor or outdoor pictures. I know a lot of therapists like to have the nature background to seem more inviting. If you have videos. For example, right now I'm filming this and we'll have this recorded version on our website. So when you have videos available on your website, that's also a great thing to do. I know there are people out there who help promote building/creating videos for therapists. So perhaps to take a look at those different services offered.

00:05:14 Anita Avedian
And navigation. What should go on your navigation? It could be a home page about the therapist services, fees, contact, a blog component. So think about what you want to go in terms of your navigation and looking at the functioning of a website, is your website simple? And if you're not sure, ask people around you or get a sense from other therapists to see what they think. Does your website provide information? We do know that people are attracted to or drawn into receiving information. So is it only providing sales? Or are you also providing some sort of helpful tips for potential clients to get drawn into your website? And is it easy to use? Websites are very complex and difficult to navigate through. And again, you can find out by checking in with a few other therapists to see if that's something you can simplify more and make it easier for your general population to use and navigate through your site.

00:06:18 Anita Avedian
Does the website function through iOS or Droid phones? I can't tell you how many times, if I'm using my computer, I could get to someone's website. But sometimes if I'm trying to get through from my smartphone, the website is non-existent or it's not coming up. There's an error page. I really recommend you guys to test out your own website link through your phones, both Droid and Apple, to make sure that everything is still functioning. I think there was a point some years ago one of my websites was not functioning for about a couple months and I had no idea until people told me about that. So I learned the hard way, of course, but that's how we learn and grow, right?

00:06:55 Anita Avedian
What about your website designer and host? So if you are ready to get started on building a site or you already have one and you want to renew or refresh that, there's different ways of doing this. I'm not as tech-savvy as my business partner, Rachel Tomasian. I know she loves to create her own websites and does it effortlessly. For me, I like to hire someone, pay someone to create the websites for me. I don't want to have to think through how to create all of this. So you're going to have to figure out what's going to be best for you. If you're tech-savvy, great. There's some great ways of creating your own. But for someone like me, who's not going to want to spend that much time on figuring that out, I'm just going to pay someone and have them create all of my information on there. And the cost. Obviously, if you're going to try and build a really nice website, it could be a few thousand dollars. But generally the start of a basic build-up of a website, if you're hiring someone to build it, can be about $400, $600. Again, very basic. You can actually use like a WordPress as a website yourself. So even though they were initially designed for blogs, you can actually create a website through that. And a lot of people do that. And there are companies such as Theravive.com and Therapysites.com and there's pros and cons to those and costs associated with that. It does bring up SEO to some degree if you're with them, but they are high monthly costs. I think about, if I'm not mistaken, $59 a month of some sort. And of course, there's a decision on domain names. And I think a domain name is so important, especially for SEO, and something catchy that is kind of fun to let people know we're www.shrinksync.com. It's exactly our name will be easy to find. But if you want to draw in attention for, for example, my anger management website has angermanagement818.com. So people are researching anger management, I'm more likely to come up because of my domain name. So when deciding on a domain name, look through to see what would be catchy for you.

00:08:59 Anita Avedian
All right. What is SEO and why is SEO important? A Search Engine Optimization. The best way I can explain this is how are people finding you? What words are they using to get drawn to your website? You could be an amazing clinician, but if you can't get people to find you, what good is that going to do for your business? So unless you're really networking and figuring out ways to get people to come to your office, you may be a very smart person and intelligent and wonderful therapist, but no clients. And so the SEO is how are people learning about you through the Internet? So if I'm on Google search and I'm going to type in eating disorders and you're an eating disorder specialist, how likely are you to come up? And that's with SEO. We want to make sure you're set up with your website and the wording to help draw people in. Again, this is something Rachel Thomasian will elaborate on in two weeks. And she also recently wrote a post that's been published on our Shrinksync website. If you want to read more about SEO, I highly recommend it. She's very smart in that. And how do people find you online? We just talked about that. And creating keywords and target audience. When you're writing things through your website, the content, are you actually also tagging those keywords so that people are drawn in to you for that reason? And there's ways we can analyze through Google Analytics. And you would have to get set up once you have your website up to activate the Google Analytics. So you can go in to see how many people are visiting, which pages are they coming to, what page do they keep exiting from while they're on your website? And all of that is obviously important for you to know what to change around on your website.

00:10:48 Anita Avedian
Thanks, Bruce. [laughter]

00:10:50 Anita Avedian
All right. And you want to test through Google suit search on your own website and see if it's appearing on the first page or second page. The more general it is. Obviously, if you're just putting eating disorders, you're competing with nationwide eating disorder specialists. But if you're in Los Angeles and you put eating disorders in Los Angeles, see how likely you are to come up. Or eating disorder therapist in Los Angeles, I highly recommend you test out a few different set of words or phrases per se to see at what page are you coming up. If you're coming up on the fifth or 6th page, that's not really the best sign. You really want to try and come up in the first page or two if possible. The first page. Let's take a look at popular ways to market your practice. There is Meetup.com, and I know Meetup. For me, it's been a wonderful experience being on there. You draw in a lot of different people who would otherwise not really seek for therapists. Believe it or not, it is paid. Meaning I think I pay about $80 every six months to be on there, which is not bad to attract so many new clients to groups. So Meetup is great if you're offering groups, and it's just a nice way of creating a community there. And as therapists, I think lately they've become a little bit more it's more difficult for therapists to be on Meetup because they don't want it set up where it's therapy groups they want it more of. Here's a community group. And there's ways around it where you can start attracting clients to your program based on that. And once you're on there, you can create groups. But very important to have a disclaimer about confidentiality. Anything with social media always put a disclaimer that if you sign up or RSVP through here, it is visible to others in the group or to the public. It's the first thing that should be written just to protect you. A lot of times people think it's going to be confidential just because you're a therapist, and that's not the case.

