Mental Health Resources for Residents and Clinical Fellows

By Ana Dolatabadi, PsyD, MA

The physician’s encounter with patient suffering and death inevitability tugs at the existential nature of one’s own mortality. This can cause inner conflict which may originate from the intrinsic and inescapable experience of death and the human being’s existence in the world relating to meaning, purpose, and value. Aase, Nordenhaug & Malterud (2008) reported that most physicians could deal with patient death but “mostly keep it at a distance” especially since vulnerability was perceived as “a burden to be handled” (pg. 768). Physicians can have strong emotional reactions to patients’ death. Grief-related job stress can lead to burnout, which on average affects more than 50% of physicians (Medscape Lifestyle Report, 2013). By confronting one’s own existential anxieties there may be more of a capacity to address patient anxieties and better process and cope with patient death.

You may still be asking yourself, why entertain this dark, scary, and unavoidable aspect of life when I don’t even have time to do laundry? The fear of having to investigate overwhelming negative feelings could dissuade you from internal investigation. The conscious exploration of this matter can often be ignored in developing and seasoned physicians alike due to time and space. This may result in a continuous undercurrent of “death” anxiety or perhaps, occasions of unruly eruptions of fear unconsciously manifesting itself in various forms. Death anxiety refers the fear of and anxiety related to the anticipation, and awareness, of dying, death, and nonexistence (Gellman & Turner, 2013). This anxiety can also contribute to symptoms of worry, depression, and stress. Confronting your own mortality and existential anxieties can help to reduce stress and, suffering, and allow you to reenter life in a richer, more meaningful, and compassionate way. Furthermore, it can make you feel more connected to your patients and their family’s experiences of losing a loved one.

For the growing physician, adjustment to medical culture and evolving professional identity — moving from student to expert — is in development. Combining this process with the increased exposure to patient suffering and death can potentially make it even more difficult to address existential anxieties and can result in prioritizing career enhancement over emotional and psychological well-being. Unhealthy coping strategies such as overworking, needing to control, and having a sense of personal omnipotence may arise in efforts to achieve symbolic immortality, defined as a quest to obtain a sense of continuity or imperishable legacy in efforts to stay connected to human life even after death (Lifton & Olson, 1974; Yalom, 1980). Physicians may also absorb the identity of being "godlike" and "all-powerful" when patients place them in that role in efforts to cope with their fears. The more "godlike" one believes themselves to be, the more one views the self as immortal, reinforcing the denial of one’s own death. 

So where do we begin? 

1. Acknowledgment that it is frightening to take a hard look at our death and existential anxieties. If we can acknowledge our anxieties with courage we have an opportunity to attend to our existential thoughts and behaviors, bringing it out of the shadow of our experience.
2. “Meaning is something to be found, not given. Man cannot invent it but must discover it” (Yalom, 1980). When facing our own mortality and finitude of our human experience we may ask ourselves, why am I here? What gives my life purpose? What do I want from life? Where is the source of meaning for me in life? And in contemplation of these questions we can look at the current forecast of our experience and further ask ourselves, do I like the direction of my life? Am I pleased with who I am? Am I aligned with my values or is it time to let go of values that no longer serve me or are out of alignment with what makes me feel alive?     
3. One avenue to meaning is found through interpersonal relationships with family, friends, colleagues, romantic partners, community, and even our patients. We impact those around us and are interconnected to the world and the lives of others. This knowing can remedy our sense of isolation or loneliness.  In contemplation of this we may realize this is an area in our life we want to enhance.  

Finally, seeking counseling services and working collaboratively with a professional can provide a supportive environment to explore existential thoughts, feelings and experiences both personally and professionally. If you are interested in setting up an appointment through the Faculty & Staff Assistance Program, please call 415-476-8279.

Citations

Aase, M., Nordrehaug, J. E., & Malterud, K. (2008). “If you cannot tolerate that risk, you should never become a physician”: a qualitative study about existential experiences among physicians. Journal of Medical Ethics, 34(11), 767-771.

Gellman, M. D., & Turner, J. R. (2013). Encyclopedia of behavioral medicine. New York, NY: Springer.

Lifton, R. & Olson, E. (1974). Living and Dying. New York: Praeger.

