MEDIA APPEARANCE

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.