00:12:45 Anita Avedian
And I discourage people from RSVP-ing on Meetup because I just rather them not take that risk of having their name appear to others. There's email and event programs. So I have a Constant Contact account. I also have an Eventbrite account and MailChimp account. MailChimp is free. It's a great way of collecting email addresses of all the colleagues you meet at networking events, EventBrite. You can post events over there and they will take a percentage of if the fees collected. I think Mad Mimi is also free. Constant Contact, it's depending on the number of contacts you have. It's a little bit pricey, but well worth it. I love the designs. If any of you have ever received my personal monthly newsletters, that's all through Constant Contact. I'm absolutely very happy with it. But you have the free version, then you have the paid versions. I think you get more out of the paid versions, but everyone knows all of this. Okay. And then there's YouTube and there's advantages and disadvantages to having a YouTube video.

00:13:44 Anita Avedian
So what are you putting up there? And the advantages are going to be that it does increase SEO and its exposure and branding. Any opportunity you have to do that, that's great. Disadvantages, obviously, be careful what you put on the web. I don't know how many of you have had experiences of posting something on the web or actually seeing someone else's video on the web and thinking, I can't believe that therapist posted that to the public. Or they're disseminating incorrect information or they don't sound knowledgeable or whatever it maybe. So people have different responses and feedback to what's posted on there. Again, something you may want to check in with a few other colleagues and see if they think it's appropriate to post onto YouTube, and if it looks professional. I like getting feedback from others because it helps just get a different perspective on things. But YouTube videos, if you've pre-recorded, like a blog video for a two to three minute blog post, great. Why not put it up there and have that associated with your website as well?

00:14:49 Anita Avedian
Okay. Monica, just to answer your question, I think you're talking about Constant Contact. And if that's the case, I think I pay about $700 a year, but that's because I have over 2500 contacts. It really depends on the number of contacts. You can just go to Constantcontact.com and find that out from there. I think that's what you're asking about. All right, let's go on to other ways of marketing your practice online. There is Yelp. And Yelp, I am going to completely caution you on using, because once you have some bad reviews, that's it. And it can work against you. And it's very difficult, especially for therapists to get good reviews because we can't ask clients to review us. That's not ethical to do. And so when do people usually post things on Yelp? It's when they're unhappy. Sometimes when they're really happy. But the thing is, we cannot ask clients to post anything onto Yelp about us. But that's up to you. Look to see what other therapists have done.

00:15:52 Anita Avedian
There is also Yelp Advertising, which is different than having your business up on Yelp, but look into those two different avenues and see if that's helpful. I think Yelp business advertising, you're going to want to spend at the minimum $200 a month to just get started. I've never done that. But you can check around with others to see what their thoughts are about that bringing in business to their program. 1 second. Okay. And then we have Google Ads, and hopefully you guys are familiar with Google Ads. I personally love them. It is pretty expensive. I probably spend about $500 a month on Google Ads, but it helps me because I have a big agency and it's worthwhile for what I do for my private practice, for the therapy component, it's probably going to be 100 or 200 a month. But again, you want to be very specific with what type of AdWords you want to use to draw in and look to see what the return on investment is on that.

00:16:50 Anita Avedian
If you're actually converting people who are coming to you through Google Ads, and if they're actually enrolling and becoming a client of yours. And then there's additional platforms, and I'm really not going to go much into it, but I just wanted to throw it out there just for your own knowledge. There's Backpage, there's Craigslist. Craigslist, those are both free to post on it's just other ways that your information is going to come up on the website. When people search for, say, eating disorders. And the Craigslist I did write, the con is that you'll start receiving a lot of spam emails. It's not something I'm recommending, but again, it's just another way of getting through SEO. And then there's a website called Thumbtack. I tried Thumbtack probably for a few months, and this is where someone comes on and says, I'm looking for a therapist, say, in Beverly Hills. And now you get to offer a bid, and you can offer three bids for $15. And you can just say, I can provide therapy for you. And then if they accept it, then your credit gets reduced in terms of financial. So it's another way of getting clients.

00:17:52 Anita Avedian
I wasn't the happiest with it, but you can try out these different things and see how it works for you. All right, I see Tony's. An online directory. So let's take a look at the different online directories that are there. With online directories, you want to create a profile for online directories, something that's going to attract clients to want to come see you and creating an optimal profile. I think a lot of the sites, such as Psychology Today, they actually offer you guidelines and suggestions how to write up your profile. And you want it set up where people are going to be drawn to wanting to come see you. They want it to have a therapeutic feel, and you want to use words that are going to attract the audience you think you're going to have. So it's not as much about you as it's how you're going to be helpful to them and what you're going to offer for them. For example, in place of talking about yourselves, write about what the client is going to gain by coming to you.