Medscape Lifestyle Report. (2013). Physician lifestyles – linking to burnout: A Medscape survey. Retrieved from http://www.medscape.com/features/ slideshow/lifestyle/2013/public#1

Yalom, I. D. (1980). Existential psychotherapy. New York, NY: Basic Books

Yalom, I. D. (2008). Staring at the sun. San Francisco, Ca: Jossey-Bass.

By Andrew L. Parker, Ph.D.
 

Just as the level and complexity of stressors affecting the practice of medicine have reached an unprecedented degree, physicians are being held accountable as never before for angry and disruptive behavior in the workplace. Among the stressors facing physicians today are increasing caseloads, regulatory restrictions, and hospital bureaucracies along with decreasing autonomy and authority. At the same time — particularly under the impact of managed health care — physician’s incomes are decreasing as the cost of malpractice insurance (not to mention medical education itself) has been rising. The combination of these and other factors has made the practice of medicine more challenging, and more frustrating, than ever before — and many physicians have reacted to these frustrations with angry behavior that hospital administrators have begun to treat with increasing seriousness and even disciplinary sanctions (up to and including dismissal). The purpose of this article is to address the need of physicians in today’s medical care environment for effective ways of recognizing and coping with these stressors, and in particular for understanding and managing their anger.

There are several key points to understanding the phenomenon of anger and managing tendencies toward angry behavior:

• Anger is an emotion, and as such it is intimately involved in the body’s neurophysiologic functions — especially so-called “fight-or-flight” reactions, adrenaline release mechanisms, and the autonomic nervous system (particularly sympathetic arousal and “kindling” processes).
• Like all emotion, anger is a largely involuntary, subconsciously triggered reaction to how we are affected by internal and external stressors; the stressors that typically trigger anger as an emotional reaction are various forms of frustration (obstructions to our actions or efforts) and/or pressure (demands on our time and energy).
• Anger runs a wide spectrum from mild irritation and annoyance through resentment and exasperation to rage, wrath, and fury; by the same token, it can manifest in a wide range of behaviors including contentiousness, argument, and intimidation to hostility, belligerence and violence.
• As frustration and pressure are facts of life, so is the emotional reaction of anger; however, while angry emotions may be virtually inevitable, angry behavior is not; we must distinguish between the emotion and the behavior, and realize that we are always responsible for the behavior — it is a dangerous form of self-dishonesty to believe that "we can’t help it," i.e., that people, places and things "make us" behave angrily, or that our justifications for angry behavior somehow excuse it. Remember: it is angry and disruptive behavior that physicians are held accountable for, not their emotional reactions.
• Learn to recognize the "early warning signs" of anger, e.g., physical tension and physiological arousal, angry thoughts and feelings of resentment or injustice; once recognized, always acknowledge the anger to yourself and then re-focus your attention on the stressors (frustrations and pressures) that have triggered it.
• Some of the most effective anger management tools apply less during emotional outbursts than between them: making sure you have adequate rest, exercise and a balanced diet, regularly letting go of grudges and resentful thoughts toward others, recognizing the destructive impact of our angry behavior on others, making amends when it has harmed them, practicing mindfulness techniques, and making good use of a faculty mentor to talk over difficulties. Such practices reduce the frequency, duration, and intensity of angry outbursts and make them easier to recover from.
• During the "storms" of angry outbursts, simple is best: If you can, take a brief time out to cool down; even if you can’t, taking a minimum of 20 slow, deep breaths will both calm you physiologically and emotionally, as well as disrupt the cycle of reactivity that drives the anger, by taking your attention off what is distressing you and promoting self-awareness.

In summary, the principles of anger management are essentially simple, but not so easily practiced. Angry behavior provides a significant discharge of tension and release of adrenaline; it can literally become addictive. At bottom, anger is the most energetic emotion and in that sense angry behavior is just a form of misdirected energy. Before you allow that to happen, ask yourself:  "What else could I be doing with all this energy?"

We at the Faculty and Staff Assistance Program can provide you with counseling services as well as referrals for therapists in the community. FSAP services are free and confidential and available for both personal and work-related issues. Please contact us at 415-476-8279 or visit the Faculty and Staff Assistance Program site for more information.

