Lena has been a family psychologist since 1993 and has seen moderate changes in her work.  When she began most individuals and families in Greece did not understand the purpose of psychotherapy, and this lack of understanding continues to influence her work into 2010.  Lena studied clinical psychology in Geneva, but found she needed additional training in Greece to provide an adequate understanding of family systems and how families change. Maria was born and raised in Australia but she studied and trained in Narrative Family Therapy in Greece .  Eva studied initially in Greece, and continued her education in the UK to learn systemic family therapy. Marilena and Tatiana also studied initially in Greece; after their undergraduate studies, Tatiana continued her education with a M.Sc. by distance in the UK, whereas Marilena followed a M.A. in Clinical Psychology. Lena and Maria ran a kindergarten to supplement their income and access families to provide a foundation for intervention in family systems through child development practice.  They have trained other practitioners, once as many as 10 trainees at a time.  Eva, Tatiana and Marilena are three of the trainees who have continued to collaborate with Lena and Maria in their practice. This group has provided a foundation for a new generation of family therapists.Some of the children who were in their kindergarten have returned for psychotherapy services as they matured.

The challenges they face stem from cultural values that discourages asking for help, coupled with a social-political system that lacks coordination of care, and cultural misunderstandings about how to intervene with families effectively while preserving connections.  Lack of financial support for ongoing psychotherapy from the health care system and the medical community undermines the possibility that families can access services needed to prevent or manage mental health problems. These family therapists live and work in a culture that views asking for help as an insult to parents, a betrayal of confidence, and sees separation and individuation as rejection.  They often have clients who are expected to remain with their parent’s home and the only means of individuation is to marry, if then.  Parents build additional levels on their homes rather than have their adult children move out on their own, and in some families the boys are not allowed to marry until the girls are married regardless of birth order.  Loyalty to parents is first priority.  For example, one of the psychologists would have preferred to study family therapy in Chicago, but studied in the UK because Chicago was too far away for her family to tolerate. They find that when family therapy is offered the parents of clients are defensive and insulted by the implication that they need help.  The stigma is strong, and many laymen do not understand the difference between a psychiatrist and a family counselor.

The psychotherapy profession is not as diverse in Greece and there is limited participation in the practice.  The stigma described above prevents families from using the help when it is available. The University offers only general psychology and clinical psychology degrees.  No counseling programs, clinical social work, or family studies programs exist in Greece.  Most lay-people do not understand the difference between a psychiatrist and psychologists and they believe all psychotherapy is psychoanalysis. The practice of psychotherapy is regulated by the European Certificate of Psychotherapy adopted in 1997, originated by the European Association for Psychotherapy founded in 1991. Mental health care issues that are complicated by family issues, such as child abuse or anorexia, lack coordination of care.  Referral to providers is limited due to misunderstanding from other professionals and lack of infrastructure.  The health care system fails to provide any preventative care or after care when major behavioral health problems require treatment.  The most these providers can expect from the health care system is short term hospitalization for major mental health crisis to stabilize the patient, who is released without follow up care; neither are provided nor recommended.  Any outpatient psychotherapy service must be paid for out of pocket by the clients requesting care.

As I traveled around Athens, Santorini and Kavala, I observed a landscape colored by graffiti, overflowing trash cans, and stay animals wandering the streets.  Although this was more prevalent in Athens than in the other areas, it was present in the three communities I visited. I wondered about the relationship between the strays and the infrastructure that supports the vulnerable populations in Greece. In America, the child welfare movement was an afterthought of animal welfare movement that resulted in the Animal Welfare Act of 1966.  The Child Abuse and Prevention Act was passed in 1974 in America, although the Social Security act in 1930 included funding for neglected and dependent children.  Comparatively, Greece signed the Convention on the Rights of the Child on January 26, 1990. In Greece, there is no centralized agency designated to provide care and assistance and to supervise the various services provided by the State. Instead, a number of government agencies are responsible for providing social welfare and health services, as well as free education and child care. Generally speaking, the Ministry of Health and Welfare is responsible for health services, and the Ministry of Social Assistance is responsible for assistance to children who are vulnerable, that is orphans, the handicapped, and trafficked children. The Ministry of Health and Welfare and the Ministry of the Interior have joint responsibility at the national level for early childhood care. Local authorities are responsible for preschools and child care services; the Ministry of Education supervises the early childhood programs at the national level. The Ministry of Labor and Social Security handles the social insurance benefits and the family allowances for each child. The Social Insurance Institute (IKA) administers benefits through local offices.  These Family Psychotherapists reported that the poor coordination of care for abused and neglected children often made providers reluctant to engage these agencies to protect the children, for fear of doing more harm than good.

