Psych Central Professional For mental health, psychiatric and psychological professionals. Sat, 04 Jul 2015 11:30:09 +0000 en-US hourly 1 Understanding Return on Investment Sat, 04 Jul 2015 11:30:09 +0000 In this article, you will discover how to implement a return on investment formula, when to use it and how to make more money with your ROI formula.

ROI means “Return on Investment.” Understanding ROI is one of the basics of running a business. Understanding a basic return on investment formula can help your best utilize your marketing dollars.

Why a Return on Investment Formula Matters

Here are examples of how you may want to spend some of your private practice money:

  • Google Adwords
  • A local newspaper advertising
  • Sponsor for an event, like TEDx or a golf outing
  • Paying for a private practice coach
  • Going to a conference
  • Attending an e-course

Having a return on investment formula can help you make decisions on what will work and what won’t with your hard earned money. 

You’ve probably heard how the people that made money during the gold rush weren’t the gold seekers, but those selling tools. That is often the case in the internet and business world as well. Those that teach can often make more than those that are doing the actual work. So it is essential that you discover how to decipher the best ROI. 

Figure Out the Worth of a New Client

I know this sounds weird. I’m not saying that your clients are each inherently worth more, but rather that we can determine the financial expectations of a new client.

These are your first steps in your return on investment formula:

  • Pull your financials for the past six months. These should have your income, total sessions, and expenses.
  • How long did your average client see you? Figure out the average. There are clients that see you once, another may come 20 times and others may see you six times. Add up the total sessions and divide by the total clients.
  • How much does each person pay? Imagine that each person sees you six times and you charge $175, then they are “worth” $1,050.

Determine the Cost of Each Client

The basics of determining the worth are fairly straight forward. 

  • Add up all your expenses for a month: rent, marketing, website, office supplies, etc.
  • Divide this amount by the number of sessions you have per month.

Example: Your expenses for the month are $2,000 and you see 10 people per week. So you have 40 sessions per month. $2,000 divided by 40 = $50 cost per client. 

When you are figuring out your return on investment formula, you may want to change numbers to see how they change the ROI. For example, if you see more people or raise your prices, the return on investment formula changes.

What’s the Return on Investment Formula for Products?

Up until now, I have shared the return on investment formula for a client-based business. That model is based on one hour of time equaling a specific amount of client time. In a consulting practice or counseling practice, this return on investment formula makes sense.

As counselors or consultants start to expand their businesses they begin to add:

  • Passive income streams
  • E-products like e-courses or Mastermind Groups
  •  Additional employees or contracts

The same return on investment formula still applies:

  1. How much is the investment?
  2. How much is the product?
  3. Divide it to discover your Return On Investment.

Here’s a case study:

Jane is launching an e-course. She’s going to invest in LeadPages, Zippy Courses, a new DSLR camera, a lav microphone, and screen recording software. The total cost of her equipment is $800. 

Jane decides to do some Facebook advertising for a webinar as a lead magnet for her new e-course. She pays $400 for highly targeted marketing. 

Her total investment is $1,200. 

However, she also spent 20 hours planning, recording and implementing her course. She’s a counselor that charges $150 per session, so her opportunity cost is $3,000. So she wants to figure out the return on investment formula for the $4,200 in time and equipment. 

Let’s play with some of her numbers:

  • If she charges $495 per person, she will need nine people to break even
  • If she charges $995, she will need five people

Creating Your Own Return on Investment Formula

We each have different reasons we want a return on investment formula. In creating yours, make sure you determine all of your costs, your investment in marketing or consulting and your expected client engagement. 

Calculator photo available from Shutterstock

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Four Easy ways to Improve Your Therapist Website Fri, 03 Jul 2015 11:00:18 +0000 Your website provides a crucial first impression to your potential clients. If someone seeking therapy is impressed by your website, it’s likely they will book a session. But if your website is poorly designed, potential clients may leave your site – and never come back.

However, many therapists are intimidated by the thought of improving their website. After all, they are therapists, not web developers!

Fortunately, there are easy ways to improve a therapy website that anyone can do. I’ve listed my four favorite ones below. Of course, this is just scratching the surface – there are a wealth of web design tips for therapists that you can explore. But these four tips are an excellent way to get started on improving your website. Let’s dive in!

Add a Photo of Yourself

Research shows that when a photo of a person is added to a website, visitors to that website become 50-100% more likely to make a purchase.

So add a photo of yourself to your website! A good photo helps clients connect with you, it draws in their attention and it makes your website look unique (because no other website will have a photo of you).

And don’t bury your photo on your “about me” page. Put it in the homepage, somewhere where people can see it when they first load the website. Let your photo help make a positive first impression when someone comes to your website.

Finally, make sure that you use a quality photo. If you have the budget for it, I recommend that you hire a professional photographer.

If you can’t get a professional photographer, still try to make your photo as good as possible – dress nicely, get good lighting, use a high quality camera, etc. If your photo is not very good, clients might assume that your therapy will be low-quality also.

Keep Your Paragraphs Short

People read differently on the internet. They skim instead of reading in depth, and if they get bored, they’re quick to go somewhere else.

That means you need to write differently when on the internet. Specifically, you need to keep your paragraphs short. You’ll notice that all of the paragraphs in this article are only a few sentences long – and you’ll also notice that you haven’t lost interest.

When you have short paragraphs, it’s easy for people to quickly skim through your material. They won’t get bored, because finishing a paragraph feels rewarding and they don’t get intimidated by a big block of text. Of course, it’s fine to have long paragraphs on occasion – but normally, short blocks of text are your best option.

Writing short paragraphs is pretty easy. One way is to try to add a line break every time you move on to a new idea.

Another way is to just add a line break every three or four sentences. It will take some practice to adjust your writing style (especially if you are used to dense academic writing), but your website visitors will thank you.

Keep Your Blog Updated

A blog is a great idea for many therapists. Unfortunately, if you never update your blog, it can become a liability. If your last blog post was years ago, potential clients might assume that you have gone out of business, or that you aren’t very tech-savvy.

So if you have a blog, keep it updated. You don’t need to be writing every day, of course. But try to put a new post out once per month. One easy way to make sure you stay updated is to write several blog posts at once, and then release one per month. That way you can set aside one day to focus on writing blog posts, and then you don’t need to worry about it for several months.

Drawing a blank on what to write about? An easy option is to write a book review of a therapy-related book. Of course, you need to read the book first – but once you’ve read a book, it’s usually fairly easy to review it and tell your website visitors if it is a helpful resource.

You can also a do a “link round-up,” where you compile several useful links and put them in a blog post. For instance, you might write a blog post about 10 great articles for understanding depression or 10 YouTube videos that offer helpful tips for anxiety.

Ask For Honest Feedback

A little feedback can go a long way. Because you designed your website, it’s difficult for you to accurately gauge its strengths and weaknesses (much like how parents have trouble accurately judging their children).

That’s what it’s crucial to get feedback from others. Having another pair of eyes to look at your site can help you notice opportunities for improvement that you missed, and can also alert you to potential problems.

So I recommend that you ask your friends and family member to use your website and offer you honest feedback. You can have them pretend to be a client or simply give their first impression. Stress to them that you’re looking for honest feedback and they should give you a wealth of information.

And then use the feedback you receive! Of course, not all feedback will be good. But think critically and look for opportunities to improve your website based on what your friends and family shared with you.

Web design concept image available from Shutterstock

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The Difference Between Male and Female Narcissists Thu, 02 Jul 2015 19:28:24 +0000 http://5.157 narcissists male femaleToo often, narcissism is portrayed as an overly aggressive male disorder. It is not. Females can be narcissistic as well although it might look a bit different from males. Meryl Streep in her role as Miranda Priestly in “The Devil Wears Prada” did an excellent job portraying a narcissistic female boss. Michelle Pfieffer did as well in playing a narcissistic mother in “White Oleander.”

There are several areas that the difference in sexes can be seen. But because this is a disorder, there will be crossover of similarities. Yet, all of this is consistent with the DSM-V definition of narcissism.

Appearance. Narcissists in general believe themselves to be attractive and are usually well groomed to attract attention. While males combine their attractiveness with charm to accomplish a goal, females use it to gain superiority. Most females tend to be obsessed with their appearance sometimes resulting in numerous plastic surgeries.

Seduction. Both male and females narcissists are generally gifted in the art of seduction, but how they seduce is different. Males use their charm to entice a mate. Females use their bodies to allure a mate. This can sometimes be seen in provocative clothing. This is different from a Histrionic Personality Disorder (HPD). HPD’s continually wear inappropriately revealing clothing whereas a narcissist does it selectively for a specific person or to accomplish a goal.

Confidence. Narcissists cover their deep rooted insecurity with a belief that they are “special.” Males tend to be self-confident, gaining their assurance from within. Females gain their poise from comparing their superiority over others. They feel good about themselves when others are beneath their own standards of excellence.

Money. The love of money is strong for narcissists as they believe money gives them power, control, success, status, and dominance over others. Males are preoccupied with obtaining money at all cost, including stealing it from family members. Females enjoy excessively spending money. Both do their behaviors without any shame or remorse for their actions.

Fidelity. If a narcissist fails to get the attention they believe they deserve, they will seek it from outside a committed relationship. While both can be unfaithful, males tend to be serial adulterers. Females act more like black widow spiders, idealizing their mate to attract and them emasculating them. For the spouse or partner, the more they give, the more the narcissist wants. It becomes insatiable.