00:18:49 Anita Avedian
And most importantly, when you are on online directories, keep them updated. The advantages of online directories is that it helps clients find you. A lot of these sites are very popular, and they're going to be the first that come up on that page on the Google search, and it's going to increase SEO. There are costs to most of them. I think on the average, they run about $30 a month. And so that's something just to be aware of. This is a list of the popular therapy directories that I know of. I'm sure there's plenty of others, but these are the ones I can think of. I think Counselingcalvania.com just comes along with your CAMFT membership if you're a CAMFT member. And all the other ones, I'm pretty sure the top two are about 30 a month, if I'm not mistaken, and the rest kind of just vary depending on which ones you're on. But again, these are all great for clients to find you online. Try out different ones. Psychology Today, actually, if you're not on it, you actually get six free months, free.

00:19:52 Anita Avedian
So really take advantage of that. Why not six free months of free membership on an online directory and see how many people end up calling you through that? It's really a great way of doing that. Okay, and then some additional helpful sites to know there's formsite.com. Actually, I think Dr. Bruce Gale is one of our participants today, and he's one who introduced me to that, and I've loved it and have been using it ever since. And that's a great piece to help you create forms and templates, intake forms and such for clients and be able to integrate that with your website. There's also Woofu.com. There's Google Forms you can use to create templates and forms for your website. PayPal, I've been very happy with. I have PayPal on all my websites, and that's how clients can pay for what they may owe or prepay for an intake through that. There's also Google Maps. Again, a great way for SEO. So have Google Maps on your website, if you can.

00:20:51 Anita Avedian
And there's Twitter for live updates, and that's something you may want to implement to be integrated with your website. And that way anytime you post onto Twitter, it comes up and shows on the feed on the website, keeps it active. And if you have ever considered having an app, I know we had developed an app once for Anger Management 818. It is so helpful for clients to have certain tips and the live calendar to know when groups are canceled and such, but really something you can consider. We don't have that anymore. But I thought it was a great thing to have. But really think of if that's something you want to have for your own company, if you have an agency or groups of clients who you want to help out with tips and scheduling and things like that. But you can also have an app that will help that could be designed to help your practice grow. Monica is asking, okay, so I'll answer the questions at the end, by the way, unless Rachel is going to answer them for you. Just so I can get through all of this information within a 50 minutes period and save Q and A at the end. So the app is usually helpful if you're servicing the age group of 30 and under.

00:21:55 Anita Avedian
Keep in mind, the older generation, we're not as comfortable with using app. We'd rather be on the computer, see this big screen. But for kids and teenagers and young adults, it's all about apps and what's in their hand with the smartphone. And the costs are going to vary depending on the app. What it cost us was only $99 for the first year, not realizing that afterwards, they're going to charge us over $100 a month for keeping it. So that's why we dropped it. All right, let's go into social media. And social media. Just thinking about whether you use social media. Not all therapists are comfortable in using it because of the confidentiality and who's going to know what it does refer to the means of interactions among people in which they create, share and exchange information and ideas in virtual communities and networks. And that's Wikipedia's description.

00:22:48 Anita Avedian
And Merriam Webster says it's forms of electronic communication as websites for social networking and microblogging, through which users create online communities to share information, ideas, personal messages and other content such as video. So when we talk about social media, this is really what we're covering. Again, briefly for right now, let's quickly take a look at some laws and ethics of social media. There's liability, this is a real big one. So what if I write a suggestion and someone uses it? Would that make me liable? I see people talking about Facebook, so let's say in the Facebook groups we see this happen quite often actually. There's legal questions asked and let's say I answer them, am I going to be liable if the person takes my suggestion and I can't be the one to say yes or no, but that's always a possibility. If we're offering advice and we're professional, I think we're liable to some degree. Be very careful.

00:23:49 Anita Avedian
And this is something we see quite often on the Facebook groups, even though I absolutely love them and I use them often, it's something that when I see I kind of cringe because I get scared for the person writing it. There's a lot of fees being discussed on those Facebook groups and we just have to be very familiar as a therapist about the antitrust laws. People ask, what do you guys charge? What happens if someone doesn't pay? How do you handle it? Anything with fee discussion, fee setting locations? Try do your best not to pose those kind of questions, especially through social media like that, because you can get into a lot of trouble, not only the person answering them, but also the people involved in the group and what has been recommended. I know when I went through the CAMFT Leadership Conference last year and they did an entire presentation on antitrust laws, that even if you're a member of that group, it's best to say we shouldn't be having this discussion, so that it relieves that person off of any liability. And we'll talk about this with Shrinksync.