By Toni R. Galace, PsyD
 

As residents you constantly juggle different roles and expectations. The amount of hours you work each week, the clinical knowledge you have to master, and maintaining a work/life balance can leave you feeling overwhelmed and prone to burnout (McCray, Cronholm, Bogner, Gallo, & Neill, 2008). With your adrenals in overdrive, you may be asking yourself, “How do I manage all of this?” when no amount of medical training has taught you how to mitigate burnout within an extremely busy schedule. When pressed for time, it can be a battle to meet even the lowest rung of Maslow’s hierarchy of needs. That is, developing a self-care routine where you can eat properly, sleep sufficiently, and/or exercise begins to feel more like a luxury than a necessity. Perhaps you have been working around these basic needs by eating sugary snacks, sleeping less, drinking coffee or energy drinks, or walking the halls of the hospital and calling that exercise. But unhealthy eating habits and working with too few hours of sleep is not sustainable; keep at it long enough and it becomes ineffective at best and damaging at worst — to yourself and potentially to your patients.

Just to be clear: I am not writing to metaphorically preach to the choir of physicians who already know how to take care of the human body. I am reaching out to residents who, despite being seen by most others as Herculean, are actually stressed, tired, and also in need of care. That’s right: You are human, too, and you deserve to be treated with the same kindness, caring, and compassion you show your patients. However, is it possible to prescribe this kind of compassion to yourself?

To be where you are now — at a leading university that provides world-class care — means you are an extremely intelligent, passionate, and driven individual. By the same token, I wonder if some of your successes were fueled not only by self-sacrifice but also perhaps by being self-critical and hard on yourself. In the medical field you live in a culture where mistakes and failures are often internalized, eliciting negative emotions such as embarrassment and shame. Additionally, perhaps in order to get through medical school and residency, cracking the whip of self-judgment at times motivated you to succeed. As a resident, however, feeling stretched thin, ever pressed for time and under constant evaluation, that tough inner critic may now be doing you more harm than good. Instead of fighting against the negative emotions or just pushing past the discomfort (Germer, 2009), it is time to consider a different and more beneficial practice to deal with your distress: self-compassion.

First, compassion itself means to “suffer with” and entails the same feelings you have towards others. That is, you notice another person is suffering and then you are moved in such a way that your heart responds to the other person’s pain as a fellow human being. You consequently feel a caring and the desire to help ease their suffering (Neff, 2009). So, too with self-compassion: You notice the distress you are experiencing, the pain and discomfort it causes you, and then respond in a kind way that eases the suffering. More concretely, Neff (2009) described three elements of self-compassion: self-kindness, common humanity, and mindfulness. Self-kindness involves having warmth and understanding toward yourself when you fail, feel inadequate, and suffer; these experiences are inevitable and cannot be entirely avoided or made to disappear with either denial or harsh criticism. Common humanity reminds us that we are all connected and we all suffer; rather than personalize and feel alone in facing life’s difficulties, you can remember that you are not the only one to make mistakes. Lastly, mindfulness is a non-judgmental stance of observing your emotions and thoughts, without either suppressing things or building them up so that you get caught in the negativity. Mindfulness builds on compassion and self-kindness, allowing you to relate your experiences to the bigger picture and remain empathic to yourself.

Now, please do not make the mistake of thinking self-compassion is self-centered or selfish, as though paying a little more attention to yourself means caring for yourself at the expense of others or putting yourself above them (Germer, 2009). Nor does practicing self-compassion make you weak; on the contrary, practicing self-compassion benefits everyone. Indeed, the more empathy you have toward your own flaws and idiosyncrasies, the more empathy and patience you will have in caring for others (Germer, 2009). So let us try another path outside the usual fare of stoicism, criticism, and blame.

How to change your critical self-talk

(Adapted from Neff, 2009)

• Be cognizant of when you are self-critical. For example, when you feel bad about something, what do you say to yourself? Are there key phrases that come up again and again? Is your inner voice angry, distant, or condescending? Learn to become mindful of when your inner judge becomes active and harmful.
• Address the self-critical voice with compassion, not self-judgment. For example, when you hear the inner critic say, “You’re such an idiot, what were you thinking?!” respond with something akin to, “I know you’re trying to point out and help me overcome my shortcomings, but the negative attitude causes me more pain than comfort.” Negative self-talk feeds into feelings of anger, irritability, or exhaustion whereas compassion feeds kindness, forgiveness, and patience.
• Reframe the observations your inner critic makes in a more positive and friendly way. If you are having a hard time coming up with the words, imagine what a good friend would say to you. Following the example above, you could say, “This has nothing to do with your intelligence. You were really pressed for time. With your quick thinking and skills you did the best you could.” Furthermore, while engaging in this positive self-talk, gently stroke your arm or pat yourself on the shoulder. Yes, it may seem silly, but the physical gestures tap into the caregiving system, releasing oxytocin and reducing stress. Therefore, if you start to act kindly toward yourself, feelings of warmth and caring will follow.

