Wednesday, November 16, 2011

Classroom Bully Pulpits; When The Bully is The Teacher.

Bullying is a problem that affects all of our children - those who bully, those who are victimized, and those who are witnesses to interpersonal violence on either an emotional or physical level.

"Statistics on the rates of bullying and cyber-bullying vary between studies due to the measures used, the questions asked, and the population studied. However, the general consensus is that one out of three children are bullied at school, in the neighborhood, or online and that one out of three children bully others.

Additionally, the rates of bullying vary considerably across countries. Approximately 9% to 73% of students reported that they have bullied another child, and 2% to 36% of students said that they were the victim of bullying behaviors. When young people, aged 11, 13 and 15 were asked to report on their experiences with bullying and victimization within the preceding two months, prevalence rates ranged from 1% to 50% across 25 countries in Europe and North America" ( ).

As a psychologist I've watched anxiously as this long time behavior in our schools has appropriately been singled out for necessary change.  I believe we are on the verge of getting it right, now that our understandings go past the proverbial bully and victim and encompass the wider reality that there are bullies, victims, enablers (the rest that watch and quietly support it through inaction) and others who, through social castigation, help fill the ranks of both bullies and victims.

There is however, a major element missing from this equation.  What about the classroom teacher who openly bullies in the classroom through emotional intimidation and ridicule?  I bring this up after once again listening to the story of a High School client who came to my office because of what she and her parents identified as depression.  I wish I had kept track all these years of the vast numbers of kids such as this client, who are and were honor students, good athletes and by all outward appearances, strong kids, who inside are being emotionally crushed under the weight of fear at school.  Before you go off half cocked, no I am not saying all High School teachers are bad in some way, nor am I saying a large number of them are.  What I am saying is that there seem to be some teachers in every school whose classroom conduct includes openly belittling and degrading students who fail to live up to expectations or are the source of other classroom disturbances.  I am also saying that I fear this is more than just one or two bad apples, so to speak.  Judging by one such incident that was the subject of a recent Today Show story ( ) things may be worse than anticipated.

Science tells me that before I open my mouth about how to fix this perceived problem, I need to know how much of a problem this is.  My gut tells me that accurately measuring the number of bullies in any school that hold the title of teacher and thus classroom leader, is far from an easy task.  The applied practitioner part of me says that my job is not so much to find out how many bullies there are, masquerading as teachers, as it is to find a positive solution for those affected.  In fact I've done a good deal of that in my years working with and supporting children and adolescents simply trying their hardest to navigate an otherwise none to reinforcing context known as the school system.

I got wise through 4 years experience as a H.S. Board member and have tried to incorporate that experience ever sense.  I started by looking at those kids who did well in school in my attempt to understand how to navigate the system.  What I found was children and adolescents who did the best seemed to have the inside track in understanding how to best help the system work for them.  One of the first things I noticed was that those parents and/or kids who openly and frequently supported the system, seemed to receive the most benefit.  Likewise, those parents and/or kids who openly rebelled against the system were often the ones most at odds with the system and the teachers within.  The degree to which one is at odds with the system says much about who is either likely to be bullied or is likely to have a history of being bullied.

It may be self evident but it is far easier to start by being supportive than it is to go from rebellion to support of the system.  In fact I'm not sure one can functionally make the change to support and actually receive the benefit?  It may be that once one is identified as a non-supporter, no amount of change will alter the initial label of non-supporter.

I also know that paying attention to what your son or daughter has to say about how their teachers treat students is a very good idea.  It can certainly offer valuable insights into how they are being treated.  Even if it is more their perception than reality, the perception is important.  Do not assume that bullying in school is a student versus student problem and be open to the possibility that the bully may be an adult who is also the leader of the classroom.

Sunday, October 30, 2011

Creating Intensive and Successful Therapeutic Relationships; Functional Analytic Psychotherapy (FAP)

Will Hunting (Matt Damon) has genius-level intelligence. He works as a janitor at MIT and lives alone in a sparsely furnished apartment in an impoverished South Boston neighborhood. An abused foster child, he blames himself for his unhappy upbringing and turns this self-loathing into a form of self-sabotage in both his professional and emotional lives. Hence, he is unable to maintain either a steady job or a steady romantic relationship.

