An Interview with Stephanie Greer
Chances are high that a person with a diagnosis of bipolar has gone through trauma or traumas at one point or at different points in their lives.
Bipolar Disorder, a condition that affects millions around the world, not only impacts the individual diagnosed but also their surrounding family. It’s becoming increasingly clear that the journey towards mental wellness is not solely an individual pursuit but a collective one. Incorporating family perspectives and integrating a family approach in treatment methodologies can be pivotal in achieving holistic healing and stability. As a part of this interview series, I had the pleasure of interviewing Karina P Diaz, LCAT.
Karina P. Diaz, LCAT, LPAT is the director of a 24-hour crisis receiving center for mental health and substance misuse and has been in private practice for the last 18 years of her career. Clinically, throughout her 20 + long career; she worked with children, youth, and their families- using strategic family therapy to help bring about healing for individuals struggling with a variety of mental health diagnoses, including bipolar diagnoses. Karina has worked extensively with under-resourced immigrant families and is bicultural and bilingual; she is keenly interested in culturally sensitive interventions and has seen firsthand the benefits of working with the whole family system for individuals affected by having a diagnosis of bipolar.
Thank you so much for joining us in this interview series! Before we start, our readers would love to “get to know you” a bit better. Can you tell us a bit about your background and your childhood backstory?
Thank you! I am honored to be a part of this interview series.
Yes, I grew up in Mexico, in Chihuahua City (population of a little over a million) about four hours south of the border of El Paso, TX / Juarez, Chih. Mexico. I attended undergraduate studies at the University of Texas at El Paso and graduate studies at New York University.
I had a pretty blessed childhood. After my parents separated, I was three, and my mother (an aspiring computer engineer at the time) moved me and my sister in with my grandmother (a nurse) and my aunt (a business entrepreneur). I grew up surrounded by smart, self-starting, and nurturing women. As a teenager, my mother moved us once more to the border of El Paso/ Juarez where she proceeded to open up a computer business in the City of Juarez, Chih. MX, still running today. I learned a lot from watching her work ethic in managing a tech-oriented business as a woman in a society, where culturally speaking, this isn’t usually the norm. We traveled with my mother quite a bit as a child and this instilled in me a healthy curiosity of not only my own society and culture but of others as well. We had a different family construct than other children in the area where I lived. I believe this experience allowed me to think about what family is, outside of the traditional sense of the word. I feel very rewarded by these experiences.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“Surround yourself with people who inspire you to become even better”. As an adolescent, I felt pretty lost. I started to look for resources in people, consistently, who could mentor and guide me to improve and help me feel better about what I was doing and where I was going. One of the people I admired and sought guidance from in my early twenties was instrumental in helping me find a career path that eventually led to where I am today. During the many years of my career, I have been blessed to find other mentors in people who have influenced and helped shape my life. Witnessing others around me, who inspire me, creates in me the energy needed to take the extra step and to think outside the box of my immediate surroundings.
Let’s now shift to the main part of our discussion. Can you tell us a bit about your background and your professional career treating patients with bipolar disorder diagnoses?
Yes, I have been in practice for over twenty years in the mental health field.
During my graduate studies at NYU, I held three internships, one at Bellevue Hospital in NY, working with youth in the adolescent inpatient unit. The second one working with the residential halls at NYU to promote wellness in the undergraduate population. While I was at NYU, there was a high number of suicides; I was part of a movement initiated by the different counseling departments to introduce wellness workshops to the student body living in the residence halls at the time. My third internship was working at a family services agency, working in an under-resourced area in Brooklyn, mainly made up of first or second-generation immigrants from Spanish-speaking countries. I worked with children, youth, and their families.
