Janina Fisher on Innovations in Treating Trauma

Janina Fisher on Innovations in Treating Trauma

by Ruth Wetherford
Trauma expert and clinical psychologist, Janina Fisher, shares her wisdom from decades of treating clients with trauma and complex PTSD.

PSYCHOTHERAPY.NET MEMBERSHIPS

Get Endless Inspiration and
Insight from Master Therapists,
Members-Only Content & More


 

Enduring Conditions and Animal Defenses

Ruth Wetherford: Dr. Janina Fisher, you’re a clinical psychologist and expert in the treatment of trauma, author of the book, Healing the Fragmented Selves of Trauma Survivors, and have worked with many of the giants in our field—Judith Herman, Bessel van der Kolk and Pat Ogden and are currently an instructor at the Trauma Center, an outpatient clinic and research center founded by Bessel van der Kolk. Since trauma is such a overused, broad term these days, can you describe how you understand trauma?
Janina Fisher: There was a time when we defined trauma as an event outside the realm of normal human experience. Remember that?
RW: I do, yes. It had to be life threatening.
JF: Boy, were we wrong. We believed it was a rare occurrence. And we now know that 70 percent of the human race will be traumatized in their lifetimes, and probably about 40 percent will develop post-traumatic issues. So it is certainly far from outside of the norm. But over the years, the term started to lose its meaning in terms of its magnitude—now people talk about having critical and rejecting parents as traumatic, so I’m a little concerned that we have found the meaning of trauma and then lost it again, but I’ll tell you the definition I use:

Trauma can be a single event, it can be a series of events, or it can be a set of enduring conditions. Slavery was a set of enduring conditions, child abuse is a set of enduring conditions, domestic violence, war, the Holocaust.
It’s actually more common for people to be traumatized in the context of enduring conditions than to have a single event and have the rest of life be easy and smooth.
It’s actually more common for people to be traumatized in the context of enduring conditions than to have a single event and have the rest of life be easy and smooth. Then, that single event, series of events or enduring conditions have to overwhelm the individual’s capacity to cope and to activate a sense of threat to life.

It doesn’t have to literally be life threatening, like a bus barreling towards you as you cross the street. The key is that we feel a sense of threat to life whether we are capable of verbalizing it or not. Small children can’t say, “I’m afraid I’m going to be killed,” but their bodies can feel it.
RW: You’re talking about the subjective experience of threat to life. Your work focuses extensively on the brain’s reaction to it and the activation of the sympathetic nervous system. It seems like many more psychotherapists are trained in this area these days, don’t you think?
JF: Unfortunately what I hear from graduate students and from young therapists who’ve just been through training is that trauma wasn’t even mentioned in their graduate programs.
RW: That’s shocking. Well perhaps you could talk a bit about this aspect of your work for our readers who may be new to it.
JF: Well, when I first became interested in trauma in 1989-90, we still thought of trauma as being something that war veterans had exposure to and victims of sexual assault. We were still putting the pieces together and hadn’t incorporated more enduring traumas like child abuse and domestic violence.
RW: Neglect.
JF: Yes. Then 9/11 brought credibility to the concept of trauma and changed the whole world’s attitude toward trauma. Pioneers in the trauma field began to make sense of why patients could recover from depression, anxiety disorders, they could manage hallucinations and delusions, but they couldn’t manage post-traumatic reactions.