Like going to the gym, this mental exercise to change your critical self-talk will take time and practice to develop. Putting in the effort will lay the groundwork for how you can relate to and take better care of yourself (Neff, 2009), and you will be particularly better equipped to take the difficulties of your rotations in stride. Additionally, if things start to feel overwhelming, reach out to your support system for help or contact the Faculty and Staff Assistance Program. Our services are free and confidential and we provide counseling for both personal and work-related issues. We also provide referrals to mental health practitioners in the community. Please contact us at 415-476-8279 or visit our Faculty and Staff Assistance Program site for more information.

For more exercises and to test how self-compassionate you are, visit Dr. Kristin Neff's site on self-compassion.

References

• Germer, C. K. (2009). The mindful path to self-compassion: Freeing yourself from destructive thoughts and emotions. New York, NY: The Guilford Press.
• McCray, L. W., Cronholm, P. F., Bogner, H. R., Gallo, J. J., & Neill, R. A. (2008). Resident physician burnout: Is there hope? Family Medicine, 40(9), 626-632.
• Neff, K. (2009). Self-compassion: A healthier way of relating to yourself. self-compassion.org.

By Joseph Zamaria, PsyD
 

The time that you spend in residency is likely one of the most challenging periods of your career as a physician, and these challenges can seemingly come from all directions. A high workload, learning on the fly, and constantly being evaluated are all par for the course. These difficulties may arise during the early stages of training, while transitioning from medical school to internship — and coincide with the stresses of potentially having to relocate and coping with the change in role from student to physician. Some challenges arrive at later stages, such as job searching or preparing to apply for fellowship. The fact remains, however, that the expectations placed upon you during residency are particularly demanding.

High expectations may certainly come from external sources — from supervisors and attending physicians, and from the reality of having to deliver optimal patient care and safety. On the other hand, another source of these expectations may be from within. High achievers naturally have high expectations for themselves, accompanied by an inner critic that preaches the importance of success. This can be useful — you would not have gotten where you are today if not for your drive and your ability to achieve. However, if those high expectations turn into excessive self-criticism, demanding success to the point of perfection, they may be adding more to the problem than to the solution.

Enter self-compassion. This construct, new to the field of social research, was coined by Dr. Kristen Neff, associate professor of human development and culture at the University of Texas at Austin. Dr. Neff states that feeling compassion for the self is very similar to the feeling of having compassion for others (not an uncommon experience for physicians).  That is, self-compassion comes from validating your own experience (e.g. “this is indeed so stressful right now — most anyone would be having a hard time!”) and with addressing it in a kind manner (e.g. “what can I do to take care of myself at this time?”).

According to Lars-Eric Petersen from the University of Halle-Wittenberg’s Department of Psychology, “self-compassion is a self-regulation strategy for countering negative self-directed feelings and emotions.” He goes on to state that “highly self-compassionate people treat themselves with kindness, care, and concern when facing negative life experience.” In other words, those who exhibit the highest degree of self-compassion are those who can most adaptively cope with external life stressors through the use of kindness.

So, how does one operationalize this concept? How to put rubber to road? There are a variety of techniques that can be used to cultivate self-compassion. Dr. Neff has techniques and exercises, as well as more resources, available for free on her website, selfcompassion.org. Most of the exercises, such as “Changing your critical self-talk,” can be completed in just a few minutes, with little more than a sheet of paper. She also provides seven downloadable guided meditations, each approximately 10 to 20 minutes in length, which can help to recognize critical emotions and thoughts and to develop a more self-compassionate mindset. As with the development of any new coping strategies, it may take consistent practice over the course of a week or two to begin to feel the benefits of the self-compassion exercises.