Children. Narcissists like to raise baby narcissists. Often they pick a favorite child and focus all of their efforts and attention on that child. The other children are left feeling inadequate, unworthy, and insecure. Males generally view children as a nuisance, frequently complaining that they, not the children, should have all the attention of their spouse or partner.  Females view children as an extension of themselves, even when the child is an adult. Everything the child accomplishes is a reflection of their superior parenting.

Competition. Nothing proves supremacy quite like competition for narcissists. They love an opportunity to excel over others at work and home. While the competitiveness is frequently praised in a job, it is not amongst family. Males treat other males as rivals. This can be seen in brother/brother and parent/child relationships. Females battle with other females for dominance. This is seen in sister/sister and parent/child relationships.

This is not a complete list of differences, rather it is meant to bring awareness as to the many ways narcissism can be portrayed.

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The Stress Spectrum Wed, 01 Jul 2015 12:00:08 +0000 At almost every moment of our lives, we are affected by stress. Whether enjoying a sense of thrill – one end of the stress spectrum – or struggling with burnout or trauma symptoms at the other end, managing stress is central to the experience of being human.

This post, drawn from my recent study on the topic, reviews aspects of stress that I think are particularly important to consider in understanding stress and how to manage it.

In Moderation, Stress is Helpful

Hans Selye first recognized and began studying a set of symptoms known today as stress. Selye coined the word eustress (1976) to describe stress levels that are helpful. Eustress is a moderate, routine kind of stress that elevates our attention and functioning and at times even contributes to a sense of excitement and joy in life.

However, beyond a certain point, helpful stress becomes too much and we experience it as distress (Selye, 1976).

The Tipping Point

The tipping point at which we begin to experience eustress as distress varies widely. A few people, thanks to genetics, family history, personal disciplines, etc., are able to tolerate quite high levels of stress before becoming distressed. Others feel distressed at the slightest disruption of routines.

As I’ve pointed out in previous post those with a life history of trauma tend to have lower tolerance for stress than others. Stress symptoms feel a lot like trauma symptoms, which means that as stress levels rise, it is normal for people with a history of trauma to experience what feels like old trauma symptoms as they approach their tipping point of distress.

Understanding this fact may help to reduce anxiety about the sudden appearance of symptoms we thought were history.

Regardless of where our tipping point is located in the spectrum of stress, the more we know about it – the signs that it is near and the factors likely to move us in one direction or the other – the better we are able to cope.

Distress and Accumulative Stress

In light of insights from trauma-related brain research, I define distress as caused by a sense of real or implied threat that activates instinctual response mechanisms that originally evolved to enable survival.

These responses – for example, elevated heart, breathing, and alertness levels – function at an autonomic level not readily controlled by rational thought. This situation makes management of our stress responses complex.

Distress is easier to cope with when it comes in short episodes followed by return to “normal.” This occurrence allows for restoration of the resources consumed by high alert. Prolonged or chronic distress is a different matter – a state of constant arousal and alert creates fatigue. For individuals who are exposed to frequent traumatizing experiences, human service practitioners or populations experiencing trauma on an ongoing basis, stress accumulates.

The cumulative nature of stress can create unexpected dynamics. Many small stresses together add up to create a large, generalized or continuous feeling of emotional distress. Think of it as many small weights adding up to a staggering load and eventually it doesn’t take a heavy additional “straw” to “break the camel’s back.”

The movement from to a chronic sense of distress to a paralyzing state of burnout and trauma-like symptoms can be quite fast. It may not even be obvious which stressor caused the shift.

When there are many sources of stress, a new stressor may be barely noticed, yet the reaction can be severe. Some people develop a sense of numbness to everything, others experience a constant sense of hyper arousal; still others alternate between the two.


Burnout is a term often used to describe this final phase. It refers to chronic physical, emotional, psychological and spiritual fatigue resulting from the stress of working with difficult clients or being exposed to the suffering of others for an extended time without adequate opportunities for recuperation.

Among other things, caregivers who are burned out typically experience a sense of numbness as well as disconnection and apathy to the suffering of others.

Burnout is often accompanied by trauma like responses. I define emotional trauma as a response involving complex debilitation of adaptive abilities—emotional, cognitive, physical or spiritual—following an event or series of events that were experienced, or perceived as life threatening (Gertel Kraybill, 2015).

The phrase “debilitation of adaptive abilities” highlights the reality that stress is normal and that we are wired with natural abilities to adapt and cope.

In traumatizing and high distressing situations (perceived or real) we don’t choose our responses. We respond on “auto-pilot” and our systems do the best they can to help us survive. The sense of debilitation may last only moments or much longer depending on the traumatic event and the existing levels of stress of an individual.

Our life history greatly influences the extent to which we experience threatening events as traumatizing. Someone with low exposure to trauma and low general levels of stress probably won’t be as quickly affected by trauma or prolonged stress as someone already struggling with a long-carried burden of accumulated stress.

Trauma can’t be treated as a stand alone phenomenon. We have to consider it in the context of life history and present dynamics of each individual including personal, family and community (religion, gender identity, cultural and racial identity and values) history.

In early stages of trauma therapy, the focus of treatment may not necessarily always be on trauma itself but rather on supporting the expansion of adaptive abilities, because these, in turn, may enable a traumatized person to find his or her way after trauma.

Designing a treatment approach best suited to the unique aspects of each person’s life history and present situation is key to treatment.

The Stress Spectrum – A Mindful Expansion Activity

In several earlier posts, I mentioned a mindful expansion technique that I find a useful tool in designing treatment strategies.

In workshops and with clients, I use the Stress Spectrum activity as an experiential psychoeducational tool to learn about stress and trauma and get to know oneself.

It helps survivors to become more aware of their body’s responses, warning signals and trigger points related to stress, and thus contribute to the creation of the individualized self-care plan.
Get a free PDF of the Stress Spectrum Activity by clicking here.


Selye, H. (1976). The stress concept. Canadian Medical Association Journal,115(8), 718.

Stressed woman at work photo available from Shutterstock

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10 Media Interview Mistakes Therapists Make Tue, 30 Jun 2015 21:38:10 +0000 http://2.7258 10 media interview mistakes

I’ve written before about how media interviews (television, podcasts, speaking engagements etc.) can be helpful in educating your community about critical mental health issues, establishing yourself as an expert in your field, and perhaps even gaining new clients (click here to learn more benefits of participating in media interviews). But our expertise is as clinical counselors, and many therapists have little to no experience with a cameraman, bright lights, and the general “show-biz” aspect of the process. Over the years, I’ve noticed a few common mishaps that some individuals (including myself) have made. In hopes of preventing our readers from making these same mistake, here are 10 common interview mistakes therapists make:

10 Media Interviews mistakes therapists(2)

1. They don’t see the value in media presence

Some clinicians may not see the purpose or value of sitting down with someone and having a formal interview about a topic concerning mental health, relationships, or some other aspect relating to their niche. “Wouldn’t my time be better spent doing clinical work or working to attract new prospects?” they may wonder. While it’s true that you must work to balance your responsibilities, participating in the occasional interview is worth your time. And there is also the possibility that interviews become more frequent and perhaps even becomes a paid opportunity for you. Then it will certainly be valuable as an income stream.

2. They begin by promoting their practice

While media interviews are a great way to get the word out about your therapy practice, avoid being pushy or overly promotional. Don’t mention your services first thing. Instead, present your message, then end by giving the name and contact information (usually the website) of your practice. Viewers and listeners will want to hear your thoughts before they are interested in taking the next step. So let your work speak for itself, then close the interview by concisely talking about your practice.

3. They prepare too much material         

Time is of the essence in interviews, and you’ll have a very specific time allotted to communicate your message. Some therapists may fear running out of things to say, so they prepare an abundance of material. But this technique can backfire, as it may cause you to be too long-winded, neglect valuable pieces of your message, rush to try to fit everything in, or cause you to run out of time. As your prepare your talking points, be mindful of your time limit and even practice your interview in that same time frame.

4. They expect those in production to help them manage nerves   

There are many individuals who work together to make sure the interview goes smoothly. The person conducting the interview, the camera operators, sound techs, etc. Everyone has a designated job and are usually very busy in their own responsibilities. If you are feeling nervous about an interview (particularly if it is your first one), know that you probably can’t expect these people to be able to help calm your worry. Trust your own self and perhaps bring a friend along if you think you may need moral support.

5. They don’t switch out of therapist mode to sound byte mode  

The way we speak in an interview is quite different than the way we speak to a client (it’s interesting that when we are in the therapist chair, we are the ones asking questions, but in an interview, we are being asked the questions). Good therapists often speak slowly, reflect back, pause often, and go deeper. However, good TV interview skills require the opposite: speak quickly, don’t reflect back, keep the interview moving, and stay on target. Someone may take something you say as a quote to use in an article or to simply remember, so try to make the things you say somewhat “digestible” and even catchy (while not being gimmicky, of course). Read here for specific ways to keep your message clear, concise, and effective.

6. They don’t ask to be invited to interview again     

If your interview goes well, there’s no reason to not do one again in the future! Building that relationship takes time and will not happen in a single media exposure. Self-advocate and ask to be interviewed again by a certain outlet or production crew. The worst they can say is no! Simply asking to be interviewed again has helped me secure and maintain ongoing interview gigs.

7. They don’t maximize their interview  

An interview is worthless if others do not view/ listen to/ read it. Be sure to maximize it by sharing it via your social media outlets. For example, when I am interviewed for a television segment, I always obtain the link, share it on Facebook and Twitter, then upload the video to my Youtube account and my blog. I want to make sure others know about it. Don’t be shy about letting your followers know that you’ve given your professional insight in a formal setting. Remember, they are interested in what you have to say!