Bessel van der Kolk had this insight that “the body keeps the score,” that what was different about trauma was how it encoded in the body and activated the animal defense responses that we share with all mammals. People thought he was nuts. I remember people coming up to me and saying, “Stay away from that guy. He’s a nut case.” But over the years, research has proven him to be accurate.
RW: So what are those animal defenses that we share?
JF: There are 5 animal defenses: fight, flight, freeze, feign death, or submit and cry for help. Fight is basically anger. Interestingly, animals are much better at fighting than humans—that’s why we’ve taken up weapons. Then there’s flight, and again, animals are faster at fleeing. Animals play possum and human beings say things like, “I pretended to be asleep,” which is the human equivalent of playing dead. We freeze like a deer in the headlights and we cry for help. Humans are better at crying for help than mammals because we have language, but all animals make sounds to communicate to their fellow animals that they’re in trouble.
RW: How do those get manifested in the effects of trauma?
JF:
Clients who have chronic submission responses tend to present as chronically depressed, hopeless and helpless, ashamed, feeling less than, and because we call it depression, we don’t treat it as a trauma symptom.
The average therapist sees the animal defenses every day in the office. For example, clients who have chronic submission responses tend to present as chronically depressed, hopeless and helpless, ashamed, feeling less than, and because we call it depression, we don’t treat it as a trauma symptom. People who chronically have the freeze, deer-in-the-headlights response get an anxiety disorder diagnosis. They’ll report, “I’ve been having panic attacks, I can’t leave the house, I can’t drive the car more than a few blocks.” Those who have chronic fight responses can’t stop fighting, can’t stop being angry, engage in aggressive behavior including aggression toward their own bodies. Some people with chronic fight responses tend to be violent toward others, some toward themselves, and an even smaller percentage have both. They have aggressive responses toward others and they harm themselves.
RW: So these patterns of behavior in adult life correlate with the animal responses that we have as children in response to various kinds of trauma.
JF: Right. We have come to understand—and this is the essence of the body keeps the score—that when something bad happens to us, not just our minds, but our bodies become sensitive to related cues. This is why when people have a car accident they avoid the place where the accident occurred for months or years afterwards. Or sexual abuse survivors who can’t tolerate being in the company of men of a certain age. The body gets sensitized to anything that vaguely resembles the original event.

Body Memories

RW: Can you talk about how traumatic experiences are encoded in the brain differently than normal day-to-day events?
JF: In the first brain scan studies, which were conducted in the mid-90s, a small group of trauma survivors were asked to write a script describing a traumatic experience and then hear someone reading the script back to them while undergoing a brain scan. I think that’s pretty brave in and of itself.
RW: It sure is.
JF: What the researchers found, which astounded them, is that the part of the brain that remembers normal narrative memories shut down when they were being read the traumatic event—even though they themselves had written the script. The part of the brain that became active was a part of the brain that we’ve come to understand holds emotional nonverbal memories.
RW: The amygdala?
JF: Yes, the amygdala. For some reason, the amygdala on the right hemisphere side seems to be the center for traumatic memories. What this meant was that we couldn’t work with the narrative memory of the event because post-traumatic memories are held as non-verbal feeling and physical reaction memories—what I call body memories.
RW: Body memories.
JF: Yes. It literally changed everything about our thinking on trauma.
RW: It was revolutionary. Why isn’t it being widely taught in psychotherapy training programs?
JF: I wish that that research, which has been replicated many, many, times, was taught in graduate school and training institutes, hospitals and clinics, because most therapists still practice the type of trauma treatment that we were practicing in the late ‘80s and early ‘90s, which consists of asking people to remember what happened.
RW: Without a sense of what to do with it.
JF: Exactly.
The “talking cure” belief that if it’s talked about, it will resolve, unfortunately does not work with trauma.
The “talking cure” belief that if it’s talked about, it will resolve, unfortunately does not work with trauma. As patients talk about the trauma, their amygdalas and their limbic systems start to go crazy, they feel overwhelmed, and they don’t want to talk about it anymore.
RW: So they leave the session feeling very undone, and they don’t want to come back. You’ve said that you learned that the hard way, as many other trauma therapists did. So, if it’s not enough to just talk about it, what is enough?
JF: What seems to be enough is a variety of activities that help us to restructure our relationship to the memories—techniques, interventions, and experiences that help to slowly recalibrate the traumatized nervous system and animal defenses that are triggered by everyday kinds of stimuli. It’s two pieces: one is the body piece and the other is the feeling-memory piece.
RW: This gives a lot of creativity and flexibility to what the therapist does in the moment.
JF: True, but one of the difficulties, and the reason why I wrote the book, Healing the Fragmented Selves of Trauma Survivors, is that there’s a relatively large subset of traumatized clients who have what we call complex trauma related disorders—some of which are reflected in DSM, but many of which are not. Complex post-traumatic stress is not in the DSM. Dissociative disorders are in the DSM, but not in a very clear, usable way. And there’s a huge amount of literature that attests to the relationship between self-harm, suicidality, addiction and trauma. There’s huge correlations between them.