In the first week of class, Will solves a difficult graduate-level math problem that Professor Gerald Lambeau (Stellan Skarsgård) is hoping someone might solve by the semester's end. Everyone at MIT wonders who solved it, and Lambeau puts another problem on the board -- one that took him and his colleagues two years to prove. Will is discovered in the act of solving the problem, and Lambeau initially thinks that Will is vandalizing the board and chases him away. When Will turns out to have solved it correctly, Lambeau tries to track Will down. 

Meanwhile, Will attacks a youth who had bullied him years ago in kindergarten, and he now faces imprisonment after attacking a police officer who was responding to the fight. Realizing Will might have the potential to be a great mathematician, such as the genius Évariste Galois, Lambeau goes to Will's trial and intervenes on his behalf, offering him a choice: either Will can go to jail, or he can be released into Lambeau's personal supervision, where he must study mathematics and see a psychotherapist. Will chooses the latter even though he seems to believe that he does not need therapy.

Five various mental health professionals fail to connect with Will. Out of sheer desperation, Lambeau finally calls on psychologist Sean Maguire (Robin Williams), an estranged old friend and MIT classmate of his who grew up in the same neighborhood as Will. Sean differs from his five predecessors in that he is from Will's neighborhood and systematically pushes back at Will and is eventually able to get through to Will and his hostile, sarcastic defense mechanisms.

How did Sean, in this fictional work, get through to Will when 5 previous therapists had not?  Through the development of an intense and curative therapeutic relationship.  Often the general public, when faced with trying to understand why or how a therapeutic encounter was successful, will look at the personal characteristics of the client and the theoretical orientation of the therapist and conclude that a good match occurred, the result of which was a successful therapeutic outcome.  Although fictional in nature, the story of Good Will Hunting is a good example of a therapist and client forming a functional therapeutic relationship that allows the client to grow and develop in his personal life.  In psychology we know the basic factors that allow this to happen and well trained therapists can often duplicate this fete with many of their clients.  These basic factors are combined in a fairly simple set of procedures or therapeutic model known as Functional Analytic Psychotherapy; often referred to as FAP for short. 

Who Does FAP work best for?  What type of client benefits most from FAP?  FAP techniques work best with clients who seek an intensive, emotional, in-depth therapy experience.  It is also well suited for individuals who have not improved adequately with traditional behavior therapies, who have difficulties establishing emotionally intimate  or functional relationships, and/or who have diffuse, pervasive, and chronic interpersonal problems typified by one or more axis II disorders in the DSM-IV-TR.

Who developed FAP?  Dr. Robert Kohlenberg of the University of Washington in Seattle and Dr. Mavis Tsai, a Clinical Psychologist in Seattle published their first work on FAP in 1987.  Since that time they have refined it and have written several books about it.  It has been studied extensively and has been shown experimentally to be a highly effective EBP (Experimentally based Procedure) for a variety of psychological disorders.

What is FAP?  How does FAP work?  Outpatient psychotherapy typically takes place one-on-one in a therapist's office and is scheduled for one or more hours per week.  It is relevant to ask how something that occurs inside an office between two people for a few hours per week can generalize to a clients outside world on a daily basis?  The answer lies in the careful identification of behaviors that occur inside the office setting that relate to the clients behavior outside of the office that either increase or decrease functional social relationships.  In FAP we call these "Clinically Relevant Behaviors" or CRB's.  In FAP we can reinforce desirable CRB's and reduce undesirable CRB's.  Everything a therapist can do to help a client can and does occur during a session.  Therapist actions that help clients during a session include identifying, eliciting and reacting to CRB's.  For the well trained and experienced therapist, every therapist action in session has one of these three effects.

OK, what are CRB's specifically?  Are they the same of different for each client?  In a general sense CRB's are different for each client but they do tend to share some common factors.  Three general commonalities include but are not limited to 1) learning to ask for what one wants, 2) trusting, and 3) the acceptance of love or being valued by others.

How can I find a therapist who is trained in and understands FAP? The best way is to ask ahead of time. Do some reading on your own and then ask some questions of your potential therapist.  Competent therapists welcome educated clients and will appreciate your efforts in finding them.  I've taught advanced intervention techniques including FAP to hundreds of graduate students and believe me, nothing would be more welcome to them then a motivated and well read client looking to make successful changes in their life through the development of an intensive and curative therapeutic relationship.

For further reading see; 

Friday, October 28, 2011

Evidenced Based Practice; Knowing When a Treatment Fits an Individuals Needs.

Over the past 10 or so years, the focus of mental health treatment for the support of individuals and families has increasingly been on “evidence based practices (EBP's).” EBP's are treatments that have been shown through clinical research to produce positive outcomes for individuals and their families. In short, the practices have been shown through research to be effective.  I like this shift in our field and you should too.

