By Cameren Boatner
Dr. Jessica Ruiz says she works to be fired.
Ruiz is the chief psychologist and director of Behavioral Health Associates of Broward, which has provided counseling services since 1962. Ruiz has been a therapist for a decade, and says her work is complete when a client is ready to leave therapy.
Ruiz realizes it’s intimidating to go to therapy, but she says you should “take the leap,” and make an appointment. She said it isn’t as scary as you think, and your first session will be all about you — not your trauma. You’ll also find out whether you’re opening up to the right person.
Parkland Cares spoke with Ruiz last week, and her answers below were edited for length.
This is common. It would be uncommon for someone to not feel a little anxious and nervous, or even very anxious and nervous. It’s the first time they’re meeting a therapist, so we let them know that it’s pretty normal.
What I like to do when I start a session is ask them if they’ve ever been in therapy before, and their experiences, and I’ll share a little bit of what the session will look like.
There’s help out there. One of the biggest things though, is to do your research first. Really make sure that you’re scheduling to see someone with experience treating trauma. If you do that, you’ll have someone who understands the challenges trauma brings and will guide you through the process at a pace that works for you.
There is hope, take a leap. Sometimes the real question is, ‘What’s the worst that could happen?’ If you don’t like it, you can slow down, stop at any point, and you can choose to see someone else. You’re in control of the process at all times — just give it a shot.
I see the first session as a great way to get to know the client and their journey.
The first session is a great way for me to learn why now they’re seeking therapy now, and to get a little bit of information about their journey up to that point. In that first session, we typically like to get information like family history, where they grew up, how they’ve done in school, their experiences with friendships, their social network, and their social support.
Are they currently feeling safe where they are, and who in their life is important. We also like to see what challenges they’re experiencing now and how it affects how they feel about themselves, their relationships, their work, school, as well as if they’ve had similar difficulties in the past.
All that information helps to get a better picture because if we only look at right now, it’s hard to really say what resources we can pull from to help, their past successes and strengths, and the challenges or experiences that could be playing a role in their life today.
By understanding how they got here and their journey, I can give some recommendations on what can be helpful at that point. It’s very collaborative, and if it seems like a match and if the person feels comfortable, and if what I’ve thrown out there makes sense, then we’ll make an additional appointment.
Sometimes, it could be that the individual is struggling with something that could require a higher level of care.
For example, let’s say someone’s symptoms are so intense that they worry about whether or not they’ll be safe if they go home. Maybe a hospital stay would be most helpful.
Sometimes, they may need an additional service too, like a psychiatrist, so we’ll provide referrals.
They still may need to see a therapist, even after going through higher levels of care and if at that point it seems like a match, then we can continue.
At the first session, we can recommend what will be helpful — whether that’s with us, with someone else, or in collaboration with other providers.
It might look a little different depending on the clinician. My approach would be to not talk about the details in the first session because that can sometimes trigger people and make them uncomfortable.
Instead, we might talk about the difficulties they’re having. I always tell the client that they’re in the driver’s seat in terms of where we go. If something doesn’t feel comfortable, it’s important that every client knows they can say they don’t want to talk about that right now.
First, I try to understand how their trauma impacts things. How is your sleep, attention and concentration, mood, levels of depression, anxiety? From there we can better determine treatment.
Some clients are not quite ready to work on their trauma directly. You have to go where the person feels comfortable. If you talk about the trauma too soon, the person may become too overwhelmed.
It’s about trust. If a person isn’t ready to touch on these topics right now, they might be in the future as they build a relationship with the therapist.
I’ll give the client an assignment as a way to continue the work we’ve been doing in the session at home. That way the change isn’t only happening in the room, it’s happening outside too. They can take what they learned in the session and use it throughout the week.
For example, we might practice in the session how to challenge a negative thought. Now, we want to see if you can catch yourself throughout the week if you’re feeling anxious and try to ask yourself, “What was I just thinking?” Then, if they ask themselves how they can challenge it, that can really help in practicing these techniques on their own.
I work to be fired. I know I’ve done my job when the person says they’re ready to go. And that works because I want my clients to have all the tools that they’ve learned here and feel confident using them on their own. And these assignments help do that.
There are limits to confidentiality.
When people are having a lot of difficulties like anxiety, trauma or depression, it’s not uncommon to have thoughts of not wanting to be around, or to want to hurt one’s self. It’s really important to be able to have that conversation in therapy.
But if a person and the clinician feel together, or if the clinician decides the person won’t be able to keep themselves safe, then we need to do what we can to keep them safe. This can include letting someone else know such as a parent, health care provider, or emergency personnel.
If a person says, “No matter what you do, when I leave here, I’m going to hurt myself,” I have to get them to a hospital.
Another limit is when someone talks about the abuse of a child, an elderly person or a disabled person in session, we also have to provide this information to the appropriate agency to make sure they are safe. If you tell me you are about to break the law, and it involves someone getting hurt, I also have to report that. (Note: Since confidentiality rules can vary in particular circumstances, read the American Psychological Association’s comprehensive guide here for more information.)
All of these limits are explained in that very first session.
It depends. Each individual is unique and comes with their own history, strengths and challenges. When we look at the MSD tragedy, there were individuals who’ve experienced trauma, anxiety or depression before the shooting. That could further impact their symptoms and present additional challenges to talk about in therapy. Those who were near the shooting, witnessed others being injured, or were injured themselves might be more prone to experiencing difficulties afterwards.
Of course, those who were farther away from the shooting were also impacted — but those with a past of anxiety disorders might also be more prone to some difficulties afterwards.
People who are going through different things like PTSD, depression, substance abuse, loss, divorce, financial struggles, lack of support system, or illness at the same time may spend a longer time with therapy.
I’ve had people that come in with full-blown PTSD a month after the event, and six months later didn’t meet any of the criteria for PTSD. Those individuals sought out help quickly, had people in their support network that they were talking to, they didn’t have significant financial stressors, and they didn’t have other traumas.
There are unique challenges. Part of it is that the trauma has can disrupt your sense of safety and trust in others.
As a comparison, let’s say someone is struggling with depression by itself. It has its challenges for counseling because it’s hard even to get up and go, and sometimes your thinking process is slower, and it’s hard to concentrate. Just how we view things are distorted, so we think something isn’t going to turn out well, something is wrong with me, and this is going to happen forever.
But with trauma, we have this disruption in safety. So on top of some of this other stuff, we have a fear of something bad happening, or that someone is going to hurt me. We heal through connections, but when you can’t trust others, or you’re worried about trusting others, that makes it more complicated.
When you talk about trauma, someone may re-experience some of the feelings they felt during the event, and who wants to feel that? So some clients respond by avoiding talking about it, or avoiding people and places and things that remind them of the trauma. Unfortunately, avoidance maintains most anxiety disorders and could make things worse.
You have to move towards being able to face your trauma in a way that’s tolerable and you need to have the tools to do it. Therapy can help you process your experiences, find helpful ways of coping with stressors and resolve symptoms.
Parkland Cares has given $55,000 in grants to Behavioral Health Associates of Broward “which opened counseling facilities in the Parkland area to provide trauma counseling close to where the victims live.”