I happen to be a therapist who likes complexity—I like challenging cases—so I kept seeing people who, despite their best efforts, could not get sober, could not manage their suicidality, could not manage their anxiety, had treatment-resistant depression no matter what medication or what kind of therapy. I became intrigued by how to help these clients.

I had the opportunity to hear a theory proposed by Onno Van der Hart and Ellert Nijenhuis in the Netherlands called the “Structural Dissociation Theory,” which is a very well-accepted model in Europe. As soon as I heard them describe this model, the lights came on, the orchestra started playing, and I thought, this explains so much, including what we now call personality disorders, which are beautifully described by this model. It explains them as neurobiologically based, and that we all have a part of our brains, and therefore part of our personality, that keeps on going no matter what. No matter what disaster is befalling us, the left brain part of the personality just keeps on keeping on.

The “Going on With Normal Life” Self and the Traumatized Self

RW: You call this the “normal life part” or the “going on with normal life” part.
JF: Right. The authors call it the “apparently normal” part, but I didn’t like that language because it fed into my clients’ sense of having a false self. So I renamed it the “going on with normal life” self.

Repeated trauma can cause splitting in the personality such that we start to develop subparts representing the animal defenses.
And then the model says we all have a right-brain side of the personality that’s emotional, reactive, and nonverbal, which I call the traumatized part. They describe the way in which repeated trauma can cause splitting in the personality such that we start to develop subparts representing the animal defenses: a part that fights, a part that flees, a part that submits, a part that freezes, a part that cries for help.

For me, this theory makes sense of the most confusing of our clients. It makes sense of borderline personality where you see a very big cry-for-help response, but an equally big fight response. And in high-functioning individuals, a very strong going on with normal life self who’s actually quite ashamed of these big fluctuations between neediness and anger, and doesn’t understand them any more than the therapists do.

As you know, the problem often with psychotherapy is that clients want help but feel shame or defensiveness as we delve deeper into issues that they need to work on. What I found was that this language of parts helped my clients look at very difficult issues without feeling shame and defensiveness.
RW: Well there is so much pathologizing of this symptomology in our field and so much pejorative language around it. To have a language that frames the symptom as a creative solution to an early problem or trauma can be very relieving.
JF: Absolutely. It opens a door. I can talk to clients about how their fight part takes prisoners, right?
RW: Or stands up for a cause.
JF: Right. And then they’re free to say, “Yes, but it’s embarrassing because that angers drives people away.” Or I can say, “The cry for help part of you is just a little kid, and of course a little kid would cry for help.” It gives them a way to be in a relationship to these reactions rather than either being mortified and ashamed or saying, “What anger? I wasn’t angry.”
RW: It’s a form of psycho-education it seems to me. Can you talk about why that is so helpful?
JF: Well, I was trained in a traditional psychodynamic way.
RW: Me too.
JF: Most therapists from our time were, and psychoeducation didn’t have any place in psychodynamic psychotherapy. But when I went Judith Herman’s clinic in 1990 as a post-doctoral fellow, it was one of the major things she was recommending for trauma. She said that we had to educate clients, that it didn’t work for trauma survivors to have an imbalance of power. Aside from all the usual ways therapy can create an imbalance of power, there’s the imbalance of the therapist knowing everything and the client knowing nothing. She said, “Your job is to educate the client to make meaning of the trauma symptoms so that the playing field is more even.”
RW: In addition to balancing the power in the interpersonal dynamic that kind of learning activates the pre-frontal left brain. You begin to have a model and words for understanding what happens to you when you are triggered.
JF: Exactly. I learned that you can activate the prefrontal cortex when it automatically shuts down in the presence of a threat by getting people to be interested and curious.
My psychodynamic training was all about asking very complicated, beautiful questions, but I realize now my poor clients didn’t have the brain power to answer these very abstract questions.
My psychodynamic training was all about asking very complicated, beautiful questions, but I realize now my poor clients didn’t have the brain power to answer these very abstract questions. But when we just help people to be interested and curious, then things start to hum in the prefrontal cortex.