Despite these challenges this group of family psychologists provide services for individuals and families they have come to develop relationships with over the years.  Some of the children who were once in their Kindergarten are now grown with families and have accessed their services or referred others for care.  These providers continue to train and supervise new psychotherapists who want to work with family systems even when the demand for services are low, coordination of care is poor, and services are not funded by the health care system in Greece.  Families outside of Athens are even more limited in terms of access due to the village mentality of the communities and even greater stigma than in the big city.  These families are even more entrenched in old world values that discourage asking for help outside or even within a family.

Hope for the future of family therapy in Greece is complicated by the the current challenging economic and political climate in Greece.  Since the profession is unregulated by licensing laws and lacks funding from health care insurance, all services are based on the consumers’ needs and ability to pay.  Outside of improving their ability to serve the need of families, there are no continuing education requirements from the licensing boards or insurance companies.  Continuing education needs are based on making family therapy interventions as effective and efficient as possible to maximize the care provided to families.  Current political unrest and lack of faith in the government makes it unlikely that these providers or families could hope for the government to support their services.  Great interest was expressed in a system of teaching deep empathy and expressive skills to improve connections and allow individuation within families, who practice these skills within their families and in their communities.

It is my hope that this meeting is the beginning of ongoing communication and support.  Access to online services such as web based training and education increases access to training and education that would have been limited in the past by the need to travel long distances, either by the trainer or the trainee.  Exposure to multiple perspectives with an emphasis on understanding the cultural implications of the Greek family systems is essential to supporting the care providers in this community.  Access to an understanding of the modern Greek family in other countries can provide help to multi-cultural families.  Our mutual interest in understanding and supporting Greek families within and outside of Greece are at the core of our commitment to support each other in the future.

Social media is a tool for creating community.  I see value in sharing my path toward making the world a better place, so I did not hesitate to include current and former clients as “friends” on Facebook.  I focus my “status updates” on affirming life messages and only post information that I would readily admit to a complete stranger.  Social media is not private, and I accept responsibility for the nature of my communication in cyberspace.

I have thought, discussed, and researched the ethical implications of communicating with clients through social media.  My practice and my clients seem to have benefited through social media.  For example, my practice has benefitted with referrals from friends and colleagues to my practice because they see me on Facebook and refer.  Former clients and acquaintances from community settings (former agencies where I have worked, churches, and schools) have referred to my practice.  Colleagues have asked me about my practice and referred those who could use my services.

Current and former clients have also benefitted from being my Facebook friends.  A former client who moved out of state stays connected to the work we did through status updates.  When they need help in another community I use the internet to research providers and make suggestions. I share community resources and my insights on current events through posts to my profile, and announce blogs from my website and upcoming workshops.  My fan page for my practice is available to anyone who wishes to address issues related to my practice.   I hope to create a community for individuals read and share resources there.

For example, one client was unable to attend therapy in the office due to a high risk pregnancy.  She accessed my support through chat and status updates as she faced life threatening complications to her baby and her own health while in the hospital.  While we chatted on Facebook, I emailed colleagues who worked in that hospital to learn how to garner behavioral health care and relayed the resource to her while she was in the hospital.  Once she gave birth and was able, she resumed therapy in the office to prevent the post-partum depression she experienced previously.   As far as I can tell, there is no way for someone to know how we are associated outside of Facebook.

Recently another client ended our Facebook connection to support the therapeutic relationship.  This client indicated that the casual nature of Facebook communications prevented the depth of the therapy relationship needed to progress to more intimate issues.  Our lives overlap in professional and community associations, and Facebook made it too difficult to let the guard down in therapy.   I understand and support the need for a boundary between our professional relationship and the casual “chatter” that happens in status updates.  Not all clients are in similar situations and some individuals need clearer boundaries.  There are clients with whom I do not accept as friends due to their difficulty with knowing casual personal information about me.

This has lead me to wonder how others might feel or have felt interacting with their psychotherapist outside of therapy.  Is it like seeing being a kid who sees the teacher in the grocery store?  Does it help to think of your psychotherapist in other roles from life such as a parent, spouse, sibling, child, or student?

I have thought deeply about the pros and cons of providing therapy to acquaintances, such as students who have attended the school where I worked, people with whom I have served on professional committees and members of my church.  I am less rigid about working with people I know in the community than some psychotherapists tend to be. I used stories from my own life when it is pertinent and seems useful in the therapeutic process, but there are some who would discourage this kind of personal sharing.