After graduating, I proceeded to work at a preventive agency in NYC that focused on securing resources, including counseling, specifically family counseling, for families “at risk” of being separated by the child welfare system due to neglect or abuse. I started receiving intensive family therapy training from the Ackerman Institute in NY as well as from the Minuchin Center in NY. I was lucky that back then, the agency I worked for paid for these trainings for the years I worked there. I was just starting my career as a therapist and worked under supervision. After this experience, I worked in two mental health clinics in East and West Harlem as well as started to see private clients. I continued to train in family therapy in one of the clinics in Harlem working with adolescents and their families who had been separated and were being fostered by other families and was part of a mobile crisis clinic. I had already worked with young adults who were diagnosed with bipolar at this point but had not seen the level of impact that family therapy has to help relieve the stressors associated with the diagnosis. I was trained during this time in brief strategic family therapy. After this, I started a position leading a program for an agency specifically focused on issues of human trafficking and domestic violence in NYC, in Queens. In this agency, most of the counselors treated children and youth individually, the Psychologist at the agency and myself at the time started to form workshops for therapists in hopes of engaging the family more closely in the counselor’s workloads. Throughout these experiences, I continued my private practice work and have for the last eighteen years.
I was a director of a mental health clinic in Brooklyn and in this role, I encouraged the counselors to work closely with the parents or loved ones in family sessions and discussed these cases in supervision and clinical consultations with the psychiatrist at the clinic. The counselors and myself were trained in child-parent psychotherapy as many of the children, adolescents, and young adults had trauma in their early life. I led a clinical shift to include infant mental health in the clinic and included treatment interventions in the form of child-parent groups.
Some of the young adults, at the clinic, particularly those who had been in the foster care system had a diagnosis of bipolar, as well as, some of the adult parents of the children obtaining mental health services.
Currently, I continue to work in my practice where I have patients with this diagnosis and am running, as the director, a 24-hour crisis receiving center for adults eighteen and over, experiencing a mental health or substance misuse crisis. Many of the folks we receive at the center have a diagnosis of bipolar, are experiencing a psychotic episode, or have had a history of psychosis.
Throughout my 20+ year-long career, I have seen firsthand the benefits of incorporating family therapy in practice working with individuals diagnosed with a mental health disorder.
When you work with patients, I understand that you often integrate family or friends into the treatment process. What do you consider the 3 primary benefits of including family?
The three primary benefits, I see of including loved ones in treatment (not arranged in order of importance) are:
- Providing support for the individual diagnosed with bipolar disorder.
The diagnosis itself tends to be stigmatizing for a lot of individuals and oftentimes they feel alone and left thinking that there is something inherently ‘wrong’ with them. Having the support of family members or loved ones who are willing to learn more about the diagnosis and how to talk about it with the individual navigating the symptoms of the diagnosis has innumerable supportive elements. This level of support can enhance motivation, reduce isolation, and promote confidence, needed to remain consistent with treatment and medication management.
2. Facilitating and enhancing the quality of communication.
With the help of a therapist adept at providing a safe space for families, learning to communicate effectively and consistently becomes a focus in every session. This can help shape, strengthen, and promote healthy boundaries between loved ones. Enhancing the quality of communication also helps family members to resolve conflict in a more productive and empowered manner. Family therapy hopes to empower and support each individual within the family to communicate clearly, and it is a collaborative effort. Every member of the family in session observes and takes responsibility for their own contribution toward effective communication between them.
Distributing this responsibility shifts the blame from one person to the responsibility of a whole. People who are diagnosed with bipolar tend to isolate when in a depressed state and when and if the pendulum swings to a state that is impulsive or manic, they tend to push people away. People diagnosed with bipolar may consistently experience anxiety as a baseline. Having the opportunity to learn new ways of communicating can really empower the individual with a diagnosis of bipolar and their family members to shift perspective and see problems or potentially stressful situations in a different light. This leads to making intentional choices on how to receive and relay information to one another in a more productive way; helping the family members and the person diagnosed with bipolar to feel pride in engaging rather than feeling consistently inadequate in relating.
3. Strengthening prosocial behaviors. Engaging in the type of family therapy work mentioned above can reinforce the message that we always have the power to make different choices when relating to others and that the way we deliver a message can look different than what we are used to, and we can feel successful in employing different techniques to letting our voices and needs be heard and in turn listen more attentively to those around us. When the individual diagnosed with bipolar experiences what it is to feel safe when feeling vulnerable communicating with loved ones, confidence in relating grows; promoting prosocial behaviors in the different communities that individuals socialize in. It may even lead individuals to make different choices about who they interact with and how they interact with them in order to sustain a more supportive environment that further promotes stability and acceptance of the individual with a diagnosis of bipolar.