RW: Can you give some examples of how you might talk with the client that would encourage their curiosity about parts of themselves that they previously were too ashamed of or too frightened of?
JF: I start in the very first interview with someone. Most clients come in saying, “I’m here because I am depressed,” “I’m here because I’m having panic attacks,” “I’m here because I hate myself,” “I’m here because my relationships aren’t working.”
RW: They’re not coming to therapy to learn about the amygdala.
JF: Right. So in that initial conversation, I ask them, “When did these issues begin? When did you start to feel depressed? When did you start to have the panic attacks? When did it become difficult to leave the house?” And I say, “My guess is that something triggered that depression.”

Triggers

RW: You start looking for the triggers right away.
JF: I do that to help them be curious. They come in saying, “There’s something wrong with me because I can’t leave the house.” And usually within the first 20 minutes I say, “Wow, you must have been really, really triggered,” and they kind of go, “Huh?” That “huh” is what I want because it means that their fixed belief that there’s something wrong with them has just been disturbed.
RW: The idea that your difficult feelings are actually in response to something rather than just in your head without connection to the real world. That’s so reassuring.

JF: Yes, it is. At the same time, I want to be careful not to do a one-to-one correspondence to a specific event because most clients are suffering as a result of enduring conditions, and if they think they have to have a single event connected to every symptom, it becomes more difficult to work with them. I try very hard to connect the current trigger—like the death of the cat, or the fight with the husband—to the enduring conditions.

“The effect of living in a world where only the cat loved you is still with you, still in your body.”
So for the client whose cat died, I asked, “What did your cat mean to you when you were growing up?” And she responded, “The cat was the only person in the family who loved me.” “Well, no wonder it was triggering to lose your cat six months ago. The effect of living in a world where only the cat loved you is still with you, still in your body.” We connect the triggers to the enduring conditions, not to single events.

The Role of Empathy

RW: So your motive is to understand the experience from his or her point of view and you call that empathy. What is the role of empathy in your work?
JF: Well, there’s empathy as most of us have learned it in school where we say, “That must have been very hard for you.” The purpose there is to connect to the client’s pain and to say, “I get that these are not just bad events, they also caused you pain.” But I find that many traumatized clients have trouble with that kind of empathy because they’re afraid of the pain that we’re trying to evoke more of.

So I tend to express empathy more in terms of why it makes sense that they have a particular symptom. I say many times a day, “Well, of course, it makes so much sense. If you’re depressed, it’s easier to be seen and not heard, isn’t it?”

I have a long-term client who I’ll call Annie—not her real name, of course—who said to me once,
“Why are therapists so interested in every gory detail of what happened to us? Why don’t they ever ask us how we survived?”
“Why are therapists so interested in every gory detail of what happened to us? Why don’t they ever ask us how we survived?”
RW: That’s such a great question.
JF: What she was saying was, “If you empathize with how I survived, that’s going to be more validating than empathizing with how victimized I was.”
RW: That appears to many to be paradoxical.
JF: If the purpose of empathy is to resonate to our clients’ feeling states, resonating to their strengths can feel very empowering, especially if you’re someone who has felt unempowered, ashamed, hopeless, weak, and your therapist says, “Wow, you were a pretty ingenious little kid to have survived that.” There’s a feeling of empowerment there as opposed to when we say, “Oh, that must have been so hard.” That pulls for the feelings of vulnerability which are connected to feeling weak, helpless, hopeless.

The Contagion of Confidence and Calm

RW: This touches on what you’ve referred to as the contagion of the confidence and the calm of the therapist. It’s related to what we think of as the placebo effect in medicine. We know that when doctors have absolute belief that their methods are going to help us get well, and they’re focusing on the self-correcting immune responses and the strengths of our bodies, it has a strong positive effect on patients.