One exercise to try is the “Self-compassion break.” For this exercise, follow these steps:

• Sit down, and think of a situation in your life that is causing you anxiety or stress. Really try to bring this situation to mind, and see if you can feel the discomfort of this in your body.
• Acknowledge the stress (e.g., “Yuck.” “I can’t stand this.” “This sucks!”).
• Acknowledge that stress and suffering is a common part of human experience (e.g., “I’m not alone in feeling this way,” “I’ve struggled before in my life.”)
• Express kindness to yourself, in the face of the challenging or stressful situation (e.g., “I’m doing the best I can with this,” “I accept myself as I am,” “I commit to giving myself the compassion that I need to get through this.”)

Another exercise to cultivate self-compassion is “How would you treat a friend?” In this exercise, follow these steps:

• Consider a time when a close friend or family member was struggling with something, and is “beating himself/herself up about it.” Imagine how you’d respond in this situation, what you’d do or what you’d say to your friend, and write it down.
• Next think about times in which you have struggled or have “beaten yourself up.” Think about what you do, or what you say to yourself in these situations, and write it down, including the tone you use to speak to yourself.
• Note any differences between what you’d say to your friend and what you’d say to yourself. Try to think about why there is a discrepancy, if there is one.
• Finally, write down how you think you would respond if you treated/spoke to yourself the same way you would to a friend.

With both of these exercises, practice and consistency are important. Try doing one of them 2-3 times per week, for a couple of weeks, before making any judgments about whether it is helpful. It usually takes about that long for the effects to sink in. If you would like to hear more from Dr. Neff, she also has brief and full-length lectures available online, including a full-length TED talk. Most are available on YouTube.

High achievers, prone to negative self-talk, may also be reticent to ask for support, especially professional help. Concerns may abound, such as worry that peers or supervisors will find out that they are struggling. Sometimes, all it takes is a brief conversation with a co-worker, friend, or family member to feel just a little relief from the stress of overly high expectations. However, it may take more. One resource available to all faculty and staff, including residents, fellows, and postdocs, is the Faculty and Staff Assistance Program (FSAP). Staffed by clinical psychologists and clinical psychology postdoctoral fellows, FSAP provides no-cost and confidential counseling for personal and work-related issues. For more information or to set up an appointment, please call us at 415-476-8279 or visit our Faculty and Staff Assistance site.

References

• Kristen Neff
• Neff, K.D. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2, 85-102
• Peterson, L. (2013). Self-compassion and self-protection strategies: The impact of self-compassion on the use of self-handicapping and sandbagging. Personality and Individual Differences, 56, 133-138.

By Manuel Manotas, PsyD
 

Imagine you are about to make an important case presentation to your medical team. All the residents, fellows, your attending and other senior faculty members are present. The room is across the hall from a very noisy nursing station and the audio/visual systems are not working; you won’t be able to use your PowerPoint presentation and you will virtually have to yell to be heard in the back of the room. Suddenly, you feel your chest tighten, your palms begin to sweat, your heart is racing and your breath shallow. You begin thinking about how your colleagues will judge you during the conference. You feel light-headed and fear kicks in — you know you are not well enough prepared! This thought pumps up your worry and you remember an old idea that you are a bad presenter. You begin to recall how terribly you have presented in the past and in your mind, you screw up this presentation too. You will do a terrible job and end up humiliated and criticized by your supervisors and colleagues. You are now frozen in fear.  In this mind/body state, it will be nearly impossible for you to deliver the presentation you have so well prepared. This is an example of how easily our mind and its future-tripping habits can control us in the present. Fortunately, we can learn to observe our thoughts and feelings in the present moment without getting caught up by them. This is called mindfulness.

In 1979, at the University of Massachusetts, Jon Kabat-Zinn Ph.D., began to teach mindfulness meditation to chronic pain patients who had exhausted all other medical and surgical alternatives. He brought this 2,500-year-old practice into the medical setting without the religious component of its origins and developed a curriculum, Mindfulness Based Stress Reduction (MBSR), which is now taught and researched in over 400 universities and medical centers across the United States. Research studies have demonstrated MBSR training reduces symptoms of depression, anxiety, and perceived stress; it has been shown to help patients with GI distress, high blood pressure, cardiovascular disease, sleep problems and chronic pain. Recent neuroimaging studies show gray matter increases in the areas of the brain associated with memory, empathy and emotional self-regulation following mindfulness training. In addition to the long term benefits of mindfulness training, there are immediate benefits including relaxation, reduced stress, and improved emotional regulation. At UCSF, the Osher Center for Integrative Medicine, teaches the full 8-week MBSR class and has an active research program investigating applications of MBSR to a wide variety of health conditions. Participating in an MBSR class can be a life changing experience. During residency, however, it may be impossible to take a full class due to its significant time commitment (eight weekly 2-hour classes, 45 minutes of daily practice and a full day retreat). Fortunately, there are many ways you can begin to develop mindfulness. When the time is limited, short practices throughout the day have beneficial effects.