8. They speak in psychobabble    

As mentioned previously, in an interview, you’re not speaking to a client, but you’re not speaking to a psychology professor, either. Make sure you phrase your ideas in ways that others can understand. There’s nothing worse than a pretentious expert talking over others’ heads. Though you want to establish credibility, your point is not to prove how smart you are, but instead to educate viewers on a specific topic. Don’t “dumb down” your message, but avoid using too many theoretical terms.

9. They don’t do their homework

It’s important to do some research about the media outlet before your interview. Ask yourself: 1) Who is the audience?, 2) What is the tone? 3) What is the format? 4) Who is the host or interviewer? 5) How can I best serve their audience? Once you’ve gathered this information, use it to inform the content that you prepare and deliver in the interview.

10. They don’t specify how they would like to be introduced

Prior to your interview, be very specific about how you would like to be introduced and referred to during the interview. Make sure to include the full name of your private practice. Also, make sure you request that they mention your website, and if it’s a TV interview, ask them to display your website address in a visual banner. You are donating your time in exchange for the opportunity to talk about your passion, and in exchange, you get to build trust with your community. So be very clear about who you are, what you do, and how the audience can find out more about your work.

What are some media interview mistakes that YOU’VE experienced? 

If you’d like to build your media skills and develop a strong media and social media presence hop on over and check out my new media training just for therapists! Enrollment just opened today and there are a limited number of early bird spots offered at a reduced fee
Rock the Media School for Therapists

Join my Private Practice Toolbox Facebook group and connect with 3100 therapists around the globe in 2 simple steps: 1) Click request to join the group and 2) Fill out this brief questionnaire before you’ll be added to the group.Get practice tips and blog updates in your inbox.

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Lego Therapy for Children with Autism Wed, 01 Jul 2015 00:23:35 +0000 http://3.456

Children with Autism Spectrum Disorder struggle with inappropriate or delayed social skills, fine motor skills, group skills, communication skills, attention skills, play skills, and more. Professionals from many fields are involved in the care of children with ASD including speech therapists, occupational therapists, mental health therapists (including play therapists), behavior analysts, pediatricians, special education teachers, and others.

I love when I see how professionals can work together to provide optimal services to youth. We all come from different backgrounds, with different experiences, different areas of expertise, different personal perspectives, and so much uniqueness yet sometimes we get set in our ways and so proud of our own discipline that we forget that others might have valid opinions, intervention suggestions, and treatment models, as well.

This is not to say that just anyone’s ideas can be used to treat any disorder or concern. Of course, there are some things that should take more weight than others, especially when strong evidence has shown its effectiveness. I am simply stating that it is admirable when disciplines come together to create a great treatment approach for children with Autism or for really any child.

Applied Behavior Analysis is an evidence-based practice for children with Autism Spectrum Disorder. However, other therapists (speech, OT’s, play therapists) can also have beneficial insights to assist in the treatment of those youth.

An article I came across, “Lego Play Therapy Benefits Children with Autism,” discussed how “Lego Therapy” has been used to help children with Autism. In this article, the author, Janet Maydem, Occupational Therapist and Disabilities Writer, discusses how play therapy is the approach used during Lego Therapy. Legos were the materials used to facilitate the children’s progress on particular goals primarily social skills and play skills.

Meydam states that Legos “offer a highly routine, repetitive, structured form of play that many children with autism find appealing.” Children with Autism often like activities that are to be performed a specific way and many children with Autism have cognitive abilities that allow them to complete a step by step process of building a LEGO creation. Others benefit from the opportunity for creativity development with the infinite possibilities that Legos allow.

It is important to consider the scientific evidence for interventions that are selected for children with Autism (and other children and adults, as well). Meydam provides the following evidence from the scientific literature for the benefits of using Legos with children with ASD:

“Research on LEGO play therapy was recently conducted at the University of Cambridge. This study focused on children with both autism and Asperger Disorder, and found that children who participated in LEGO therapy showed improvement in social skills. Research into the value of using LEGO as a part of play therapy are well documented.

Another study conducted in 2008 evaluated social skills interventions for 6-11 year olds, including LEGO therapy. Children with autism were randomly assigned to intervention groups and therapy was provided for 1 hour per week over 18 weeks. Researchers found that the LEGO therapy group displayed more improvement than the other groups on autism-related social interaction scores.

A report published in Autism in 2006 studied the long term outcomes of LEGO therapy for children with autism. Children with autism who participated in LEGO therapy were compared to children with autism who participated in another form of therapy. The children who received LEGO therapy showed significantly more improvement on outcomes measures than the non-LEGO group.”


In order to facilitate positive change in children with Autism, follow these tips.

  • Identify the jobs involved in building with Legos as a group (such as one person can sort the blocks, one person can read and state the directions, one person can put pieces together, etc.)
  • Work on turn-taking skills and sharing
  • Work on communication skills by prompting children to use polite, appropriate language (which includes requesting Legos appropriately, using multiple word requests, using manners-if the child is at this point with his communication skills, etc.)
  • Provide reinforcement for appropriate behavior (depending on the child’s preferred reinforcers, you can provide praise, edibles, or tokens for specific goals)

As I mentioned, this article sparked my appreciation for disciplines sharing their expertise. I used to focus my career and education on play therapy while more recently I have turned toward Applied Behavior Analysis (ABA). In this article, the author describes a play therapy approach to working with kids with Autism, but I certianly see the ABA-related information in the article, as well.

I work with children with Autism and we work on many of the goals specified in this article including communication and social skills (including turn-taking, sharing, etc.). ABA also uses “rewards” (although we don’t tend to call them by that name, instead we would use the term “reinforcers” for what this article refers to as “rewards”). ABA also uses praise and tries to strengthen the use of praise as a reinforcer to get the child to participate more in a particular behavior. In ABA, we also work on helping children with transitions and adjusting to changes in the routine or coping (i.e. “behaving appropriately”) when things don’t go the way they want them to. See the following excerpt:

“LEGO therapy groups encourage collaboration, pretending, and non-verbal communication. These groups can also provide participants with a system of rewards and praise when changes to the building project are completed, allowing a child to successfully break from routine, repetitive patterns. This process helps children with autism develop creative responses and improved coping patterns when faced with changes in routine.”

So, as I see it, we can all be proud of our own disciplines, but we should use ideas from each other to help the kids we work with to the best of our ability. We should use evidence-based and research-supported interventions, but if we think outside the box, if we develop our own creativity, maybe we can come up with even greater interventions that will allow us to give our children all that much more success.

In my case, it’s possible that I could facilitate greater skill development in the children that I work with when I consider using ideas from another discipline (such as certain ways of using Legos in a group) while also sticking to the ethical guidelines of my field of ABA and providing services in the framework that I am licensed to provide.

[image credit: Marzanna Syncerz via Fotalia]


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Essential Tips for Working with Virtual Assistants Tue, 30 Jun 2015 12:30:43 +0000 In a private practice, I realized that my growth was based on my own time. A few years ago, I delegated my first task. I hired someone to return phone calls for about an hour per day. Then, as if by magic, they appeared in my calendar for an intake. I realized that I was increasing my ability to grow, by outsourcing non-essential aspects of my private practice.

Delegating tasks is one of the concepts of leadership and management in any industry, be it in business, the medical world or even in sports. In basketball, one cannot just play the role of a center, a point guard and a shooting guard at the same time. No matter how good physicians are in treating their patients, they just can’t be nurses themselves as well.

In the private practice world, it is not any different.

Delegation is a very important task for better functionality. Thus, the world is not a stranger to virtual assistants.

What is a Virtual Assistant?

A virtual assistant can fall into numerous roles. At the most basic, it is someone who is not usually working in person. They are location independent. They are basically your hired contractor. They assist you in running your business functions in the virtual world called the Internet.

Be it Information Technology functions, marketing, blogging or encoding — you can count on virtual assistants. VAs typically fall into two categories:

  1. Project-based virtual assistants
  2. Role-based virtual assistants.

For example, you may have someone work on a project, like transcribing podcasts or designing images for your blog posts. Or, they may have a specific role, like an intake coordinator. An intake coordinator can answer phone calls, return inquiries and schedule and answer potential client’s questions.

Virtual Assistants make tasks easier and you can often save more in hiring virtual assistants.

Remember these different tips to be able to work as smoothly as possible with your virtual assistants.

Virtual Assistant Tip #1: Good Communication is a Must

As with any other functions or tasks, good, proper, clear and concise communication is very important to ensure a smooth-sailing relationship with your virtual assistants. Having virtual assistants has forced me to identify my own processes. In doing so, it has forced me to outline my expectations and has saved a back and forth between us.

Do not keep your assistant guessing what you want and what he or she should do. When you want something done, communicate properly. Communicate what, when and how so that your assistant gets a better picture of the task at hand. A gap in communication can cost a great difference in quality and output and you will probably not retain your VA.

Most people want to feel successful, so the clearer you are, the more smoothly tasks go.

Virtual Assistant Tip #2: Set Clear Goals in Every Work Assignment

As mentioned before, set clear goals and expectations for every work assignment. When you do, your virtual assistant can have a clear and concise view of what you are expecting him or her to do. Setting clear goals can also clear doubts on the assistant’s part because he or she will know what is expected.