What are some of the challenges you run into when working with families? How do you balance responding to the needs of the family with the needs of the patient?
Certainly, the challenges in working with families are very real. One of the main challenges, in my mind, is that you as a therapist have to build trust, not only with one individual in front of you, but multiple. In working with an individual who was diagnosed with bipolar many years ago, for example, it took several in-home sessions with his grandparents and him in another room until he agreed to come into the office and have a family session. At the time, I had flexibility in doing home sessions as well as in-office sessions. Working with families requires adaptability and flexibility.
For many of us being able to have a conversation with our family members can be challenging enough, now imagine what it may be like for folks who are ambivalent about treatment, and the people in your home are the ones driving the desire to engage you in treatment. With this family I gave as an example, I respected the boundaries that the young man had at the start of treatment and also respected the grandparents’ desire to engage in family therapy. I respected the current structure long enough to build trust and to allow for the young man to engage when he felt safe enough to engage. Once he did, we agreed, that all three family members would engage in eight to twelve family-focused sessions. Respecting the current structure of a family and allowing room for the sessions to look differently until they could all be in the same room at the same time, helped all family members feel valued and respected. Within the sessions, everyone had a turn to speak up and hear each other. Family therapy requires that the family therapist believes and trusts in the process and in the innate desire to feel better.
Family dynamics can greatly vary depending on the sociocultural backgrounds of the individuals involved. How do you tailor your family approach to respect and incorporate different sociocultural perspectives and values?”
This is a beautiful question. One of the main reasons I actually gravitated toward structural family therapy as the main model I use with families is that inherently this model is built to understand and respect the family hierarchy and culture. Using this model with families, I start by building trust within their current construct to allow room for all perspectives. Through the years, I have worked with families from different socioeconomic backgrounds that are culturally diverse. My ability to respect, and acknowledge their concerns and value system by approaching them with curiosity and humility is how I build trust with all members of the family.
Likewise, inter-generational dynamics can sometimes play a significant role in the therapy process. Can you share any insights or experiences on how inter-generational understanding and communication facilitate the healing process?
In the case I shared as an example earlier in the interview, the grandparents of this young man, had become sole custodians. His father had died at a young age and his mother was misusing substances at the time, she had not been able to recover and was very absent from the family picture. This was everyone’s first time in therapy and it came about after the young man had been arrested. He underwent an evaluation and was diagnosed with bipolar. Mother had lost her rights as a parent when the young man was a child. His grandparents had become his parents at a very young age. There were vast differences in generational attitudes and perspectives about behaviors and ways of relating to one another that greatly influenced the family’s dynamic. This, together with the shared grief that grandparents and youth felt about not having their daughter and his mother home with them, was underpinning the severity of the symptoms the young man felt. Being able to hold a space where these feelings and thoughts could be uncovered by conversations and activities that could elicit emotional expression greatly reduced the young man’s isolation and anxiety. He started to feel better, engaged in treatment, and felt understood and acknowledged. Being able to strengthen these relationships was crucial to facilitating healing for this young man and his family.
Family therapy really asks that every family member be present, witness, and engage with their loved one who is diagnosed throughout every step of their recovery. This means that at every step they can learn to support one another in real-time throughout episodes of depression, or mania.
Many mental health professionals don’t have training in working with families. How did you learn the techniques you use and what would you recommend to professionals that want to learn more about this approach?
I learned these techniques by taking training in systems theory and structural and strategic family therapy for many years while working with families simultaneously, post graduate school. While training in strategic family therapy I was supervised and observed through my recorded sessions (with permission of course). We took part in ongoing consultations and studied the way we as therapists intervened. It required me to practice being okay with my own vulnerabilities and insecurities as someone in training and learning to really observe myself objectively and actively. I have continued to take courses and workshops to sharpen my skill set.
Therapists interested in learning more about family therapy do not necessarily need to have a master’s degree in marriage and family therapy to take part in family therapy training. I suggest to look for an accredited program and I would greatly recommend working with families under supervision while taking part in training especially if you are new to the process. It requires a constant look at how we perceive family and our own family of origin. Family dynamics and different situations can be triggering for the therapist aiding the family; it is important to recognize our own biases and belief and value systems. Being in our own therapy or analysis would not hurt either! I think it is responsible of us as therapists to engage in our own self work as we treat others.