00:24:47 Anita Avedian
But part of why we created the Shrinksync app is also to create a safe platform so that we can monitor and make sure people don't post things that may get others into trouble, as well as the person who's asking the questions. So if you do see those inappropriate discussions, you could just write, I don't think we should be having this discussion, or just a friendly reminder about the antitrust laws. We can't talk about fees. What about confidentiality with laws and ethics and social media, what is confidential, what's not? And be very clear about social media in your disclaimer consent form, in your intake, or in the consent form that you have a client complete. And when I say that, I mean I have a whole social media component that says please do not befriend me on Facebook or LinkedIn, I let them know I would rather them not like my page or follow me because of my concern of the breach of their confidence. I'm pretty clear about what I have in my consent. You can't control much.

00:25:45 Anita Avedian
I can only control not becoming their friends. I can't control if they're going to follow me on anything except for tell them this in my consent. Also, something else I've noticed often is a lot of interns are writing MFTI. And if you look at the board of behavioral science regulations, it's a huge no no. And the only time that that could be written is if it's pretty clear on that same page that the full name MFT registered intern is spelled out. So it could be very misleading. This is something we've been seeing pretty often in the last year, which is a little bit scary, both for the intern as well as the supervisor, because both going to be liable for that. So these are some dangers with the social media is you have to be really updated with what is legal, what is not. And I think there can be some concern with when you keep seeing other people writing MFTI, for example, all of a sudden you think that's okay because so many others have done it, and it's really not.

00:26:41 Anita Avedian
So be very careful with what you're putting out there when you're posting things or requesting things and what your name looks like, period. All right. And then about thoughts and feelings about using social media in your practice. You want to keep an open mind before deciding what you want to do. Figure out what platforms you want to use. You don't have to use all the platforms. Start with one. Start with Facebook, or start with LinkedIn or Twitter, whichever is your preference, and see if social media is really helping your practice. Not everybody wants to use it. Not everyone is comfortable with it. Some people are excellent at networking, for example, going to association meetings and doing that. And so these are things to think about. Just because I'm here saying how great social media can be for your practice doesn't mean you should go do it unless it's something that's going to be fitting for you and something you're going to be able to keep up with. Okay, so some pros and cons of using social media, some advantages to that is it could spread your message quickly, easily, and it's free.

00:27:47 Anita Avedian
Most of social media, when we use it, it's free. How great is that? In the past, we had to create postcards and stamps and mail it to thousands of therapists just to gain the same type of audience. Now that can be done within minutes. So it's a great way for that to occur. Exposure to potentially millions of people. You provide useful information to the public. Again, what are you posting? What information are you providing? Are there helpful tips. That you're offering to the public. For example, is there a blog entry you've done that offers some sort of clinical tool or something that is like a tip, a stress management tip that you're offering others? It's also a great way to help promote your business if you're starting a new group. I see that often with people posting, hey, I have a new group starting and here's the specific focus. What a great way of getting that out.

00:28:38 Anita Avedian
And of course it increases your visibility and some disadvantages. I'm sure some of you have noticed, including myself, sometimes I post too many posts onto Facebook Groups or LinkedIn and there's others who potentially post on a daily basis. And when that happens too frequently, it can actually become a turnoff to some other therapist. So be very careful with how often you post and what you're posting and is it all about me and marketing? Or is it also about helpfulness and being there for others? Also, some disadvantages of using social media is you're going to have to deal with patients who try to friend you online. Setting boundaries. What information are you going to provide to them when they're requesting your friendship? And you're going to have to do that respectfully and nicely. And another thing is using social media can be time consuming. On the average, if you're spending 15 minutes to 30 minutes a day, that's great. Some people spend hours a day, some people spend maybe half an hour in a month.

00:29:41 Anita Avedian
Get into it and start small and see what's working for you. I like the 15 to 30 minutes a day, if that's at all possible. And you also need to follow through and do some upkeep. So if you open an account and there's absolutely no activity, what good is that? And so you want to be able to keep something active once you have it started. Don't stress on that too much. But if you can, for example, blogging, you want to do like a weekly blog. In preparation for use of social media, be sure to have a functioning website. One of the main purposes of social media is to promote your website and attract people to come and get your SEO to increase. Also, you want to set up Google Analytics to determine which platforms are actually translating into referrals. So if I go into my Google Analytics, I'm going to see if people found my website through my LinkedIn posts, my Facebook post, or Twitter post. And that's a great way for me to know what to focus more on. Of course, a professional picture of yourself.

00:30:38 Anita Avedian
Make sure you don't put a picture with someone cut out that you have your arm around. I'm joking, but no, I'm serious actually. And then have your business contact information. I see some websites and there's no email address or phone number, no way of someone contacting them. Don't be that. Don't get too scared about putting some sort of contact information up there and also understand why you're going to do something before you do it. So if you're going to get onto Facebook, why are you choosing Facebook versus LinkedIn? Just get more of an understanding about the different platforms and see which one actually works better for you. And here is a list of the different social media platforms. My personal favorites: I love LinkedIn and Facebook, and then of course, I try to do a monthly newsletter at this point. I've had Twitter for a long time and I'm just not the biggest Twitter user, and that's just who I am. I know Rachel, my counterpart, loves Twitter, and she can talk to you a lot more about that.