Back in the 80's a common question I received from my peers was "what's your therapeutic orientation?"  I have to laugh now as I look back.  For me, being trained in both applied behavior analysis and clinical psychology often meant I had t o choose my answer based more on the characteristics of who was asking the question than on any particular merits of the elements of the treatment procedures themselves.  This also meant the needs of the assumed client took a backseat position to the need to appear competent in the eyes of the person asking the question.  The most often heard response by ethical but sensitive clinicians was a confident exclamation that one was "eclectic."

I'd like to say with confidence that the situation has truly changed however I can say the situation is quickly evolving and with some help from consumers, will change greatly in the next few years.  With that in mind lets take a closer look at EBP's, how the research works and why it benefit's consumers so significantly.

This focus on EBPs in mental health follows the release of a series of national reports calling for the broader dissemination of EBPs.  These reports include those by the U.S. Surgeon General (1999), the Institute of Medicine (2001), the President’s New Freedom Commission Report on Mental Health (2003), and more. Also, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for
Mental Health Services (CMHS) released Evidence-Based Practice Implementation Resource Kits for the mental health system regarding children and adolescents.

Before going farther, one word of caution.  Although there is a growing emphasis on the use of EBPs, individuals and families must maintain their right to choose the most appropriate treatment that meets their unique needs. Choice is necessary and highly valued by individuals and families because proposed EBP treatments may conflict with an individuals or family’s beliefs, may have been tried and failed, or an individual or family may know that a proposed treatment will not work for the current situation based upon other previous experiences.

How was the research done to determine the best EBP's?  The research in this area is ongoing so we tend to know more about the current best treatment procedures than we do about the all-time best treatment procedures.  In a typical study, participants are assigned to one of two groups. One group receives the treatment that is being studied to better understand its effectiveness, while the second group does not receive that treatment, and may instead be given usual treatment, placed on a wait list, or given an alternative treatment. The two groups are compared to see whether the outcomes for the group receiving the treatment being studied are better than the outcomes for the group that did not receive that treatment.

The studies typically use uniform training and a treatment manual to guide providers (psychiatrists, therapists, social workers, and other health care providers) in the treatment. They also provide supervision
and oversight to help ensure that providers follow the treatment protocol or procedures.  In general, those treatments qualify as an EBP that produce positive outcomes in two or more studies and are preferably conducted by more than one research group.

The outcomes typically measured in studies include some combination of the following:

1. Symptom Reduction and Improved Functioning
                • Improved school attendance and/or work performance;
                • Improved significant other, family and peer relationships;
                • Decreased involvement with law enforcement or the juvenile justice system;
                • Decreased rates of substance use and abuse; and
                • Reduction in self-harm and suicide related behaviors.
2. Prevention of Deep End Service Use
                • Decreased hospital admissions, institutional care, and other types of out-of-home placement.

Cautions About EBPs.  Much has been learned in the last decade about evidence-based practices in mental health and more remains to be done. First, the development of EBPs does not mean that these practices are widely available. There are many EBPs that are only available in a limited number of communities around the country. Many mental health providers have not been trained in EBPs and thus lack the training to provide these interventions for individuals and their families. Some providers also resist change in the way they practice, often believing that their clinical judgment, based on years of experience, produces the best outcomes. Individuals and Families need to find providers that are open to change and are willing to partner with them to provide the most effective and appropriate interventions.

Just because a individual or family is receiving treatment that has not been recognized as an EBP, does not mean that the intervention will not be effective. Many factors lead to successful service outcomes, and some of them can be difficult to evaluate. For example, the benefit of a strong therapeutic relationship between a provider, individual, and family can be a factor leading to positive outcomes as long as the provider uses the skills necessary to change concerning behaviors. Families highly value mental health providers who respect the family’s expertise about their child or loved one, and spend adequate time with the family through a thoughtful needs assessment and in developing and implementing an effective treatment plan. How these factors play into positive outcomes for the individual and family can be hard to measure, but are important factors in positive change.

Not all, but many EBPs have been studied in culturally and racially diverse communities. Consequently, the existing research base for some of the interventions in children’s mental health does not address the effectiveness of the practices in all communities. Fortunately, more attention is being paid to the need to adapt EBPs, whenever possible, to better meet the values, needs, and culture of individuals and families in diverse communities.