Kabat-Zinn defines mindfulness as a way of "paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally." When truly in the immediate moment our perception is more accurate, and we respond simply and appropriately to the issue at hand by recognizing our feelings, thoughts or emotions and without identifying with them. This is very different from how we usually get caught up in our mental and emotional reactions, which are based on a story we tell ourselves based on past experience. With mindfulness training, we learn to recognize our stories and begin to free ourselves from their push and pull on our mind.

Re-imagine the presentation situation at the beginning of this article. This time, when you notice your body tightening and heart racing, you are able to acknowledge these feelings and the thought: "Here I go again — always screwing up presentations." Instead of believing this thought as true, you take a deep breath, feel your feet on the ground and notice how your body relaxes and your thoughts slow down. Simply observe the thoughts, sensations and feelings that arise without fighting them, acting them out, or even judging them. This frees you from old ideas and bodily tensions and allows your energy and attention to re-focus on your current presentation. The sooner you recognize old patterns and refocus, the easier it will be to disengage from unhelpful thoughts and reactions. When you are pressed for time, there are many simple practices that are helpful. Below are a few you might want to give a try.

One-minute meditation

• Stop what you are doing/thinking
• Close your eyes 
• Feel your body sensations as they are (do not think about your body, but actually feel its sensations)
• Focus your attention on your breath, notice how it feels in your nostrils when the air flows across them — cool on the in-breath, warm on the out-breath.
• Choose an area of bodily sensation and focus your breath there. For example, you might focus your breath on the tension in your abdomen and notice how it expands and contracts with each inhalation/exhalation. 
  • Expect your mind to wander and get distracted. This is what minds do. 
  • Every time you notice your mind wandering, simply bring it back to your breath, without judgment.
  • Letting go of judgment and self-criticism is an important part of this practice. 
  • Practice frequently, and extend your practice time (5-10 minutes) as your schedule permits.

Daily mindful activity

It can be very helpful to develop this habit. Choose an activity that you do on a daily basis (e.g., teeth brushing) that is simple and repetitive and does not require much thinking. Commit to bringing your full attention to this activity. For example, while brushing your teeth, feel how you hold the brush, how your hand moves, the sensation of the brush in your mouth, the flavor of the toothpaste, etc. Be prepared for your mind to wander and get distracted into thinking about something else (Did you order those patient labs?!). As soon as you notice that you have drifted, bring your attention back to the sensations of your body as you do your activity. Remember that the mind’s tendency is to drift and this will happen repeatedly — don’t use this as an excuse to beat yourself up. Beginning this practice can be very challenging and you may get lost in distraction the whole time. As you practice bringing your attention back again and again, your mind will begin to habituate to being in the present moment. 

Mindful movement

You don’t have to take a yoga class to get the benefits of mindful movement. Throughout the day, you can introduce very brief times (as little as 1-2 minutes) when you simply stretch while being aware of your body sensations. This simple exercise connects and grounds you. Our body is how we operate in the world, it is not separate from our mind and it is a powerful tool that is always available to bring our attention back to the present moment.

Mindful deep breathing

Deep, purposeful breaths have a very powerful calming effect. It is easy to undervalue the power of this simple practice. When tensions are high and anxiety rampant, we tend to take very shallow breaths or hold the breath. Counter this by taking a few deep, regular breaths to activate the parasympathetic nervous system and the relaxation response. 

Although mindfulness and other coping mechanisms can be effective strategies in coping with everyday stress, at times work or personal problems can interfere with your functioning and you could benefit from some extra support. The Faculty and Staff Assistance Program (FSAP) can help you by providing you with counseling services as well as referrals for therapists in the community. FSAP services are free and confidential and available for both personal and work-related issues. Please contact us at 415-476-8279 or visit our Faculty and Staff Assistance Program site for more information.