Caring for a family member with bipolar disorder can sometimes be challenging and might lead to caregiver burnout. How does your approach incorporate strategies for self-care and support for family members who are involved in the caregiving process?
I often recommend and refer folks to support groups for caregivers who are taking care of a family member diagnosed with bipolar disorder. Caregivers need to know that there is support for them as well and that they are part of a larger community. Engaging in their own support outside of family therapy often helps to find other resources to continue to nurture themselves while taking care of a loved one. Taking care of the whole is important, exercise, meditation, yoga, cooking classes, and anything that can bring about a sense of comfort and calm are some things that I have discussions about in sessions. I am a licensed art therapist, and creative expression tools such as collaging, drawing, and painting are things I bring into session to facilitate the experience, and oftentimes times these activities safely experienced in sessions transcend to the home environment as well. Engaging in creative endeavors can be of great benefit and self-care for the caregivers as well as for the patient.
Preventive education is often seen as a powerful tool in managing bipolar disorder symptoms. How do you integrate education and awareness for family members within your family approach to treating bipolar disorder?
Education in family therapy is ongoing in my practice, especially in those initial sessions, it is a great way to engage the family in conversations and help create a deeper level of awareness and perspective into the experience of the individual diagnosed with bipolar. Education destigmatizes the illness or the individual’s behaviors and can elicit empathy for the individual.
Some of the behaviors associated with the illness can be exasperating for family members, it can heighten levels of frustration and irritation and can further alienate the individual diagnosed with the disorder. Education can be a great tool in every session to further understand the illness and ways to help promote recovery and wellness.
The more accepted the person diagnosed with bipolar feels their levels of motivation naturally rise. Motivation is a great tool for managing symptoms outside the session. Feeling a sense of belonging and acceptance is very important for individuals managing the symptoms of the disorder.
What are 5 things you wish more people knew about people navigating life with bipolar disorder?
1 . The diagnosis does not come before the individual.
I believe greatly in the power of language and recovery-oriented language for us in the mental health field. How we refer to patients or how we speak about a diagnosis and the person experiencing distressful symptoms is very important. Using person-centered language or using names of people ahead of a diagnosis humanizes the experience. It can make or break trust and help destigmatize attitudes about mental health, diagnosis, and treatment.
2 . Chances are high that a person with a diagnosis of bipolar has gone through trauma or traumas at one point or at different points in their lives.
It is important to be trauma-informed whether or not one is in the field of psychotherapy.
Early adverse childhood experiences are a high-risk factor and can be a precursor to bipolar disorder. Having multiple adverse childhood experiences can produce an earlier onset of the disorder. Being trauma-informed means that you recognize that adverse childhood experiences are prevalent in all communities and cultures across the globe and that we are all susceptible to the effects of traumatic experiences. Compassion goes a long way.
3 . There are different levels of readiness for a person with a diagnosis of bipolar to engage in treatment and tolerate the consistency required by the process.
The person struggling with the symptoms of the diagnosis will have a difficult time explaining why it is they feel the way they feel. Regardless, people want to talk about it with those they feel safe doing so. Try not to go into a fix-it attitude and learn to listen attentively and without judgment; who knows, if the person has not acquired treatment yet, having someone listen to them in this way could be the deciding element they need toward engaging in treatment.
4 . Do not avoid talking about the diagnosis with your loved one.
It can be difficult to speak to someone about their diagnosis or how they feel about being diagnosed with bipolar. Avoiding the conversation altogether can have the opposite intended effect and your loved one may end up feeling like they are not important to you.
5 . Knowledge really is power.
If a loved one has a diagnosis of bipolar, read up on it, and inquire about the diagnosis and treatment modalities. Call up different resources and maybe even join an educational group or workshop regarding the diagnosis, symptoms, and ways to manage. This can really open up your perspective and create a more accepting and compassionate outlook.
There is a lot of misunderstanding when it comes to mental illnesses, especially involving psychosis. What do you wish more people were aware of either in the professional field or the general public?
Yes, unfortunately, there is a lot of misunderstanding when it comes to mental illness, even in this day and age. This is why I think it is so important to have an interview such as this one.