Co-occurring disorders are common in mental illnesses. This is especially true for substance abuse disorders, attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder. It is important for families to understand whether research supporting an EBP includes studies with children, adolescents, and adults with co-occurring disorders. If not, families may want to request several interventions which are likely to improve the outcomes for the disorders that are impacting them.

Research gaps persist in effective treatment for a number of serious mental illnesses that impact the lives of children and adolescents, including bipolar disorder, early-onset schizophrenia, and eating disorders. There is limited research on child use of psychotropic medications, outside of research on the use of stimulants to treat attention deficit/hyperactivity disorder. The limited research that has been done on medications tends to focus on the short-term effects of medication, without examining the long term safety and effectiveness of medications. Fortunately, the scientific understanding of medications continues to grow, with increased information about combining medication with other therapeutic interventions—often involving parents and families as co-therapists, to produce the best results.

New research is being conducted so that more EBPs will be available to treat early-onset mental illnesses. Unfortunately, there is currently not a central clearinghouse or single resource for families to access to learn more about EBPs in mental health and the availability of those EBPs in communities.  We will get there so stay tuned and ask questions in the meantime.

Tuesday, October 25, 2011

Getting to Diagnosis in Autism and Autism Spectrum Disorder's; What Does Our Road Look Like?

I recently read an excellent blog post ( ) titled “How many doctors does it take to diagnose and autism spectrum disorder.”  The bottom line was the average age of first diagnosis of autism in the UK was 5.5 years of age and for higher functioning ASD’s such as Asperger’s it was 11 years of age.

Perhaps a more frustrating realization was less than10% of parents received a confirmed diagnosis at their first clinic visit.  For another 40% it took two clinic visits and in total only 63% of parents reported having a confirmed diagnosis on or after their third clinic visit.  According to the article, “in many instances, parents waited more than 5 years before a diagnosis was confirmed.”  Given the knowledge that the earlier the intervention, the better the outcome and that most research points to age 4 or before as the ideal starting point, the protracted diagnosis time would seem detrimental to both parents and children.

Not surprisingly 40% of parents said they were not happy with the diagnostic process.  It hardly seems surprising that the more professionals parents saw on this quest for a diagnosis, the more negatively they viewed the process.  Often these parents were given the advice of “wait and see if they grow out of it” rather than encouragement to seek treatment help asap.

In my opinion, the problem lies not so much with the lack of standardized assessment criteria as it does with general knowledge of where to go initially to get a diagnosis.  I know my own experience, having children with mild to moderate hearing impairments, was that there was no obvious place to go.  Our local hospital at the time had no children’s center and our regular family doc’s didn’t have the right equipment.  If it wasn’t for the lucky location of a large University within 10 miles of our home, we could have spent countless hours and days going from one expert to another.  As it was they were able to make the diagnosis on the first visit and then to identify for us, a list of professionals capable of treating our kids.

It seems likely that the point of first contact for parents who suspect a developmental problem is the pediatrician.  It also seems to me that the creation of local and stand alone, multidisciplinary developmental diagnosis and treatment programs are a good option.  I look forward to the publication of research in the US that looks at experiences of parents of children with ASD’s here, so we can accurately understand the process they go through to receive a diagnosis in order to unlock access to the necessary treatment.


Howlin, P. & Moore, A. (1997) Diagnosis in autism: A survey of over 1200 patients in
the UK. Autism: International Journal of Research and Practice, 1, 135-162.

Howlin, P and Asgharian, A. (1999) The diagnosis of autism and Asperger syndrome: findings from a survey of 770 families.  Developmental Medicine and Child Neurology. Dec;41(12):834-9.

Thursday, October 13, 2011

Young Adults and Psychosis; Diagnosis and Treatment.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) refers to psychosis in varied terms depending on the diagnosis.  For instance in schizophrenia, psychosis is defined as 2 or more of the following symptoms over the course of a one month period * ;
1.  delusions
2.  hallucinations
3.  disorganized speech
4.  grossly disorganized or catatonic behavior
5.  negative symptoms - affective flattening, poverty of speech, etc.

*  For a diagnosis of schizophrenia an entire clinical picture, consisting of additional signs and symptoms, must be present for 6 months or more.

The question faced by most family members and significant others, when these signs and symptoms present themselves, is whether this is in fact the start of a schizophrenic disorder or the result of the use of various substances or, due to a medical condition.  An important second question is whether or not the individual agrees that they are suffering from psychosis and what, if anything, they are willing to do about it.