After I have interviewed and brought on a VA, I have a few ways to accomplish this step:

  • Record a training video: We have a conversation on Skype that I record. I may do a screen share so the VA can return back to the video without asking me. For example, I trained my podcast transcriber to upload to WordPress. In doing so, I saved myself time and he now has additional marketable skills.
  • Have the assistant create a checklist: Making a checklist helps the VA gain autonomy. You also then have training for future VAs.
  • Create Google Document: I love using Google Drive for documents. We both contribute to it and it is current training for future use.
  • Build a Trello Board: I use Trello to organize tasks, steps and to cheat checklists. Here’s a video that will help you see exactly how I do it.
  • Give a clear set of deadlines and explain how the work should be sent especially if you are letting your virtual assistant work on blogs and articles.

Virtual Assistant Tip #3: Trust is Integral

Working with a virtual assistant can be very difficult for many people. Business owners often have a difficult time letting go. A virtual assistant won’t do things exactly like you. and it is sometimes uncomfortable at first to see someone else working on the project.

Some people become very worried that their assistant may not be able to work on the project on time and properly. They become afraid that the finished output is not what they want and how they want it. As a result, they become engrossed in always pestering their assistants about what they are doing and if they are doing it correctly.

Guidance in tasks is important but constant prodding to the work may be annoying and may cause your virtual assistants to lose confidence in their work. You, as the employer, hired them in the first place because they have the right skills and qualifications that you need.

So why are you not trusting them now?

You should be able to let go and trust them to do the job. If you create strong objectives and expectations, the VA should be able to be successful. You can give your evaluation of their output after they present it so that they can improve the next time around.

Virtual Assistant Tip #4: Positive Reinforcements Help

I will often give bonuses for going above and beyond. Also, I may give an incentive for being done early. For example, when I have Hector do the podcast transcriptions, I may say the rate is $100 with a $50 bonus if they are completed by a specific date.

Many people are good at giving out criticisms to different works—pointing out all the negatives but failing to notice all the good points. Why is that? It may be because they want their assistants to know what they should improve on the next time.

However, pointing out the positive will help the relationship. Further, taking personal interest in a VA will build connection. What are they into? What’s their family like?

Recently, I Skyped with my VA, Hector. He does all of my podcast transcriptions. We talked a while about his family and church. He lives in the Philippines and it was great to learn about his culture!

According to psychologist, B.F. Skinner, positive reinforcements are important as they reinforce good behavior and keep a person motivated to repeat it. Only pointing out all the negative points may cause your assistant to lose focus and dedication to do his or her work.

Virtual Assistant Tip #5: Respect your Virtual Assistant

Treat your assistant as your partner and team member. That person is filling a specific job and is not your subordinate. Your assistant is there to work professionally to help you and not cater to your whims and wishes.

Virtual Assistant Tip #6: Always Pay on Time

Monetary reward is also a form of positive reinforcement. To you, it may just be a small delegation of tasks, but to your assistant, it’s a job and it is provides for daily needs. Always pay on time based on what was discussed beforehand or set expectations if ever there are delays in payment. Do not keep your employee waiting.

Virtual Assistant Tip #7: Ensure A Good Relationship

When there are things with which you are not comfortable or satisfied, tell your assistant. If ever you need to terminate the professional relationship, you should make sure to still leave a positive impression.

Again, feedback helps both sides to be successful.

For more on the subject, I’d highly recommend Chris Ducker’s book, Virtual Freedom: How to Work with Virtual Staff to Buy More Time, Become More Productive, and Build Your Dream Business .

Bringing on a strong virtual assistant is a great way to more quickly grow your private practice. In a future article, I will be discussing virtual assistant roles and how to find them!

Man on the phone photo available from Shutterstock

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Why Some People Age Well and Others Rot Tue, 30 Jun 2015 09:56:55 +0000 http://5.147 grandparent babySpend some time in a nursing home and observe two very general types of elderly people: ones who are still happy and others who are still miserable.  Both of their stories have a fair share of life tragedies, health problems, loss of loved ones, wars, disappointments, and successes.  Yet one group walks away with a sense of having lived life well despite all of the tragedies and the other with regret despite any successes.  How can this be?

Erik Erikson defines the last of his eight psychosocial development stage as Integrity vs. Despair. It begins around age sixty-five and ends at death.  The outcome of the previous seven stages sets the standard for this last stage in life.  A person who has progressed well in previous stages will most likely end well.

When a person ages, their ability to moderate thoughts, feelings and emotions diminishes so good habits that were formed earlier tend to remain such as eating right, exercise and proper rest.  However, if a person’s life was filled with negative habits such as smoking, anxiety, and limited activity these habits tend to become more exaggerated with age. This is especially true with thought habits. When there is a pattern of positive thoughts, that continues; however anxious or obsessive thoughts tend to worsen.

The Psychology.  The end of a life brings a natural time of reflection especially after retirement.  A sense of “what I do doesn’t matter anymore” sets in as “who I am as a result of what I have done” becomes the stronger reality.  Those who are able to reflect on their life and feel a sense of accomplishment end their life with integrity.  As opposed to those who reflect on their life and feel a sense of failure end their life with despair.

Life with Integrity.  Integrity is the ability to look back on your life and find satisfaction, fulfillment, acceptance of both successes and failures, and pride in a life well lived.  The outcome of integrity is wisdom in having lived life well and with it comes a natural desire to share gained wisdom with younger adults and children.  The elder adult who has gains integrity takes an interest in the lives of their family members, is active in their community or church, has a variety of hobbies they enjoy, is proactive in physically caring for themselves. They also don’t get angry over new limitations due to age, health, and decreased cognitive functions.  Many cultures outside of the U.S.A. value the elderly and esteem them for such gained wisdom and insight in many areas of their life.

Life with Despair.  Despair occurs when you look back on life and find regret, disappointment, wastefulness, and bitterness over missed opportunities.  The outcome of despair can be depression, isolation, disinterest in activities they once enjoyed, avoidance of family, and untreated medical conditions.  The elder adult who despairs tends to focus on the negative outcome of current problems, blames others for their condition and reworks history in their favor.  These individuals often engage in addictive behavior to hide from their despair by abusing prescription medication, alcohol or fantasy living in gambling, excessive TV watching, and overspending money.

The Cure.  It is very difficult to take a life ending with despair and transform it to integrity.  Sadly, many fall into despair as they feel a sense that it is too late for them to do anything or to contribute anything in a meaningful way to others.  It is really not for another person to judge whether or not a life is useful or whether or not it can be used in the future.  Every life has value and is able to contribute even in a nursing home.

Erik Erikson’s eight stages of psychosocial development span the entire life of a person highlighting key struggles that each age group meets as they grow older.  At the end of a life, it is clear which path a person has chosen as a lifetime of successfully confronting each stage produces good fruit which age well.  However, if a person produces bad fruit, it is likely to rot.

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Starting a Private Practice as a Mom: Part 1 Should I? Mon, 29 Jun 2015 17:31:49 +0000 http://4.546 Starting a Private Practice as a Mom_I started my private practice with a baby at home. My son was born in January of 2007. In April of 2007, I was all set to return to my “safe” county job on a part-time basis. We had done the daycare tests, it was Sunday, and my first day back was Tuesday. And then, I literally got a clear message from my higher power that I was “supposed to quit my job.” (Ask me about it sometime- one of the craziest things that has ever happened to me). So, on Monday morning, I quit my job. 
I Had No Plan
Truth is, I had no plan. I didn’t have months of income saved up, I didn’t have loads of vacation time coming (I had used it all during my maternity leave). All I had was a clear message that this was what was supposed to happen. I had a part-time job teaching for University of Phoenix, and thankfully, our monthly expenses were pretty low. We lived in a little 2 bedroom Craftsmen house in a simple neighborhood and hadn’t yet purchased our first home. 
Private Practice Didn’t Occur To Me
Around the time I quit my job, I friend referred me to teach at the local junior college, so it gave me even more of a “buffer” financially. My husband had a decent job and it included some benefits. But, truth be told, my job at the county had paid more than his job, and included 100% paid for benefits for our entire family. I honestly didn’t even consider private practice initially. 
I Started Selling Tupperware
It is HILARIOUS to me looking back on it. I went to a Tupperware party throw by sister-in-law who was getting into it- and her “up-line” said it would help her. So, I jumped in and started doing that. My first real experience with running a business. The gal who got me started taught me how to run the numbers, how to market the business, etc. It was hilarious to introduce myself as someone who had a Master’s degree in Psychology but who was selling Tupperware so I could be home with my son. 
Moms Group
Being home with my son for the most part gave me the opportunity to do things like attend a Mom’s group. It was an amazing experience that included lots of art, journaling, and self-reflection. Again, I received another clear message. I was supposed to start a private practice. Except, I had no idea how to do it. 
In part 2, I will give more of the story of how I started a private practice with a nursing infant at home. However, the biggest lesson for me in this process was to trust. Trust myself. Trust my higher power. Trust my deep knowing of what was meant to be. Starting a private practice isn’t what everyone is meant to do. You have to know somewhere down deep that this is what you are meant to do. That there is a deep purpose for you doing this- otherwise- it is a whole lot of work starting a counseling practice from scratch! 
Homework: So here is your homework. Do you know? Do you know down deep. Spend a solid 32 minutes just free journaling. Ask yourself if you have a deep knowing that you are supposed to be doing private practice. And then, go from there. When your brain argues the point, write that down, and then respond to that. Just let it go… for a FULL 32 minutes. 
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Blog Post Writing for Therapists Mon, 29 Jun 2015 11:15:21 +0000 If you are new to writing blog posts, it is challenging to know how to start or what to even write about. Many therapists have a desire to get their message out there to a broader public. Blogging and “content marketing” are great ways to accomplish this goal. Here are some ideas to think about when you are writing your articles.