00:31:35 Anita Avedian
But I personally am more about LinkedIn and Facebook for the most part. I'm not going to talk about this. And, oh, Bruce is saying you can also see how people found you through the analytics section on your contact form on products such as formsite. Absolutely. I agree with you, Bruce. So these are some Twitter resources if you are using Twitter, and there's Hootsuite.com and there's Socialoomph.com, Tweeadder.com. Anyway, so you have this list and you can see what they're about. You can check out the different websites. As I mentioned, you'll have these slides so you can visit these websites later on if you have a Twitter account to help you through that. Facebook, let's be friends. So in order to have a Facebook business page, you do need to have a Facebook personal page. A lot of therapists get concerned of, if I have a personal page, our clients going to see that. Look through the privacy settings, make sure everything is set up properly in terms of privacy.

00:32:33 Anita Avedian
And if you're not sure, you can just talk to another therapist who's familiar with it or talk to Rachel or I, and we can do some consulting time with you regarding any setups around that. But you do need to have a personal account. And then through your personal account, you can join all the different therapy groups and create your business pages. You get to connect with mental health professionals through Facebook, get to like their pages and ask for that in return, if possible. Joining the different community groups - I think right now there's about six, seven or eight different therapy community groups on Facebook, and most of them are in Los Angeles. I highly recommend joining them. Most of them have the same people involved. And so what you will see if you join all of them, is you're going to receive one person posting on the same post onto all six of the groups. So if you're okay with receiving or posting on all six like that, that's fine too. But I do recommend you checking those out. Who do you want to like your page?

00:33:30 Anita Avedian
Is it clients you're wanting to follow? You or other therapists? I personally prefer therapists to like my page, and I want to make announcements for CEU events or workshops that I offer through my business page. I don't know if I have clients on there, but that's not what I try to reach for clients to want to like my page. And the kinds of information I share on there-Sometimes I'll put some helpful quotes that are nice, inspirational. Sometimes I'll put to you events or I just publish my book. So I post that up there. Again, most of my followers are therapists, so it makes it easier for me to want to promote to them. And any blog posts or newsletters I'll post on there as well. And you will have the option actually to not permit others to make comments. This is something I really want you to consider setting up because once you have people making negative comments, it's very difficult to remove something like that. There's different settings that's, again, something for you to look into, but there are privacy settings you can have up and that's an option you're going to have for that.

00:34:36 Anita Avedian
LinkedIn. I absolutely love LinkedIn. Even though they changed their system a little bit regarding the emails and messages, I think LinkedIn for me has always been one of my favorites. It's a professional group and they have different groups for interests. For example, there's links for strength. There's Southern California mental health professionals, all sorts of therapy groups up there. And what I recommend is if there's a need or if you see that, let's say you want to meet other therapists who specialize in trauma. So you just start a LinkedIn group. First, search for it to see if it exists, and if it doesn't, you just create your own group and start inviting other professionals to be part of that and there you have something that you're starting that is part of your specialty. The types of groups, I actually started on my own because what I realized for most of the LinkedIn groups, people are posting clinical discussions, which is great, and I love that and I want to learn through that.

00:35:28 Anita Avedian
But I also wanted to figure out a way that I can promote CEU events because I was part of so many professional associations. I wanted to figure out a way to disseminate the events, the announcements, through the group. So I decided to create a group called CEUs for Mental Health Professionals in the greater, typo there, in the greater Los Angeles area. And that way we can post CEU events in there. And there's about 500 people in there. Great. What a fast way of getting that information out. I post something in that group. It emails everyone in the group that those are new posts around the CEU event. I listed the other few that I started. I think I have five that I started. But this is something you guys can do if you see that there's a group that's lacking or missing that you would like, just get it started. Be the pioneer behind that how to use groups.

00:36:21 Anita Avedian
You can start discussions or you can participate in the group discussions that are already existing. It's a great way for you to share your blog posts and newsletters, and you can send people private messages. So it's a great way of connecting with other therapists. If you want ideas or post questions, you can do so in the specified groups.

00:36:41 Anita Avedian
The caution here is, I was just reading what Rachel wrote, is that what you'll write will be reflection of you. So again, try to be politically correct. I see some bullying going on and it does not look good, both on the Facebook groups and on the LinkedIn groups. It's not that common, but it does happen. So be very careful when you're actually disagreeing with people, how you're disagreeing. I noticed therapists getting defensive pretty quickly and using attacking language, and for me, all I see is, oh boy, this person doesn't know how to handle themselves, especially in a public setting like this, and it stays up there. That's it. And that can be used against you. So just kind of caution yourself around that. There's endorsements building rapport on LinkedIn, which is great, and recommendations that people can recommend you as a therapist on there, which again is great. Announcements, pretty much any announcements I do, I put through Facebook, LinkedIn, as well as Twitter, and that's my way of doing that. Blogging. All right, I hope most of you are into blogging or interested in it at some point.

00:37:47 Anita Avedian
Blogging is wonderful. It's a great way for you as a therapist to get your special ideas out. Think about what your goal is for blogging, whether it's to gain clients or if you want to obtain speaking opportunities. So if I'm completely blogging on social anxiety, and I've been blogging on that every week for a year or every month for a year, and there's associations who are potentially seeking for a speaker on social anxiety, they may think of me as the expert because I have a blog around that. And so that's what I mean when there are speaking opportunities. Peter, you're asking, 'how do you start a blog?' Maybe we should do something on blogging very specifically.