Many in the mental health field are concerned that there appears to be more psychosis these days than previously seen.  While the prevalence of schizophrenia appears to hold steady at about 1% of the general population (the same for most countries), the prevalence of psychosis is thought to be on the rise.

When we see psychosis in the hospitalized elderly or others post surgery, the diagnosis is almost always delirium and resolves itself within a few hours or days.  It's frightening to unprepared family members as there is a rapid change in consciousness or cognition.  It is almost always related to a medical condition or procedure and/or in some cases, medication or substance use.

When we see psychosis outside of medical settings and in young adults, with an onset over several weeks or months, the story is normally much different and of a much greater concern.  Is it the start of schizophrenia, a schizophreniform or a schizo-affective disorder?  Or is it the result of a drug induced psychosis?  How people proceed once they see the above signs and symptoms, can determine to a significant extent, what the eventual outcome is (prognosis).

A bit more background is important here, before proceeding on to diagnostic and treatment considerations.  Schizophrenia, schizophreniform and schizo-affective disorders tend to start in the late teens through the mid 30's.  It is thought to affect men slightly more than women with the onset for men tending to be younger (teens to mid 20's) whereas women tend to succumb between their mid 20's to early 30's.  For both there is a generally accepted sequence of 3 stages; (prodromal, active, and residual or remission).

The prodromal stage is almost always marked by a 6 month or more time frame of a gradual appearance of both positive and negative signs as well as a social distancing.  Often these signs and symptoms tend to come and go.  Often they are not even recognized fully for what they are until after the individual proceeds into the full blown active stage.  In hindsight family members then recall that some behaviors seemed odd but because of their transient nature, easily ignored or overlooked.

The positive signs are things that are not supposed to be there such as the symptoms of psychosis above.  The negative signs are things that are supposed to be there but aren't such as a cognitive slowing or decline, the ability to experience pleasure, and normal speech patterns.  Instead of over-looking these issues it is best for people to identify them and discuss them.  Often people who are experiencing a psychotic disorder of some type are not able to see it as a problem and/or actually prefer to operate at that level.  They resist treatment or even discussing the issue and often their denial equals or exceeds that seen in alcohol or drug dependent individuals.

I believe it's best to proceed in treating psychosis by assuming a default position of an etiology of a drug induced psychosis unless other factors rule that out from the start.  Today, more than ever, a variety of substances could be, and often are, the cause including but not limited to the use of alcohol, marijuana, a variety of so called "club drugs" and even the excessive use of caffeine, energy drinks, a variety of diet supplements or just about any stimulant compound.

Too often a default diagnosis of schizophrenia is arrived at prematurely and people are left with little hope or understanding.  Medications known as anti-psychotics (neuroleptics) are started without adequate patient and family preparation and the large number of side effects quickly begin to produce significant problems in treatment compliance.  Instead of having the start of treatment begin on a sour note, it makes much more sense to start with an educational approach and to develop a functional therapeutic alliance with the individual.  It is likely that an anti-psychotic will have to be used at some point but only once the individual and family are prepared for the short term difficulties of treatment and understand the long term nature of the care necessary.

Once individuals and family members are "on board" so to speak, high potency-low dose medications can be started and plans for stopping all mood altering substances put in place.  When done right, treatment with medications can be very short term and side effects minimized.  When necessary a once per month shot can be used along with therapy.  Drug induced psychosis can be effectively treated within 8 to 12 weeks and the likelihood of relapse minimized.  Once the intensive phase of treatment is completed, treatment can be scaled back over the next 3 to 6 months to do all that is possible to eliminate the possibility of relapse.

Related Article;

Thursday, September 29, 2011

Mental and Emotional Health on The Decline

Is Mental and Emotional Health Improving?  I think not.  Judging by the explosive growth of the use of pharmaceuticals in treating mental health and emotional issues, reports from College campus counseling centers, the reported drain on services of Community Mental Health Centers and the rising numbers of severe mental health issues found in our incarceration facilities mental and emotional health is more than likely decreasing.

Given that as a society we are even more connected and more tuned in electronically, how could this be happening?  I believe the answer lies in some basic concepts and understandings gleaned generally from Behavioral Psychology and Clinical Behavioral Analysis in particular.