  • You need a title, opening paragraph, body, conclusion and possibly a “call to action” if indicated.
  • Your real title (for search engines) should be straightforward, such as “How Life Changes After Motherhood .”
  • You may have a more “clickable” social title, such as “Mom-Shock: How A Baby Turned Me Into A Lunatic.”

Popular posts are often lists (“5 Ways to Boost Your Sex Life”), questions (“Is My Anxiety Normal?”), problem/solution (“Uncommon Ways To Cope With Depression”), checklists (“10 Things You Need To Do While In Therapy”), research (“New Research Article Explains Why We Hate To Ask For Help”) or a personal essay/rant (“Why I Fired My Coach”).

These are just popular examples, but there are plenty of others.

Getting Started

The opening paragraph must be attention grabbing. It must draw the reader in. If it doesn’t, people will simply not read it.

If you are writing about a problem or issue, present it here. Do not think like a therapist –think like your clients! No one calls your office and says “I need help for my insecure attachment style.” They call saying “I need help for my marriage,” or “I keep choosing jerks, or “I need constant reassurance from my boyfriend.”

You must think about what your clients are Googling in the middle of the night. Use their language. You want the reader to say “that’s me!” when they read what you are writing.

The body must be related to the title and opening paragraph. Be sure to write about what you say you are going to write about according to the title. This section is a place for your list, tips, descriptive paragraphs or essay depending on the type of blog post you are doing.

If you are writing paragraphs, do not be too wordy. If something can be said simpler, then do so. Avoid psychobabble or acronyms that you do not explain. Paragraphs can also be as short as a few sentences. The use of sub-heading, numbers or bullet-points also works well.

The conclusion should summarize what you just said. It should also leave the reader feeling hopeful. They should also clearly see that you know what you are talking about and would be a valuable resource for their problem.

A Call to Action

Some sites allow a “call to action” at the end of your post. If they do, definitely take advantage of this option. This place is where you subtly add your plug.

For example, Jane is a licensed psychotherapist in St. Louis who has helped countless clients overcome anxiety. Visit her at and download her free e-book “Overcoming Anxiety in 5 Easy Steps.”  However, this space is not for a resume or a time to list all your services!


If you are new to writing blog posts, start by writing anything you want. Get practice at the process. Write at a minimum of one or two times per month. After about six months or so, start to funnel your topics toward your niche. At some point, you should be exclusively writing about your therapy focus area and brand. This approach will help you be seen as an “expert” in this field.

Your blog post articles should be around 600 – 1000 words. Use keywords but you do not need to go overboard. Do not purposely throw keywords in the article unnecessarily. After enough writing about your niche, you will start to come up in search engines organically.

Writing is not for everyone. Think back to your high school and college days. If you were graded poorly on writing projects or you just plain hated to write, then this is most likely not the best marketing avenue for you.

The toughest part is in the beginning when you stare at a blank page not knowing what the heck to write about. After writing consistently for a while, I assure you that this problem will vanish.

Also, your best ideas may come to you while trying to fall asleep (how convenient!) or when in the shower (even more convenient). Remember, the biggest thing that holds people back, more than ideas or skill, is confidence.

Therapist blogging photo available from Shutterstock

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READ THIS FOR A LAUGH: Funny yet Amazing ABA Song, Video, & Pictures Mon, 29 Jun 2015 01:46:10 +0000 http://3.453 As I mentioned in an earlier post, I am now training to become a Board Certified Behavior Analyst and work as an ABA (Applied Behavior Analysis) Supervisor for children with Autism Spectrum Disorder. I love my job. I love working with the kids and watching them grow and progress. I also love ABA and considering how it applies in everyday life even for those without disorders or disabilities.

Continue reading for a very fun ABA song and more!

On my personal time (which is pretty limited since I’m in school, work full-time, am a freelance writer, and am a mother to three young, wonderful kids), I even look up information about ABA just for the fun of it. So, I thought I would post some great links that I came across for your pleasure, as well.

I came across this AWESOME song about ABA by a group called the Autoclitics.

[image source: Facebook: BehaviorMan]


[image source: SimplyFreeBlog]

I hope you got a good laugh out of this post. It certainly brightened my evening as I searched the web for great ABA links.

Thanks for reading!

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Diagnosis Codes Changing Oct. 1 to OCD-10 Sun, 28 Jun 2015 11:45:40 +0000 The DSM-5 came out in 2013 and some of us are still getting used to changes in some of our frequently-used diagnoses. Well hang on, because all diagnosis codes are changing on October 1. This shift affects both network providers and out of network providers.

A Little Context

Think of DSM codes as one section of an extensive list of all medical diagnoses called the International Classification of Diseases (ICD). So if you are asked for an ICD diagnosis, don’t worry – you can use a DSM code and it will be the same.

Right now, the DSM codes we are using are from the ICD-Ninth Edition, or ICD-9. But these codes are changing to a new code set, the ICD-10. This change means that for all session dates October 1, 2015 and after, insurance plans will require ICD-10 code numbers for the same diagnoses we’ve been using.

The new codes are completely different than the current ones we use.

But here’s some good news. For each diagnosis in the DSM-5, you will see under the name of the diagnosis listed both ICD-9 codes (for use prior to October 1) as well as the ICD-10 codes (in gray and parentheses, starting with a letter) for use starting October 1, so you’ll be ready when the transition takes place.

Remember: Do not use both ICD-9 and ICD-10 codes on the same claim form.

What This Means for the Claim Form

When coding diagnoses on the CMS-1500 claim form after October 1, you will put the new diagnoses in Box 21 as you currently do. However, in the upper right-hand corner of Box 21 where it asks for ICD-Ind (ICD Indicator), starting in October you should put a “0” (not a “10”) where you currently put a 9 — just before the vertical dashed line.

It may be time to shell out for your DSM-5 if you haven’t already. You can get your copy from the American Psychiatric Association or from (Save money by ordering the paperback).

Frequently Asked Questions

“Are the diagnoses changing, or just the code numbers?”

The diagnoses themselves and criteria won’t change, just the codes numbers.

“What if I submit claims after October 1 for sessions prior to October 1?”

Use ICD-9 codes for dates of service prior to October 1 and ICD-10 codes for sessions October 1 and after.

“What if I am billing for some sessions prior to October 1 and some afterwards?”

Use one claim for pre-October dates of service and one for those October 1 and after.

“Why are you telling us so early?”

I plan to repeat this news as often as I can before the changes happen, to reach as many therapists as possible before this change. Otherwise, this fall, claims and super bills are going to be rejected by insurance plans, requiring resubmission and delayed payment.

Sign up for my free e-newsletter to stay in touch with more important updates.

Swirl of numbers image available from Shutterstock

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Five Reasons Private Practices Fail Sat, 27 Jun 2015 13:00:50 +0000

Although many people would love to venture into the world of private practice business, it is not an easy world. According to studies conducted by the United States Small Business Administration, the survival rate of business enterprises is not very favorable. Only about two-thirds of businesses survive for two years or more. Not only that, but the number keeps on dwindling further down as more years pass by. 

Less than half of the businesses established survive for six years or more. 

With these statistics in mind, it only shows how difficult running a business can be! But how difficult is it to maintain a business? What are the top five reasons why private practices tend to fall short in their lifespan?

1. Resource Requirements are Underestimated

Opening up a private practice requires more than financial resource and guts. It entails a more detailed process and planning than one might think. Aside from being able to have the needed capital, one must have a clear and concise plan on how to start the business. 

It isn’t just a simple checklist that you can complete overnight. You should know some basics: 

  • Where to locate your practice?
  • Who will be your ideal clients?
  • Will you take insurance?
  • How many clinicians will you employ?
  • How much is your workers’ salary or percentage?
  • How can you pay for the business’ bills and taxes?

Many private practices fail because owners don’t start with basic business principles. Being a great clinician does not equal having a great business. If you are not ready and prepared, you will be easily swept away by the turbulence of challenge.

2. Low Client Satisfaction

Revenues, product quality and cost-effectiveness are very important in business, but are you offering good service? Common ways that people let down their clients are:

  •  Not returning phone calls or emails quickly
  • Having a hard to navigate website
  • Having an unclean office
  • Not having additional amenities like water or coffee
  • Not having a scheduling system
  • Sloppy confidentiality

Counseling quality and cost-effectiveness can attract a lot of consumers, as quality and cost are two of the most important things that consumers look for in products or services. However, as you improve your quality, you can improve your rates. Having great revenues ensures that the business can keep on running. 

Client satisfaction makes the private practice continue to exist. Not knowing how to really communicate to the clients on their preference and suggestions can close your doors.

3. Too Common: No Uniqueness

When I first launched the Practice of the Practice Podcast, I did a lot of research. The only other private practice podcast at the time was the American Counseling Association. They had not posted in more than four months. Thus, when I launched, right away iTunes ranked me #1 and I could say I was the #1 podcast for counselors in private practice. There was no competition! 

In the business world, there is much competition awaiting everyone. The more common your business is, the lesser is your chance in winning. If there are a lot of counselors in your area, you have to set yourself apart!

So how do you tell your story as a private practice? How do you market those skills and niches? 

One of the reasons that businesses fail is because the team lacks the marketing skills. 

Clinicians have to clearly state the advantages of the counseling. Sometimes customers won’t know how great your practice is unless you present it through your website, social media and traditional local media. 

4. Lack of Planning Goals 

Many people who venture out into private practice don’t properly plan their outcomes. In my private practice consulting, I teach my clients about having one or two KPIs. A KPI is a “key performance indicator.” 