00:38:28 Anita Avedian
But once you have a website, you can integrate a blog into there like a Word Press site and create articles. The articles can be about two paragraphs or three paragraphs, informative, and you just post that. It's a lot more than that, but that's just a quick overview. The blog can be very specific or general and pros and cons to each. So, if you're a therapist who just wants to provide different information you have, social anxiety, eating disorder, anger management, so forth, so forth, you can do that. But I think it's very helpful when, let's say you have a general specialty. If let's say you're mostly about I'll use mine, for example, anger management. So we incorporate stress management, communication skills, listening skills, empathy emotional intelligence. So you think about all the breakdown of components within anger management and start putting blog posts around that. And then frequency. How many posts at the minimum?

00:39:22 Anita Avedian
Or can it be too many? I personally, I like the either every week, every two weeks, or monthly blog post. I think that's fine. You don't want to do something daily, it becomes overwhelming to be on the receiving end of that. But again, some people like that. And you want your blog to be informative, engaging, connecting with other therapists, conversational. You want it to be automated, meaning every week it's going to go out, or every month it's going to go out. And you can set it up as to how often you want it to go out and what day and time, you want it to be something timely. I know people who have amazing blogs out there. Let's say we'll say every Monday 9:00 a.m., my blog goes out the entry and you could actually put all the entries in a month in advance and set it up that way. And you want it to be simple. What is this other, oh, sorry Bruce, I just read your little comment there. And then think about who is your audience. If you are blogging, is that going to be for your clients, for the general population, or is this for the therapist?

00:40:21 Anita Avedian
So through my Constant Contact account, I have my little folder of certain information just goes out to the clients and another blog will go specifically to therapists and some go to both. And so figure out who your audience is and make sure your blog is designed to be okay for those populations. And how do you get people to sign up to read your blog? And one way I like to think about it is to offer a free product of signing up. For example, here's an ebook or a worksheet read through this worksheet. But hey, sign up for our blog to get on our newsletter. And what's a blog about? Informative articles is always helpful. People love information. Highlights about your practice, perhaps you just hired a new intern or you started a new group community work that you're doing. And I would recommend for you to read or review other therapist blogs. I think it's great to see what's out there and what seems like it's something that is more along the lines that you would like. Use RSS, which is Real Simple Syndication, I'm not going to get into that right now.

00:41:23 Anita Avedian
And having blogging websites. So there's Blogger.com, Wordpress.com Squarespace.com, and I wrote the descriptions next to each one so you can have an idea of where you can get started with creating a blog. And then there's Technorati.com and it's an index of all the blogs in the world. If you do have a blog, make sure you list your blog on there so people can find you. Again, it's about how people are finding you. Newsletters. This is again something I would recommend, and in fact, your blog post can be a part of your newsletter if you want to incorporate a couple of the articles you've done, along with some announcements that you have or some association you're part of and you want to announce that event. And again, our newsletter is going to be sent out daily, weekly, monthly, or bimonthly, and perhaps even inviting guest authors. So, let's say it's not your particular specialty, but you wanted to add something, invite another specialist to come and offer that for you.

00:42:20 Anita Avedian
And what you want your newsletter to be - Informative, you want it to be timely, automated, interesting? Is it simple? Is it engaging? And then there's Listservs. I'm pretty sure a lot of you are on Listservs already. And if you are part of an association such as CAMFT, there's already a Listservs going on or GAMPHA has a Listservs. The Listservs are really a number of therapists who are part of a Listserv. And there's community discussions, say I have a question about a particular diagnosis, or how do you treat someone with schizophrenia? I may post that up there just to get some ideas or some tools to help someone with stress or anxiety. And so this is a great way of getting, receiving, asking questions and engaging discussions. Some of them are okay with you making announcements, but for the most part with Listservs, they're kind of careful with not doing marketing stuff as much as clinical information.

00:43:16 Anita Avedian
But still, it's a great way for people to associate your information with your name and contact information.

00:43:25 Anita Avedian
So, tools for automation, these are just another list. And why I wrote this here is because if you have a blog or a newsletter, and once you've done the blog post or the newsletter, you've designed it, let's say through Constant Contact or Blogger.com or whatever it may be, you can actually set it up with my one writing of that post or newsletter that I can now disseminate that within 30 seconds through one of these tools or through my Constant Contact system, and within 30 seconds it's already on Facebook, LinkedIn, Twitter, and wherever else I may have interest for it to go. What a fast way disseminating information. It's really a wonderful thing. Just make sure what you're writing is going to be appropriate to your audience. So you have these websites and information here. So I'm sorry, are there questions? I'm going to come back to the questions, let me just get through this and we'll come back to it. I left ten minutes in the end to answer all the questions and in the meantime, Rachel can potentially answer some of those.

00:44:27 Anita Avedian
So Shrinksync and its benefits I do want to introduce Shrinksync, since this is now going to be one of the newer versions of a different platform for digital networking and marketing. It is a digital networking hub for psychotherapists and treatment centers. It's free for therapists. If you're a therapist, you can join for free, have your colleagues join for free. You get client referrals and you get to find other therapists who can potentially see the clients that you have interest in to help them out, to be able to refer them to a therapist that you trust. And it's a great way of staying connected through the community room. There's discussions that occur in a community room, just like with Listservs and announcements. It's really a combination of different discussions and questions that are posed there and it's also a great way to stay current with the various CEU events. And I'm going to break this down a little bit. So all of you are familiar with how to navigate through Shrinksync, our app.