Lets start with a basic understanding of a few terms or principles.  The first is ratio strain (RS).  RS is a term that comes from researchers in the field of experimental analysis of behavior and refers to a phenomenon discovered while researching schedules of reinforcement.  In essence it was found that when animals were asked to produce too much behavior for too little reward, emotional responding appeared where the animals were observed to apparently be frustrated and angry based upon their levels of acting out and aggressive behavior.  The definition of ratio strain is now the “Disruption of operant responding when a ratio schedule is increased rapidly.”  Take my word for it, too much behavior being asked for in a context of too little reward.  Something you may have recognized in your life at some point?  A normal thought you may have had during that moment was that the people around you were taking you for granted; that you were doing more and being noticed for it less.

The second term important to understand is Behavioral Activation (BA).  BA refers to a third generation behavior therapy where the goal is to increase the amount of reward or reinforcement a person receives in their environment while simultaneously reducing the punishment they currently receive.  In other words the idea of BA is to help people get more of the things they want, desire or appreciate and to also reduce the amount of pain, struggle, stress, or frustration they experience.

Given an understanding of these two terms one can easily see how our current lifestyles, and the speed at which we live them, could naturally result in an over-all decrease in our mental and emotional health.  For those fortunate enough to benefit from the speed and who report a great deal of reward, good for you.  No one should begrudge anyone for having a fulfilling and rewarding life; that is something we all strive for. 

For those not so fortunate, morning eventually arrives and the struggle continues.  At some point many make successful choices and the context of their lives change for the better.  For others, over time, things pile up and mental and emotional health decreases even more.

Friday, September 23, 2011

Lesbian Identity Development

One of the most prolific area's written about in the popular press today is sexual identity, sexual orientation and sexual preference. When a women identifies herself as female with a sexual preference for other females she embarks on a journey of self discovery that often results, if successful, in acceptance of a Lesbian Identity or role. Due to a myriad of public and family ridicule, the journey is often confusing and tumultuous. While the exact mechanism involved in choosing ones sexual preferences has yet to be fully explained, there is no doubt among professionals that it is not a choice in the standard sense of the term. One is either attracted to members of the opposite gender or the same gender. A few are attracted to both and a very few to neither. The purpose of this post is to outline the development of lesbian identity and the various phases women often go through on their way to successfully attaining a healthy identity as lesbian.

McCarn and Fassinger (1996) developed a four stage model of lesbian identity development that is currently regarded as the strongest prevailing explanation of this journey of self discovery.  This theory incorporates both stages in the individual journey as well as speaking to the issues involved in being part of a marginalized minority group.  Stages as used here refer to a sequential developmental trajectory that a women may move both forward and backwards through time; it best reflects a lifelong journey affected by social and political contexts over time.

"Awareness" is the first stage and is generally regarded as a time of feeling different.  An awareness develops that there are variety of sexual orientations possible and one is not limited by a heterosexual orientation.  There is no indication of an age range for this stage and it is possible that awareness can and does occur at any age.

The second stage is termed "Exploration" and involves an individuals consideration of their relationship, both emotional and physical, with other lesbians.  This includes attraction to other females as well as ones possible membership in the lesbian and larger gay community.  Self questioning might include issues related to both emotional and physical intimacy with other women as well as the social meaning of identification with the LGBT community on the whole.  Exploring social opportunities within the lesbian community or experimentation with a lesbian partner may begin here.

A "Deepening/Commitment" phase can then follow as the third stage.  Here, as the name implies, a greater appreciation and understanding begins to develop and pride emerges as a women begins to fulfill who she feels she was meant to be.  Anger is also possible related to the natural despair that can follow with the realization that prejudice and discrimination can come with such identity.  For many women, especially those with a valued public identity to lose, important questions regarding "coming out of the closet" now get scrutiny.  Many are now forced to accept an underground identity wavering between the relief of fulfillment and the fear of public discovery.

The final stage is termed "Internalization/Synthesis" and it is here that a deeper identification is formed with ones sexual orientation and other aspects of ones life and identity.  The direction of visualization changes from a person looking inward towards a new orientation and fulfillment as a lesbian towards a outward view of a full fledged member of the lesbian community looking at a society not yet fully ready to accept her with the same tolerance as if she was heterosexual.

Keep in mind that a women moves through these stages within her own time frame which is also sensitive to the opportunities of lesbian social contact in her environment and the quality of the emotional and physical relationships she develops; the same as if she was heterosexual and learning to navigate the trials and tribulations of that world.  In essence some of these stages may be mastered within a short time frame while others may take years.  And stepping back, to a previous developmental stage, is always possible.  For some, development may arrest at stage three while others may halt their development at stage two or even stage one.

Anywhere along this developmental trajectory, informed and competent psychological help and support can be beneficial.

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