The ethical guideline from the American Association for Marriage and Family Therapy (AAMFT) that governs my profession discourages dual relationships due to issues of power. If I were a customer or employer of a client that would make it difficult for the client to feel completely safe being open with me for fear that it would affect our business relationship. The same applies if I was a teacher, or professor, etc. My ethical code states to “avoid dual relationships when possible” and if not possible to talk about the issues of power openly to avoid disrupting the therapeutic relationship. Aside from that broad statement, the only clearly defined restriction states that we shouldn’t engage in a sexual relationship for at least 2 years following the end of therapy, but that level of intimacy is not what we are considering here.  Webinars offered by my professional liability insurance cautions about securing internet communications with encryption whenever sensitive confidential information is being shared across the internet, and I have researched these resources for online communications.

Since I have worked in home based and school based settings I have seen how valuable it can be to know the community in which a person interacts with others, and Facebook is a community where people interact. In fact, I continue to see people and the family members of people I knew or worked with at the high school where I worked as they have gone to college and become parents.  I have worked with a former teacher of my son’s preschool once that dual relationship had ended and the former professional association did not seem to interfere in our working together.  I have worked with members of my church and this association did not appear to interfere in our interaction at church or in therapy.  The most important consideration to me is the comfort level of the client and family. The research says that there are two factors that have the most influence in therapy success 1) the client’s confidence in the provider, and 2) the provider’s confidence in their ability to help. As a family therapist, I value knowing my clients and their family and community well. I feel confident that I can discuss the wide variety of options available to assist them and make a good referral if it seems that I am not the right provider for their situation.  If the family is comfortable and their situation is an area that I have expertise in treating, I do not hesitate to serve if the family wishes to work with me.   I will respect the level of privacy and separation my clients need on Facebook and in other community settings.

I welcome discussion of the issues raised here and will not indicate in any way if any of the comments are from clients or community members.  If you feel more comfortable commenting privately, my contact information is available on my website.  The responses to my blog are moderated and I reserve the right to remove any comments that undermines your privacy or others.

My husband, Chris was raised in a dual Catholic home; Roman Catholic and Greek Orthodox.  His father went to Greece and convinced his mother to marry him and move to the US.  They had two weddings, one in the Greek Orthodox Church and one in the Roman Catholic Church because they each wanted their marriage to be recognized in by their own faith. Each year they celebrated both wedding anniversaries four days apart from each other.  Although, Chris attended Roman Catholic School and church services, it was clear that each of his parents had their own faith.  Once her husband died, Chris mother returned to the Greek Orthodox Church for her spiritual community.

As I child I attended the Presbyterian Church with my mother, while my dad proposed alternative perspectives to the bible stories I was taught in Sunday school.  I distinctly remember him comparing the Bible story of the loaves and the fishes to the story of Stone Soup. My dad emphasized that the miracle was that Jesus taught the people to share what little they had with each other to create a sense of community.  To my father the primary value if church is a shared community, rather than a reverence for the mystery of life.  Around the same time that I discovered First Unitarian in Albuquerque, my parents joined a Unitarian church in Sacramento.  My dad was amazed to find a church that would let a devout agnostic be the Board chair.

The decision to attend two Easter services this year was an exercise in preparing Jacob for our trip to Greece and giving him a sense of his cultural heritage before we go.  I appreciate the Unitarian’s commitment to telling the many stories of Easter each year, and didn’t want him to miss the religious education.  Our church is large enough (750 members and rising) that they provide two simultaneous services on Easter; a more contemplative service in the sanctuary and an intergenerational service in the social hall. As we found our seats, I head the ministerial intern announce that we would need more chairs for all the families coming in.

As a child development expert, I appreciated how the intergenerational service involved us in the story using multiple senses.  We used grape juice to blot stains on a napkin to symbolize the plagues of Passover. We sang a song that represented the story of Jesus resurrection.  Pictures were projected on a screen illustrating the Greek myth of Demeter and Persephone’s the return of the spring.  Each story was represented by a bead we put on a ribbon.  In closing, we joined the participants from the sanctuary in the courtyard to hang our individual contributions on branches connecting the two services to each other as we sang together.  The service was rich in symbolism that Jacob learned, participated in and understood.

For Jacob and Chris, the Greek service was very different.  Since Chris attended Greek School as a child, Catholic School and Catechism, he understands the symbolism of the Greek Orthodox Church in ways that Jacob and I do not.  I could see comfort in his face from familiar sights, sounds and smells as he participated in the Greek Mass.  The crosses, portraits of saints, and smell of incense were very beautiful and I appreciated the multi-sensory experiences, but I did not understand what they meant. He has taken Greek languages classes at that church and recognized on of the classmates from his class.

I was grateful that Jacob requested to sit in the upper balcony because after the novelty of lighting candles and kissing a portrait wore off he was in agony with the monotony of the service.  Even the singing of the priests in Greek and English was in monotones that were the kind of sounds that induce sleep. After a half an hour, Jacob was threatening to walk home alone. I consented to take him to the park across the street while Chris stayed for the end of the mass where they passed out traditional blood red dyed eggs to the children.