A KPI is the bottom-line result of what you do well. For example, a KPI could be:

  • Total sessions in a month
  • Total gross income in a month
  • Satisfaction on a survey

So if you’re doing marketing well, your KPI will change. If your social media is doing what you want, your KPI will improve. 

KPIs can easily get lost in the battle. It is not only in business but also in almost anything one should do.

5. Too Rigid: Not Being Flexible Enough

Some private practice fail to adapt quickly to changes in the market, like customer needs and competition. Private practices that thrive will move quickly. They will write blog posts about current topics and trendjack what is being discussed in the media.

They’ll actively engage on social media and find new ways to enhance their website. Being sluggish in adapting changes can cause private practices to be left with few clients.

Avoid these pitfalls and you’ll grow a healthy, thriving private practice that will increase your influence and your income! 

Declining graph photo available from Shutterstock

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PTSD and Sexual Dysfunction in Veterans Fri, 26 Jun 2015 11:40:53 +0000 Sexual dysfunction is a common complaint of many people seeking psychotherapy. In fact, it’s estimated that approximately half of women and a third of men suffer from some degree of sexual dysfunction. What is sexual dysfunction? There are several perspectives among mental health practitioners on the concept and definition of the issue.

However, in general, it’s broadly defined as any problem that occurs during the sexual response cycle-excitement, plateau, orgasm and resolution that causes dissatisfaction for the individual or couple.

The latter is an important point that shouldn’t be overlooked. Indeed, the issue may not be a problem for one partner but causes significant distress for the other. Therefore, in therapy, it’s important to assess potential impact on both parties, especially during couples therapy.

Categories of Dysfunction

There are three categories of sexual dysfunction that make up the majority of problems. These include disorders of desire, arousal and orgasm.

Deficits in desire usually present as a lack of interest in sex to include foreplay. Even though the person may feel emotionally connected to his or her partner, there is no desire to be intimate. On the flip side, a lack of emotional connection may be the culprit associated with the reduced desire.

The most common arousal complaint is an inability to become physically excited during sexual activity. Although it may seem similar to reduced desire, an inability to become physically excited during foreplay and intercourse is generally not because the person doesn’t want to be intimate, but an issue of becoming physically able to be intimate.

Concerns related to orgasm include an inability to have an orgasm or a delay in reaching orgasm that causes distress for the person or couple. Often, this problem is the most embarrassing for the partner (or couple) to discuss. There is a social stigma and shame associated with both men and women who have a difficult time reaching sexual climax.

Causes of Problems

The causes of sexual problems vary. Some are purely biological or medical in nature whereas others have psychological origins. Although service members and veterans are generally not at greater risk of developing sexual problems compared to their civilian counterparts, there’s a common factor that contributes to the sexual dysfunction of many with post traumatic stress disorder.

The connection between PTSD and sexual dysfunction is one that has been studied for the past few decades with increasing interest over the past several years. The increased interest as of late is a direct result of the wars in Iraq and Afghanistan and the hundreds of thousands of veterans who have been diagnosed with the trauma-based disorder.

Any clinician who treats service members or veterans with PTSD is well aware of the co morbidity between these two clinical issues.

A number of theories exist as to why there is an increased rate between PTSD and sexual dysfunction. And there are a number of theories as to why this co morbidity plagues so many who have served.

Individuals suffering from PTSD are often highly anxious. Anxious people produce excessive amounts of hormones and neurochemicals. Some of these substances negatively impact sexual functioning by constricting blood vessels and blood flow, both which are important to sexual health.

Over time, the flux of chemicals and strain on the sexual response cycle lead to a variety of sexual concerns for many service members and veterans.

A core symptom of PTSD is feeling emotionally disconnected from loved ones. For many people, loving feelings for a spouse or partner are few or absent. And, without the emotional connection, it’s difficult to develop and maintain intimacy.

Intimacy is the bedrock of a healthy sexual relationship.

Common Treatment

A common treatment for PTSD is the use of medications that regulate the level of the chemical serotonin in the brain. Serotonin plays an important role in sexual functioning. When taking these medications, it’s not uncommon for men and women to report delayed and absent orgasms and reduced interest in sex.

For men, it’s not uncommon to hear complaints of difficulty achieving or maintaining an erection.

However, it’s important to note that in some individuals with PTSD, sexual dysfunction gets better following medication treatment. This outcome is especially true for those individuals who have a strong depressive component to their PTSD.  Considering that a common side effect of depression is reduced sex drive, this correlation makes sense.

The relationship between PTSD and sexual dysfunction is a complex one. A number of factors can contribute to sexual problems, which can cause significant distress for the person or couple.

However, the fix is often relatively simple. It may include individual or couples therapy or a switch to a different type of medication.

Regardless of which fix is best for your patient, the first step is to assess the presence, degree and impact of sexual dysfunction. All too often we neglect this important aspect of overall psychological health.
*This article was adapted from a previous article written by Dr. Moore for his column “Kevlar for the Mind.”

Distressed man in bed photo available from Shutterstock

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Loneliness: a Source of Distress Thu, 25 Jun 2015 12:00:41 +0000

What makes loneliness an anguish is not that I have no one to share my burden, but this: I have only my own burden to bear.
–Dag Hammarskjold

Unmet longings for intimacy can be lethal. Sociologist Emile Durkheim’s research on suicide revealed that factors such as social integration and anomie, a sense of purposelessness and disillusionment rooted in the breakdown of social morals and norms, influence the rate of suicide.

Loneliness, defined by analyst Frieda Fromm-Reichman as the want of intimacy, is associated with higher rates of mortality, surges in adrenal hormones, high blood pressure, alcoholism, obesity and relational discord and familial estrangement.

Undeniably physical and mental illnesses take their toll on the lonely. Journalist and science writer of the New Republic Judith Shulevitz has gone as far as to describe loneliness as “a public health crisis.”

At some point in therapy, the subjective experience of loneliness, complex in its depth of emotional experience and circumstance, is an identified source of distress for the clients I treat. In the United States, New York City is unrivaled as the leader in single-individual households.

`Weak Ties’

Yet even urbanites who reside with others and/or have strong networks of support, report feelings of isolation, alienation and rejection. They often describe dynamics with myriad friends as superficial, limited and unsatisfying.

In fact, what is consistently passed off as intimate bonds appears comparable to what sociologists refer to as ‘weak ties.’ Social media, action groups and business networking are dependent on having a wide range of ‘weak ties’ or acquaintances.

While these fleeting encounters may prove beneficial with advancing personal and vocational goals and can even offer a temporary sense of well being, the need to be fully seen and understood remains unrealized. And as Fromm-Reichman contended, denied longings for intimacy leaves one bereft with loneliness.

For those who present with “traumatic loneliness,” a condition rooted in histories of severe psychological, emotional and sexual abuse, the intensity of desolation and despair is staggering.

Traumatic Loneliness

While eastern philosophy posits the paradoxical wisdom of embracing one’s essential aloneness so as to cultivate a compassionate relationship with our malaise and ‘non-being,’ for those suffering with traumatic loneliness, this guidance is tantamount to psychological annihilation.

The absence of a secure, safe, sustaining and loving attachment in childhood results in developmental arrest in which innate fears of abandonment, absence of a core identity and pervasive feelings of not existing persist.

Such individuals live in a state of perceived danger, locked into psychological defenses designed to protect the self from further harm. Relationships are either shunned or compulsively sought to assuage interpersonal distress.

The basic psychological need for connection is mired in fatalistic assumptions and traumatic enactments of abuse and victimization. Additionally, such early life traumas are correlated with neurobiological abnormalities compromising the body’s ability to regulate stress. Clearly, the sequelae of chronic trauma requires a more realistic and comprehensive approach when addressing the plight of loneliness.

Author Jodi Picoult wrote,

“Let me tell you this: if you meet a loner, no matter what they tell you, it’s not because they enjoy solitude. It’s because they have tried to blend into the world before and people continue to disappoint them.”

Suffice it to say, throughout life numerous losses, betrayals and rejection contribute to one’s experience of loneliness. As Picoult alludes, it is not so much the relationship itself, but what occurs in relationships that can foster feelings of disillusionment and discouragement. Yet in order to persevere, one must consider that all suffering can potentially be a catalyst for growth and change.

With that in mind:

“Pray that your loneliness may spur you into finding something to live for, great enough to die for.” –Dag Hammarskjold

If as Bertrand Russell contends, love is the guiding principle to escape loneliness, it follows that finding bonds– be it spiritual, vocational, creative, therapeutic, romantic or filial, which are great enough to live or die for, means the fundamental pursuance of what inspires love.

It may seem overly simplistic to contend that love is the panacea for loneliness and yet any sort of communion characterized by compassion, conscious commitment, and generosity enhances our physical and emotional well-being.

Nevertheless, crystallizing what form love needs to take to afford healing and wholeness is a complex individualistic task. It is an emotionally demanding journey requiring risk, consciousness and humility. Yet it is through this courageous undertaking that loneliness becomes solitude, and the peace of one’s inner spirit and imagination triumphs.

Lonely man photo available from Shutterstock

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Why Mid-Life Crisis Happens Thu, 25 Jun 2015 10:32:37 +0000 http://5.143 degasA bad outcome of a mid-life crisis tosses people into counseling. They report that the person they knew became entirely different over night.  It is almost cliché that with a mid-life crisis comes the impractical sports car, the extramarital affair, late nights at bars, new friends who are twenty years younger, hipper clothes or a dramatic career change.  They never thought it would happen to their spouse or friend, but it did.  How?