It’s so important to think of empathy not just as for the painful negative aspects of the self, but for the positive surviving parts.
JF: Absolutely. Certainly we want therapy to be a safe place for people to share their pain, but why shouldn’t it also be a safe place to share their pride, pleasure, excitement, curiosity? Trauma survivors can get deeply mired in the trauma the more they go for the grief and anger.
RW: And many trauma survivors don’t have a lot of sources of recognition and appreciation. They’re not coming in with stories of little triumphs through the day, so when the therapist does point it out and they see that it’s not just window dressing, that it was substantive, that’s so affirming.
JF: Exactly.
RW: Would you talk about the role of the person of the therapist?
JF: As you know, it’s a topic near and dear to my heart because what I’ve come to realize over my 37 years in this field is that we are really the instrument of psychotherapy.
Research shows that the relationship with the therapist is still the strongest variable affecting therapy outcome, regardless of the model being used.
Research shows that the relationship with the therapist is still the strongest variable affecting therapy outcome, regardless of the model being used.
RW: I believe it.
JF: We have so many models now which are wonderful, and I like most of them, but we have a tendency to assume it’s the model helping rather than us helping. But who and how we are makes a huge difference. You and I are probably both old enough to remember the blank screen approach.
RW: I hated people who were blank screens.
JF: Me, too. And now we understand that if the therapist is a blank screen and the client has suffered abuse or neglect, it is immensely triggering and even threatening. It’s not going to feel neutral. Freud’s idea was to be neutral so as not to be threatening, but that’s just not how it works, particularly with clients who’ve experienced trauma.
RW: Carl Rogers pointed out that there is no neutrality because a blank screen or silence or non-responsiveness is itself a response usually perceived by the right brain as rejecting, or at least disconnecting.
JF: It’s funny, I didn’t love Carl Rogers when I studied him in graduate school, but I’ve really come to appreciate his work because he got this idea that the therapist is the instrument, and how you play your instrument makes such a difference in the client’s receptivity.

RW: How do you think therapists can be more personally connected with clients?
JF:
We are both triggers of hope and triggers of fear
. First and foremost a willingness to be curious rather than to assume from the diagnosis or from the presenting symptoms that someone is in a certain category. The willingness to assume that every symptom represents what was once an adaptive way of coping with and surviving their circumstances, because we become who we become in a habitat, in a context. Lastly, and this is hard for therapists, but remembering that we are both triggers of hope and triggers of fear.
RW: Can you say more?
JF: If we get caught up in seeing ourselves as triggers of hope or safety only, we’re going to pathologize the client when the client gets afraid. I’ve had very few clients in 37 years who’ve actually said, “I’m afraid,” but I’ve had lots of clients who’ve been reactive and angry, defensive, resistant, suspicious—all of which are expressions of fear.

It’s very important to know that even as we are building a relationship and creating safety, we’re also triggering fear. So we do our best to notice those moments that we can hear or decipher the fear and then do what securely attached parents do, or what dog owners do: Change your body language and your voice to help change the child’s state, the dog’s state. We do it without thinking.

I watch how the client responds to what I just said, and then I vary my next remark based on the data I just got. So I say something and I see the client looking a little uncomfortable, then I’ll smile and say something light and see if the client’s body relaxes. Or I might say something that really underscores how bad they feel—“Wow, I get that this is really awful”—and see if the body relaxes. Or is this a client who feels defensive when I say, “Wow, this is really tough.”

They feel safer not because I have good boundaries and a therapeutic frame and all those good things, but because I’m scaring them less and less.
They feel safer not because I have good boundaries and a therapeutic frame and all those good things, but because I’m scaring them less and less.
RW: In my consultation with trainees where we’re going over audio or videotapes, it’s usually apparent that when the therapist says something that sounds pejorative or a little bit pathologizing, there’s a loss of empathy because of some perceived threat, and it’s often unconscious. An angry client, particularly a smart, articulate angry client, can be a trigger for the therapist. What are some things that you do to help yourself stay non-defensive? Not triggered?
JF: I sort of have a split screen. I’m very attentive to the client and to resonating to the client’s frequency, but I’m keeping an eye on me, too. There are certain things that are little red flags for me like a particular kind of client who’s very sweet, helpless and depressed. I’ll have this feeling—I don’t act on it—but I have this feeling that I just want to take the client in my arms and go, “There, there.” When I notice that feeling, I know that I’m being inducted in as a savior and rescuer, and I know that that’s not a good road to walk down.
RW: So step one is to recognize your own reactions and to know in advance what your own triggers are.
JF: Absolutely. With very angry devaluing clients I’ve learned to notice a couple of things. One is my body tension. I had a very, very devaluing client a couple years ago, and one day I noticed that even though I was very rational and accepting, my body was tense—it was defensive even though I was forcing myself to be appropriate.