00:45:26 Anita Avedian
And first you want to look at what's in your inbox. So the inbox is that very first icon that you click on with Shrinksync and you're going to see all the different requests, speaker requests, job postings or announcements. There's going to be client referrals, which is what we really want to help build our practice. And so if you do see a client referral come through, someone seeking for a therapist who can work with children with social anxiety or autism. And we have Dr. Bruce Gale here who can respond to that, so and we'll talk about how to submit a sync. And that's basically also on that front page where there is a little icon that says to submit a sync. And you can put out your information of what you're looking for, the type of therapist, what insurance they take, or if the person can't afford much, then you can say looking for someone on a sliding fee scale. And there's also how to respond to a sync, which I'll show you the image of that.

00:46:23 Anita Avedian
But when you see this come through in your inbox, it's a great way of tapping onto the request and letting them know to consider you as a therapist because you fit the bill of what the request is, such as your child psychologist who's going to be able to work with a child who has anxiety issues or social issues. So here's an image of this. This is a product instant utility offered upon login. And if you notice for your profile, you can edit your profile. That first image you're looking at is Rachel. It's her maiden name Goukassian, and she's going to have specialties included there. And so that way when I'm searching for someone who specializes or who let's say is out in Beverly Hills, she's going to pop up for what I'm looking for. And then you get Leads. So you see on that second icon, the middle image, that's what you're going to see on your cover of your film when you look at all the entries that come through that day, not just through strength sync, but through others as well, and you get to respond.

00:47:29 Anita Avedian
So in that third image, you get to see the back side of it. You get to see what the inbox looks like and what kind of an announcement it is, whether it's a client referral or job and internship. And that overlapping page is what you see when you want to respond to a referral request. So, it's really simple. If it does feel complicated, we are more than happy to answer any of these questions for you. Our team, including Eric, Rachel and I, are available to try and help you through this. How to submit a post for job opportunities you saw on this back page over here on the very top, there's a little section that reads Submit Sync. So you're going to click on Submit Sync and then it's going to ask you about the job. What I recommend is to have a contact information. If there's a link, a website link, that's the best way of getting people drawn back to that information because it's an app that's limited of what you're writing. So if you have a website link, it's the best way for someone to get a lot of information about the job posting and the second one posting CEU events.

00:48:29 Anita Avedian
This is wonderful, especially if you're offering a workshop yourself as a therapist, or if you're part of associations and you're trying to help them grow. Get your associations or a few people from your association to be on Shrinksync so the person who's responsible for marketing can get and disseminate the information about events out. We have over a thousand subscribers at this point, primarily in LA. But throughout California, and we're opening up nationwide. So we're growing really quickly and it's a great way of announcing CEU Events for free to all these therapists. How to best use a community room? You know that's a place you can introduce yourself and talk about new groups you're starting or office space you may have. Just be careful not to write anything around fees because of the antitrust laws around that, and submitting blog posts. If you guys are interested in submitting a blog post to us, just email the ShrinkSync and we will put that up on our blog site.

00:49:22 Anita Avedian
At some point, I think we're going to try to do something weekly. And as mentioned a week ago, we already put up what Rachel wrote about the SEO and website. And then if you notice in the second icon of the Shrinksync app, there's an area where you can actually search for agencies and treatment centers. It could be residential, it could be IOPS. Those are wonderful ways to try and help your clients get into treatment pretty quickly. And all you have to do is type in the city and the type of problem that they may be facing, such as addiction. And you just type in the information and it'll draw up all the treatment centers that focus on that that are in the area. And the creating your profile - This is something you can click on the last tab on your phone, and there's a section where it'll help you create a profile and include the specialties you have and the location and locations you're in.

00:50:23 Anita Avedian
And if you need troubleshooting help and whether you're not able to log in, which is really one of the bigger problems people face, or if you want to remove your submission, just contact us and we'll help you through that. For example, if you submitted a thing for client referral and then you realize you didn't really need that, you want to remove that, or you've had too many responses and you want it off the announcement, you can go in and actually remove the listing. And there's two ways of doing that. But again, if you need help with that, let us know. We have FAQ listed on the website, and that's the website link to have your questions answered around Shrinksync. So, in summary, we reviewed about digital marketing, the importance of having a good website, because that's going to be a reflection of you and your practice. Explored popular ways to be found online, including a little brief piece about SEO, understanding the various online platforms for marketing, the therapist search directories, making sure potential clients can find you, and a little bit about navigating through Shrinksync.

00:51:21 Anita Avedian
And if you do have questions, both Rachel and I, questions about wanting to learn a lot more. Both Rachel and I are available for consulting. She's really the very tech savvy person, and I can help more with the marketing and networking. And so that's our private practice essential website link that's on there, and we have our phone numbers on there. And really what we would love for you guys to do, if you can, is once we're done with this webinar, we'd love for you to invite your colleagues to join for free as therapists because we're trying to grow our community, and the more people we have, the better business for everybody. So thank you very much. I'm going to look through the questions right now and see what I did not answer and see what Rachel answered.