The parishioners of St. George’s served a luncheon for their congregation after the service.  They served us lamb, peas cooked in olive oil and dill, orzo, salad and rolls to approximately 100 people.  A dessert table offered sheet cake the Greek Easter cookies like Chris’ mom made every year.  There was a bottle of wine and chocolates on the tables. The food had a similar impact on us as the mass for Chris.  The flavors were familiar to Greek cuisine and made the experience taste like home for Chris.

A woman, who became a member a year ago, introduced herself and reveled in how surprised she was to find a spiritual home in the Greek Orthodox Church. I observed many congregants who did not appear to be of Greek heritage, but did not find that unusual.  The priest spent some time talking to a family during the luncheon and a centrally located table, but he did not make his way to our table in the farthest corner. Based on my experience at the annual Greek Festival each October, I was concerned about parking and we arrived early, but the parking lot only had a few cars.  Jacob said he would use a yellow mug at this church so that we would be greeted as newcomers, but this small church had no yellow mugs.  Aside from the one woman who introduced herself, no one else made an attempt to welcome us. There were plenty of empty chairs in the sanctuary and in the social hall for lunch.

I am not surprised that I feel at home in the church that I have attended for 15 years, and that Jacob has attended since before he was born.  I am not surprised to feel like an outsider at a church that has such strong Ethnic culture associated with its faith.  However, I walked away with a greater appreciation for the effort we make to make our church experience welcoming and inclusive of all who choose to attend; from the services designed to create a sense of participation in the story and something tangible that brings the sermon into my child’s hands, to the yellow mugs that indicates that a newcomer would appreciate being greeted. Without the familiarity of language, the meaning of the stories, the explanation of the symbolism and the welcoming gestures from those who do belong; our church might feel foreign to a newcomer, too.

I was a heavy kid have a VERY vivid memory of being pushed through the uneven parallel bars routine by the gym teacher and three other students ”because every kid had to complete each routine to pass the class.”  There were many physical activities I could do well as child, like dance and swimming, but lifting my body over that top bar was not one of them.  From age 9, I dieted with my mom when she decided to try to lose weight.  Each time I lost weight, and then gained double almost immediately after I reached my goal.  In High school, I was labeled as “fat,” but I at 5’8″ tall and 150 pounds I WAS a healthy weight!!!  At 18, I swore off diets and tried to accept myself the way I was, but I had a fat brain, and a culture that told me I was fat. By the time I was 27, I was over 300 pounds.  I began a 12 step program and took many years to gain physical, emotional and physical recovery.  I started by accepting myself at the weight I was.  Later, fitness tests showed me that 165-185 is the best range for my body.  I reached my optimal body weight of 175 at 42 years old.   My son was exactly the same weight and size as I was at birth. I wonder if “overweight” is defined differently now.  He looks like he is a normal weight, yet he has always been in the 95th percentile for height and weight, and he is close to 90 pounds at 8 years old!  I probably had his same body at his age and was labeled fat because I was HEAVY.  If I was boy they would have put me on the football team and rewarded me for my size, but because I was a girl, I had to be pushed over the uneven parallel bars!

Adults and Children need help to find physical activities that

1)      Improve self esteem,

2)      Are accessible,

3)      Feel good,

4)      Provide internal motivation to keep it up,

5)      Manages feelings more effectively than food or inactivity.

One of my favorite tools for setting fitness goals matches activities with personality styles and preferences (extroverted, social, competitive, focused, etc.) to find the activities most suited to your style.  It took me YEARS to figure this stuff out, but now I help others find that is right for them before they start a plan for exercise.  I have used exercise videos to allow me to get exercise in my own home, but I still need external encouragement to keep it up, whether is it a video, a class, an online fitness journal or bragging!

Physical activity is SO GOOD for you.  Research shows that exercise has longer lasting effects than medication for most low to moderate forms of depression and, along with sleep, is one of the best interventions for other mental illnesses.  But sometimes you have to feel better to move at all, and that is when medication may be necessary.  Helping kids to feel good enough to try something is essential, and one of the best ways to get kids to move is for the adults to get active.  We walk, ride bikes, swim and will add Roller skating with Jacob as a means of transportation, in organized events and as play.  Doing what you like, what feels good and what works is the key.  No one could have done it for me.  When I participate in the physical activity I enjoy, am good at, and I feel encouraged, and perhaps I will avoid going back to 300 pounds.

I hope the ideas presented here support you and your family to make fitness a priority in your relationship!

I hope to create an interactive discussion about making relationships a priority in your life.  I plan to host discussions about creating and maintaining healthy relationships for couples, parents,  partners, friends,  and kin.  Please share your insights in the comments section to add to the discussion.