So I deliberately relaxed my body. And when I relaxed my body, the whole conversation went better. Another time with the same client I noticed that I was walking on eggshells. And even before the session, I was worried about what I was going to do that was going to piss her off. You know the feeling.

“Oh my God, there’s no therapist in this therapy”

RW: I do, yes.
JF: And then I brought myself up short and I though, “Wait, I’m more like a kid with a parent in this therapy; she’s the grown-up, I’m the kid. Oh my God, there’s no therapist in this therapy.”
RW: How did you bring yourself back to your normal functioning adult self?
JF:
The little kid may be inside you, but the therapy doesn’t need the little kid.
The therapy needs a therapist. I just stayed with this kind of imperative: A therapy needs a therapist. And I reminded myself, “Janina, you know how to do this. You know how to be the therapist and connect to that part of you that is the therapist. The little kid may be inside you, but the therapy doesn’t need the little kid. The therapy needs a therapist.”
RW: So first you recognize it and then you remind yourself. I think this can happen numerous times during a session with a difficult client. It’s helpful to recognize it, and then relax the body, use your sensory motor knowledge and take some deep breaths, and remind yourself, for instance, that the angry client is triggered by something.

JF: It helps the counter-transference to remember that the anger is a part of this client but that if there weren’t other parts of the client attached to me, the client wouldn’t be here.
RW: What about the “heal thyself, doctor” aspect of being a good therapist? Knowing ourselves and working through our own triggers?

JF: I think we have to be careful not to pathologize ourselves either, but to think of therapy as a collaboration between two human beings. Of course it’s going to be complex because we humans are complicated. It’s like being a parent. You yell at your kid, you feel badly, you think, “Oh my God, I’m a terrible parent,” which usually makes things worse as opposed to, “I just yelled at my kid. I don’t want to do that. How do I calm my body?”
RW: And then repair.
JF: And then repair, right. If you were asking me offer advice to therapists about what I think is the most important piece of the equation, it is the same message I’d give to parents: Worry less and enjoy them more.

RW: Worry less and enjoy more.
JF: Yes. Even when they’ve self-harmed, they’re angry at you, they’re contemplating suicide, everything is blowing up—try to enjoy them because that is healing in and of itself. Our clients have not had the experience of being enjoyed in their difficult moments.
RW: That’s so true. I want to thank you so much for taking the time to be interviewed and sharing your wisdom with the Psychotherapy.net audience.

JF: Oh, it’s a pleasure. Thank you.


© 2018 Psychotherapy.net, LLC
Bios
Janina Fisher Janina Fisher, PhD, is a licensed clinical psychologist and instructor at the Trauma Center, an outpatient clinic and research center founded by Bessel van der Kolk. Known for her expertise as both a therapist and consultant, she is also past president of the New England Society for the Treatment of Trauma and Dissociation, an EMDR International Association Credit Provider, a faculty member of the Sensorimotor Psychotherapy Institute, and a former Instructor at Harvard Medical School. Fisher has been an invited speaker at the Cape Cod Institute, Harvard Medical School Conference Series, the EMDR International Association Annual Conference, University of Wisconsin, University of Westminster in London, the Psychotraumatology Institute of Europe, and the Esalen Institute. She lectures and teaches nationally and internationally on topics related to the integration of research and treatment and how to introduce these newer trauma treatment paradigms in traditional therapeutic approaches.

Janina Fisher was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.

Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.

Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.
Ruth Wetherford Dr. Ruth Wetherford is a San Francisco–based psychologist who has been practicing psychotherapy and teaching for the past 30 years. She specializes in family of origin work with individuals, guided imagery and Eye Movement Desensitization and Reprocessing. Her website is www.drruthwetherford.com.

Ruth Wetherford was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.

Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.

Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.