Specific to psychosis, what I observe, in the public and even with some providers is that there is a lot of fear involving psychosis and the behaviors that may accompany it. Psychosis is usually a temporary episode where the person experiencing it, disconnects from their present reality. This episode is usually brought upon by the person having a mental health condition or misusing substances. People experiencing an episode of psychosis will likely experience fear as they disconnect from reality, and confusion and will be challenged in interacting with those around them.
I have witnessed, this as a director of a mental health clinic and now of a crisis receiving center where people experiencing psychosis are often referred to as “psychotics”, by practitioners and people in the community. The use of stigmatizing language can greatly impact the way we perceive psychosis.
Individuals who experience psychosis are rarely violent and are at much greater risk of harming themselves than others. In mental health settings where there is seclusion and restraint and a lack of trauma-informed care, the symptoms of psychosis can be exacerbated by the sheer nature of the facility. Oftentimes times these episodes of psychosis are worsened by the way providers interact with the person experiencing the psychosis, within mental health institutions. These events, or incidents then have the capacity to color the way the person experiencing psychosis is viewed.
This is why it is so important to destigmatize language, become trauma-informed, and learn more about mental health.
In the entertainment industry, dramatizing people with mental illness is often a way to bring people to the box office. Sadly, this perpetuates the misrepresentation and misinformation of mental health diagnoses. Perpetuating the stigma around mental illness and mental health care creates barriers that prevent people from seeking treatment.
One of the many things to remember about psychosis is that psychosis is a symptom, not an illness. People experiencing psychosis might hear voices as they disconnect temporarily from reality and also believe things that may not be true in the moment. While this temporary disconnect can cause unusual observed behaviors, it will not necessarily mean that the person will suddenly become aggressive. It is important to note that if we anticipate aggressive behaviors while interacting with a person experiencing psychosis and startle, threaten, or set strict limits and overact we may cause even more fear for the individual, and may inadvertently incite the individual to act out aggressively. As the person disconnects from the present, they too are experiencing a number of very confusing messages about their immediate reality, behaving in ways that present as unusual and scary to those who are observing. Highlighting even more so, the need to educate and include family or loved ones in treatment.
As well, there are many signs to look out for before an episode of psychosis ensues. An early onset of psychosis tends to be gradual, and connecting the person as soon as possible to treatment can be life-altering for the individual and heightens the chances of that individual living a fulfilling life.
It can be challenging to distinguish early signs in a young person between normal developmental transitional changes in behavior and signs pointing in the direction of mental illness but these changes could indicate the need for an evaluation by a mental health practitioner. Usually, people who can spot these signs are those closest to the individual or that live in the same household.
Things like a drop, in grades or work performance increased trouble in concentrating or thinking clearly. A sense of suspicion or uneasiness with others or a decline in personal hygiene, isolation, and increased intensity of emotional reactions or lack thereof, when explored and assessed early can provide the best hope of recovery.
We are very blessed that some very prominent names in Business, VC funding, Sports, and Entertainment read this column. Is there a person in the world, or in the US with whom you would love to have a private breakfast or lunch, and why? He or she might just see this if we tag them. 🙂
How can our readers further follow your work online?
I do have a website! Karina Diaz Therapy | New York Therapist
Thank you for your time and thoughtful answers. I know many people will gain so much from hearing this.
About The Interviewer: Stephanie Greer, PhD is the Co-founder and CEO of Akin Mental Health — a company dedicated to guiding families on their journey supporting a loved one with mental health challenges like bipolar disorder, schizophrenia and severe depression. Stephanie is passionate about this topic from her own personal experience growing up with a mother who struggled with bipolar 1 disorder and found a path forward to overcome the obstacles and live well. Stephanie’s professional experience includes a doctorate in neuroscience as well as design research roles at Hopelab and Apple. Stephanie brings this personal passion together with her world-class science and technology background to support families across the US in their personal journeys supporting loved ones with mental illness. To learn more about Akin Mental Health and join our community, visit us at akinmh.com.
Karina Diaz On The Benefits of Using a Family Approach for Treating Bipolar Disorder was originally published in Authority Magazine on Medium, where people are continuing the conversation by highlighting and responding to this story.