Erik Erikson defines his seventh psychosocial stage as Generativity vs. Stagnation which occurs in the late thirties until the mid-sixties.  This time period in an adult life encompasses the mid-life crisis years which can begin and end anytime in between.  So what is a mid-life crisis?  It is when an adult evaluates where they are in life compared to the dreams and goals they once had for themselves, to the status of others they desire to be more like, and to their potential to leave their mark on the world around them.

The Psychology.  If a person sees how their contribution to home, work, church or community adds value to the lives around them, then they develop generativity.  Generativity is expressed through concern for guiding the next generation, desire to leave a positive mark on the world, making a difference in the life of another, creatively using gifts and talents for the benefit of others, and feeling successful regardless of financial status.  If a person don’t see how their contribution adds value, then they become stagnate or stuck.

Mid-Life Crisis and Generativity.  Not all mid-life crisis’ need to end in disaster, some are actually for the better and can motivate a person to live up to their full potential.  For instance, perhaps they are in a profession which they “fell into” mostly by accident but dream about another profession.  This may just be the time to go back to school and get a desired new degree to work in a profession they are passionate about doing.  By now as opposed to twenty years ago, they have a better understanding of their capabilities, talents, gifts and purpose in life along with responsibilities, time constraints, and natural limitations.  This combination enables a person to be more focused on reasonable goals that are not selfish in nature but add value to the lives around.

Mid-Life Crisis and Stagnation.  On the flip side of a mid-life crisis is the potential to become even more self-involved and to alienate others.  This mid-life crisis is very different from the one mentioned above however it begins the exact same way.  An evaluation of life leads to an even greater desire to satisfy all the needs, wants, and desires that have been put off.  To justify the behavior, a person may say, “I deserve it” or “I have given so much to others, it’s time to give to myself”, or “I’m tired of sacrificing for others”.  This is a heart issue more than anything. If someone really give out of a desire to show love to others, then no strings would be attached. This includes any anticipation of thanks, appreciation, or returning the favor.  In essence, they expect nothing in return.  If however giving is out of a desire for some type of reward, then the gift is selfish and manipulative. This includes verbal (a thank-you), physical (touch, hug or sex), emotional (happy feelings or feelings of obligation), or mental (think nice things about you or need to return the favor).  This thinking is the seed from which a negative mid-life crisis grows.

The Cure.  Since at the base of a mid-life crisis is the condition of a person’s heart, there is no other cure other than a complete change of it.  It is not unusual for a trauma or crisis during this period to spark a dramatic change in direction. Unfortunately, this cannot be manifactured, rather it needs to be a more natural outcome, otherwise it will not be a real change.

Sometimes, something as simple as a 360 evaluation can help to spark change. When a person has the opportunity to see themselves how others see them, this creates discussion which can lead to change. It well is worth the effort to guide a person in the positive direction of a mid-life crisis for them, their family and the community as a whole.

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Good Friends, Good Marriage Wed, 24 Jun 2015 13:00:52 +0000 In my work counseling couples, I am often asked, “what makes for a good marriage?” There are a number of responses to that question: good communication, trust, realistic expectations, compromise, sharing, teamwork and more.

One of the key factors that I frequently see in successful couples, even those who have a ‘bump in the road’ on occasion, is that they have a good friendship.

When we meet a potential partner, we are often so consumed with the thrill of a new relationship that we are at risk of making the wrong choice of partner based upon our immediate ‘rose tinted’ enchantment or short term feelings of excitement and desire.

Often we believe this amazing new person to be something that ultimately you discover they are not, which leads to disappointment and the relationship fizzling out or falling apart.

A Stabilizing Component

Time is a factor that would reveal the truth about the strength of a relationship. Some people can even run for a couple of years on the strength of the ‘initial’ attraction before the decline starts. But for many people in the heady stage of new love, they rush in only to find themselves locked into a bad relationship or having to deal with the aftermath of a rash decision when things start to fall apart.

Friendship in a relationship is a component that can be extremely stabilizing and can help towards maintaining long-term longevity of a marriage.

Friendships, even non-romantic friendship,s involve cooperating and working together. There is a respect and support between friends that honors the relationship and makes it mutually satisfying, otherwise it wouldn’t work.

We are more able to walk away from friendships that don’t work if they are one-sided or destructive because the level of investment and risk is often less than in a romantic relationship. Non-romantic friendships also involve feelings, but they usually don’t encompass the strong feelings of romantic love as well as friendship.

An Added Dimension

So friendship in marriage adds a dimension that helps to strengthen and sustain the relationship. Friends have fun together, they play and they laugh together.  When talking to singles looking for a prospective partner for an intimate relationship, I have found that they rank the ability to have fun together and have their partner make them laugh as an important desirable attribute.

There is less chance of feeling ‘lonely’ in your relationship if you are friends. Communication is usually better and more sincere and true friends rarely have secrets and therefore, trust is stronger in ‘romantic/friend’ type relationships.

A friend shares him or herself, and in an intimate relationship, the possibility of sustaining a long-term union is higher as the couple will often share ideas, hopes and dreams that help them keep a focus on their future together rather than dreaming of what they would do if they were free.

Friendship is key to blissful relationships. Physical beauty fades with age. Disease, aging and childbirth rob us of our youth and outward attraction. If you are truly keen to have a marriage for keeps, you would do well to make friends with your partner.

Friendly couple photo available from Shutterstock

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Tips to Control Your Anger Tue, 23 Jun 2015 12:15:58 +0000 When we think of anger, we think that it is bad and harmful. But what if we think of anger as actually being good and helpful? According to Hoy & Griffin (2012), “anger is like a warning signal alerting you that something is wrong. It can provide the energy to resist emotional or physical threats. Anger can help you mobilize your resources and set appropriate limits and boundaries. Your anger can give you strength to resist threatening demands or a violation of your values.”

Of course, if you do not express your anger it can cause physical and emotional harm. If you do not talk about your anger, you are pretending that everything is fine. Holding these feelings in for too long can cause an increase in heart rate and blood pressure, ulcers and can damage your relationships.

It is beneficial to express your anger assertively. In other words, confront a situation by expressing in a healthy way what you think and feel.

When you become angry and you express that anger in an unhelpful harmful way, what exactly are you trying to get out of it? Will it make the situation better? Will it make it worse? What are the pros and cons of reacting in an angry and aggressive way? What about if you control your anger? What will you get out of it? Here are some tips that I use with clients to help them with anger issues.

Ten Suggestions to Try

1. Cognitive perception: I like how people usually say “he/she got me angry and that is why I yelled” or “he got me extremely mad and that is why I hit him.”

Do other people have the power to control your actions and your thoughts or do you have the personal power to control the way you feel and act? In other words, who controls you? You have the power to choose to be angry, sad, happy, frustrated, etc.

When I try to explain this concept to clients, I like explaining how two situations can get two separate reactions from two different people. For example, if someone fails a test, one person may think angry thoughts at the teacher, start cursing or blaming the teacher for giving him a failing grade.

Another person, however, who fails the same test may look at the grade and think to himself that he needs to study harder for the next test and that he received a failing grade because he did not study as much as he should have.

Why did one person have an angry reaction and the other didn’t? In reality, you make the decision to get angry, the situation does not make you angry. It is your perception of an event that gets you angry. If you change the way you perceive things, then perhaps it will not cause such a negative reaction.

2. Be aware of how your anger feels in your body: Your body gives physical warning signs when you get angry. Become aware of them and take steps to manage the anger. Try leaving the situation or doing some relaxation techniques.

Some signs may be breathing faster, getting red, having a pounding heart or clenching your jaw.

3. Be aware of the triggers: Fatigue, alcohol, pain, substance use, and stress are factors that can impact anger. Also, family life can have an impact. If a person comes from an aggressive family with low levels of positive interaction, there might be a higher chance that the individual will learn to also be aggressive and to deal with conflict by getting angry and aggressive.

4. Take a time-out: If things get out of control, remove yourself from the situation so you can cool down. Take a walk, go to the gym, call a friend or listen to music. Take that time-out to calm down and then you can approach the situation when you are calm.

5. Learn relaxation techniques: Practice breathing deeply from the abdomen, do some progressive relaxation techniques, meditate, do yoga, go to the gym or go for a walk. Try taking advantage of your senses by visualizing your favorite place, playing your favorite music, smelling your favorite scent, tasting your favorite meal or trying a different cuisine.

6. Problem-solve: When in a confrontation, establish a plan by writing options and solutions that can help resolve the conflict. Try the options to see which one works. If one does not work, try using another option.

7. Listening: Learning to listen can build communication. Try paraphrasing what you heard. This practice will help clarify any misunderstandings that can lead to anger. For example, “In other words…” or “What I hear you saying is…”

8. Learn to Assert Yourself: According to Hoy & Griffin (2012) “Assertiveness gives you the opportunity to air your grievances and frustrations in a healthy way instead of burying them or eventually blowing up.”

Read self-help books or get guidance from a professional to help you learn skills to become assertive. Use “I-statements” to describe a problem instead of using “you” such as “you did this…” By using “I-statements” you avoid blame and you are asserting how you feel.

9. Think of things to say to yourself: It can be helpful to say positive things to yourself before or during a conflict. For example, “Is it worth getting into an argument?” “Will it make a difference in a week?” “What will happen if….?” “What are the consequences if I react in this way?”