00:52:04 Anita Avedian
And once you close up the webinar, you're going to receive an evaluation that we would like for you to complete if you wanted the CEU. And that's something Rachel will send you guys as soon as she receives the evaluation. Yes. Word Press. There's a Word Press site.

00:52:27 Anita Avedian
Susan, let me see. Okay, so there are technical stuff that were going on there. Thank you, Bruce.

00:52:44 Anita Avedian
I love Bruce's information here. Okay.

00:52:50 Anita Avedian
And I know Tony mentioned Facebook ads. There are Facebook ads that's kind of similar to Google Ads, LinkedIn ads. They all have it Yelp ads. And that's something that you can try out the different ones, see which ones have better hits for you. I have not used, actually did use Facebook ads, and it did not benefit me at all. I thought it was a waste for me, and I probably did something wrong, but I'm sure there are ways that are helpful. What else? Bruce you're asking if I use the standard business or enhanced version of PayPal. I think I use the business. If I'm not mistaken. I need to look I've never even looked into that. But I have different PayPal accounts, and I think all of them are business. And Facebook is much more costly. Personally, Google AdWords takes a lot more learning. And Google AdWords, you guys, Google representatives, are really there to help you. So if you do have Google AdWords, I highly recommend being on the call with them every month to update.

00:53:50 Anita Avedian
There's always new information, there's always new things happening with the Google search, and it's important to keep that information updated for you. And let's see who else wrote what.

00:54:07 Anita Avedian
I'm just going from the start with all the questions. Okay, Peter, I think I answered your question with how to start a blog.

00:54:19 Anita Avedian
And then yeah, this recording we're going to put onto YouTube and the Shrinksync website. Let's see.

00:54:28 Anita Avedian
Okay.

00:54:33 Anita Avedian
Oh, Susan. Yeah. You can create a profile on Shrinksync. I'm pretty sure you can do it through our website. If not, just do it through your app. But it's important to have a profile up there so that people know what your specialties are and you would come up. Oh, I just saw that. Oh, sorry. I see that we can't offer CEUs. That's true. I learned from this today. Yes, yes. Bruce, for MFTI, it's one of the biggest things I keep seeing. So just to make sure if there is an intern that they're actually spelling out MFT registered intern. And if you go on the BBS website, that's the way to spell it out. If it's MFTI anywhere on that page, on that same page, they need to have it written out that they're an MFT registered intern. But something to just really keep in mind. I'm really not a proponent of MFTI, even if it's spelled out somewhere. Because if that's the only place a person looked, can it not be misleading for the person to think that that person is licensed? They don't know MFT is a license.

00:55:39 Anita Avedian
They don't know MFTI is not a license. And so we always have to think as the public, are we setting ourselves up as misleading that we're licensed? And that's really what I have to share about that. I think some of you are writing some things right now to ask questions.

00:56:02 Anita Avedian
I hope you guys enjoyed the webinar. I hope this was helpful. I tried to get all the information in within an hour. Kind of glad I did. But keep in mind, again, February 10, 9:00 a.m., Rachel will be setting up the invite for that webinar for SEO on website. She's very knowledgeable, so I think you'll learn a lot about that.

00:56:23 Anita Avedian
And February 17, is navigating your kids digital life, and that will be with Mercedes Sanudillo.

00:57:01 Anita Avedian
Bruce, I see writing one cost 30 a month. The other does not.

00:57:14 Anita Avedian
I think you're talking about Psychology Today or, oh, I just saw all these other questions. Sorry. Hold on.

00:57:20 Anita Avedian
You're welcome, you guys.

00:57:29 Anita Avedian
Thank you, you guys, for the feedback, and I hope you guys have a wonderful day. I'll still stay on for any more questions in the next few minutes.

00:57:49 Anita Avedian
Yeah, Susan, we'll have it on our site in a few days. We'll have this whole pre recorded or recorded webinar on there. And, yeah, keep an eye out for the link that Rachel will send out. Thank you, Robin. I appreciate that feedback. And to everyone else, welcome. And Debbie, thank you. I'm glad it's been helpful, you guys.

00:58:21 Anita Avedian
Great. Okay, so any other questions, you guys?

00:58:29 Anita Avedian
I see Terry is writing, great. You're welcome. Karen and Terry. Well, I hope you guys have a successful day. Bruce self promote. I have a publication that came out today in Encyclopedia of Clinical Psychology. Bruce, you're going to have to do a webinar for us. Bruce will be on in March. We'll have to confirm with him first, apparently.

00:58:59 Anita Avedian
Bruce, don't get scared. It'll be great. I learned a lot from you, remember? So we'll have to just invite you in March and disseminate your intelligence of tech stuff with us.

00:59:17 Anita Avedian
All right, you guys. Well, have a wonderful day and I hope you'll take from this and start a blog or newsletter or get involved with social media in proper ways and that it will be very advantageous for you guys. Take care and thank you for participating with Shrinksync and tell others about our app so we can grow.