10. Forgive: This action is powerful and is often very difficult to do. Forgiveness is not forgetting or denying what happened. It does not excuse the offender. It is not the same as reconciliation (Hoy & Griffin, 2012). “Forgiveness brings our lives back into a state of harmony and peace.” (2012) It helps you to free yourself from the anger and pain and to let go of the control that the other person has on the way you are feeling.

Hammer and plate photo available from Shutterstock

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The Addicted Narcissist Tue, 23 Jun 2015 10:45:58 +0000 http://5.139 narcissistic abuse cycleOne of the hardest types of people to deal with is a narcissist in the middle their addiction. They are completely exhausting. The combined selfishness of narcissism and addictive behavior is overpowering, relentless, callous, and frequently abusive. This destructive blend of arrogant thinking in that they are always right and that they do not have a problem leads to devastating consequences.

There are many parts to the addicted narcissist and their road to recovery. The point of this article is to recognize the injurious behavior so more reasonable expectations can be established during the process and for the family.

Origins. In both addicts and narcissists, shame is the common denominator. Stage two of Erik Erikson’s Psychosocial Development which occurs between 18 months and three years old has shame as the negative outcome. Not all narcissists or addicts have trauma during these years, but it can be a good place to begin. Because there is a strong concurrence, about 50% of narcissists are addicts of some sort. Some studies suggest that fetal alcohol syndrome in a child is a sign of a female narcissist.

Enablers. There are frequently two enablers. One bolsters the ego of the narcissist and one unknowingly encourages the addiction. The narcissistic enabler minimizes all signs of addiction and fosters feelings of superiority over others. The addiction enabler is likewise blind to symptoms of addiction therefore justifying financially supporting it. Both are needed to maintain the self-image of the narcissist.

Sometimes, the victim of narcissistic abuse is the sole enabler. This person naively empowers both behaviors to continue. They have been told that the addiction is in their minds and they are the one to blame for it continuing. Saying like these are common. “No one else sees what you are seeing, you are the crazy one.” “If only you would do…, then I won’t have to…”

The Cycle. The addiction cycle is comingled with the narcissistic abuse cycle. It begins when the narcissist feels threatened. They become angry and take out their frustration on a victim. Sensing resistance from the victim, they retreat to their addiction. The drug of choice reinforces their idealistic fantasies, perception of omnipotence, and extravagant schemes. However, this results in the enablers retreating from the narcissist. Now confused, the narcissistic ego feels threatened and the cycle repeats.

Step One. The most difficult step is to get a narcissist to admit to their addiction. This is the first mandatory step of all addictive recovery which is particularly problematic for a person who believes they are above others. Not only are they reluctant to admit there is a problem, but they refuse to allow someone inferior to point it out. This is why confronting a narcissist about their addiction usually results in substantial rage.

Rehab. The only rehab a narcissist willingly attends is an elite facility.  Even there, they expect special treatment and believe the rules are for others. During group counseling sessions, they are bored and view it as trivial. Sometimes they become intolerant and even abusive towards staff members. Instead of taking the time to heal, they look for loop holes in the system, complain about inefficiencies, become single-minded about insurance/costs, and blame others for having to be at rehab.

Recovery. A narcissist is unwilling to wait the prescribed time period to see if the recovery is effective. Instead, they expect immediate results and others to comply fully with their miraculous healing in a very short time period. Unfortunately, because the narcissist has grandiose beliefs about self, they rarely learn during treatment thus making their prognosis poor.

Relapse. It is not impossible for a narcissist to recover from an addiction. In fact, when they see it as damaging to their image, they are able to eliminate the addiction almost instantly and without emotional consequences. However, they do return to the addictive behavior later as a way to demonstrate they ultimately have power and control over the drug of choice.

Just because the narcissist feeds off illusions of grandeur, doesn’t mean the family support system needs to strengthen that belief. A family can be supportive while having reasonable expectations for the narcissist’s prognosis. It is far more loving to accept someone within their own limitations than to insist they become someone they are not.

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Evidence-Based Practice: Guideline or Limitation? Mon, 22 Jun 2015 11:45:57 +0000 From its earliest foundation, psychology has taken upon itself the task of merging science and the human experience (McReynolds, 1997). The intention was, and has been, to provide the best available care and have credibility for such care in a field where clear results and standardized variables are minimal if not non-existent.

When working with human beings, very little seems to be clear and evident. Culture, neurobiological factors, attachment, genetics, gender, religion, etc. all have independent and collective impacts on each of us as humans, whether these factors themselves or our perceptions of them.

As defined by the APA Presidential Task Force on Evidenced Based Practice (2006), Evidenced Based Practice in Psychology is defined as the “integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.”

In layman’s terms, it means that we, as therapists, are to use methods that have been found to be effective with clients/patients through empirical research. These treatments must be relevant to the client/patient’s presenting issues and must take into account their cultural influence and self-determination.

To gain credibility in a “hard” science world of medicine, we must show scientific evidence for scientific outcomes, right? This is, of course, dependent upon the definition of the therapeutic process. Is it medical or something else? Is treating a condition in humans that concerns perception, interpretation and a long list of confounds as cut and dry as any scientific equation of “do this to get this?”

Movement in Psychotherapy

Within the past few decades, we have seen a significant movement in the field of psychotherapy; a shift from medical to relational and experiential. Methodologies, such as Emotionally Focused Therapy and Imago Relationship Therapy have emerged as practices that touch on the foundation of all human existence – attachment.

They suggest that healthy, strong attachments lead to healthier functioning, while the reverse leads to emotional distress and learned behaviors associated with reactions to the absence of said attachment.

From an attachment perspective, what happens in the room during a session is more indicative of unconscious connections formed between the therapist and client. It’s in this space where clients learn and gain increased comfort with vulnerability that has, likely up to this point, not served them well.

We have found that, beyond anything else, the relationship is what matters. Whether in the context of individual, family, couples, children or adults, we, as therapists, are creating a safe space for our clients to feel connection, to experiment with these feelings without judgment or conditional regard and to learn boundaries to take care of themselves without fear of losing perceived value.

Embracing Mindfulness Practices

Also having its time in the spotlight are mindfulness practices, and rightfully so. The Eastern philosophies of Buddhism have been welcomed into Western culture as the distant cousin we all knew and loved, but were reluctant to embrace until our friends thought he or she was cool.

I find it interesting how we are finally embracing practices once used in ancient times and seeing them as new or “alternative.” Make no mistake, mindfulness practices are not new. They are not even new to Western culture. However, only in the last decade (or less) have they been more widely accepted.

Before the introduction of scientific study, these spiritual and experiential methods were the only things available. For clarification, spiritual does not mean religious. Religion can most certainly be spiritual, but my use of the word is in reference to a deeper, metaphysical existence.

At its core, mindfulness work is about paying attention to right now (Kabat-Zinn, 2012). We allow ourselves to be present in our current experience, separating past trauma or any fixation on “what if” in some distant future.

This experience is also what happens beyond the limitations of talking. In fact, yoga and meditation require no talking at all, yet are the fundamental exercises through which we can find balance and connection. Can we accurately measure and put into empirical writing an unconscious experience that is, in fact, beyond language? If it cannot be measured, can it ever be EBP?

Well, some certainly think so. Jon Kabat-Zinn has been a pivotal player in the use of mindfulness practices for mental and emotional health with Mindfulness-Based Stress Reduction being taught all around the country to clinicians and non-clinicians alike.

Bessel van der Kolk has been in almost every conversation concerning trauma for the past several years. His work surrounding practical and effective treatments for trauma recovery have openly advocated for meditation and yoga (Emerson, Sharma, Chaudry, Turner).

Art Therapy Shows Promise

Even art therapy, perhaps a lesser known and younger discipline in mental health treatment, has shown impressive results in treating a spectrum of issues, including sexual trauma (Pifalo, 2006) and attachment-related issues (Ball, 2002), just to name a few.

Have they found some way of miraculously making unconscious, spiritual levels of functioning scientific? I wouldn’t be so quick to minimize these processes to science. You see, what is actually being measured are the occurrences of the stressors or symptoms pre and post treatment.

The application of practices, such as yoga, meditation, clinical hypnotherapy, art therapy, etc. is measured in effectiveness by how they impact the presence of psychological symptoms for distress in clients, which is exactly what EVP entails, according to the definition previously stated in this article.

If someone presents with night terrors, severe anxiety, avoidance and reliving a violent event, we know the above methodology is working when this client’s symptoms are significantly reduced or no longer present.

Measure What We See

The fact is, we cannot make something as deep and spiritual as connection and inner balance scientific or measurable. What we can do, however, is measure what we can tangibly see, the negative symptoms of distress.

Evidenced based practice has its place. Without it, we open the door to every person with a “good idea” to attempt projecting what worked for them onto others. Maybe that would be fine. Perhaps one could say that is what’s missing in current treatments. I’m a bit cautions and apprehensive to join that campaign just yet.

Another component for consideration in evidenced-based practice is managed care. How many clinicians are incorporating yoga, meditation, hypnotherapy, art therapy, etc. into their practice, but only billing for the CBT aspects of that treatment or only doing fee for service, because managed care will not reimburse these techniques?

Why no reimbursement?

Their claim has frequently been a lack of Evidenced Based Practice. If nothing else is to be gained from the five minutes spent reading this article, my hope is that we at least come together to understand and advocate for our field, accepting that it is science, but also much more than that.

Effective psychotherapy is the inclusion of both science and human/spiritual experience. In order to use the most effective treatments, we must be confidently given the space to do so, even if the results are unspeakable, even if clients don’t have words or tangible, measurable accounts of what has happened, but feel differently in a way that works for them.

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