Psych Central Professional For mental health, psychiatric and psychological professionals. 2017-09-22T10:24:17Z Christine Hammond, MS, LMHC <![CDATA[Loneliness: A Constant Battle Seen with Personality Disorders]]> http://5.1674 2017-09-22T10:24:17Z 2017-09-22T10:24:17Z John regularly told his wife, Jane, “I feel all alone in this world (within our family, at my job, or in our neighborhood).” In the beginning of their marriage, Jane erroneously believed that she could fill that void in his life and went to great lengths to demonstrate that John was not alone. However, he would have only temporary relief at best and in most cases, her efforts were never enough to stop the comments.  After ten years of attempts, Jane became discouraged and gave up trying to satisfy John’s loneliness needs. This is when John’s loneliness intensified even more. Loneliness is a common thread in people with a personality disorder (PD).

The feeling of loneliness is due to three main reasons, all of which are part of the definition of a PD. First, a person with PD has an inaccurate perception of reality.  So while they might actually not be alone they tend to feel isolated due to their unique perspective on the world. Second, their inappropriate and impulsive responses to others unintentionally push them away. And last, their inflexibility and difficulty changing their habitual mannerisms makes true intimacy difficult for them and their partner.

To get a more accurate understanding of the problem, it is important to distinguish between the different types of PDs and how loneliness manifests. Only then can a partner set more balanced expectations. Each of the PDs address: the cause of the loneliness, how the person with a PD expresses it, and what a partner can do to neutralize it.

  • Paranoid PD. Their obsessive fear, both rational and irrational, drives others to run away because the anxiety and stress is so high. Loneliness feeds the paranoia which causes isolation from others in an unhealthy relational downward spiral. Partners wanting to neutralize the effect must not dispute the fears but accept them even if they are highly improbable.
  • Schizoid PD. Their natural detachment from others makes it impossible for anyone to get close. This PD lives hermit like and is not easily discovered. Partners, who are involved even if at arm’s length, need to protect the PD’s privacy at all costs.
  • Schizotypal PD. Their odd and eccentric behavior deters most from getting close because of their peculiar thinking. Their feelings of loneliness are strung together with random events and unrelated sequences leading to unusual conclusions. Partners should see this pattern as normal for the PD and resist the urge to tear it to shreds.
  • Antisocial PD (Sociopath & Psychopath). Their fantasy of hurting others, threats of harm, and intimidating stares scares most people away. This PD generally is comfortable feeling alone and prefers life to be this way. Most expressions of loneliness are actually attempts to manipulate others. Partners should be on guard.
  • Borderline PD. Their extreme mood shifts and high emotional tolerance are nearly impossible to match for a person who does not have Borderline PD. Feelings of loneliness and the fear of abandonment is sometimes expressed in self-harming or self-injurious behavior. Partners need to reassure the abandonment fear to neutralize the loneliness.
  • Histrionic PD. Their sexualization of mundane events and in uncomfortable moments is awkward and unappealing to others. Typically, this PD seeks out some type of sexual contact to overcome feelings of loneliness. Partners should encourage this PD to use words, not their body to express their fears and feelings.
  • Narcissistic PD. Their daily need for affirmation, attention, adoration, and affection is a tremendous burden for others to bear. Usually their loneliness is expressed in fits of anger. This is a strong indication that their needs are not getting met. Partners can reduce the intensity of the outbursts by supplying the needed attention.
  • Avoidant PD. Their fear of being shamed by a partner to them causes them to push away their partners which intensifies isolation. Most of these PDs want relationships and show loneliness through withdrawal. Of course, this makes matters worse, not better. Partners should realize that the distance they feel is actually a cry for attention.
  • Dependent PD. Their fear of having to make decisions alone and need for constant reassurance from others is exhausting to a partner. Neediness or asking input over mundane decisions is an indication that this PD is feeling lonely. Partners should resist the urge to become frustrated by the lack of decision making and find ways to assist without making the final choice.
  • Obsessive-Compulsive PD. Their insatiable need to compartmentalize, quantify, and qualify a relationship pushes partners away who just want to live and enjoy life. Loneliness is often expressed as rigidity in routine, judgmental comments, and suffocating partners with countless questions. Partners should resist black-and-white thinking and instead offer shades of grey as solutions.
  • Passive-Aggressive PD. Their backhanded and sarcastic way of dealing with confrontation drives others away because they are unsure of when the next attack will happen. Loneliness, for this PD, is treated in the same manner as anger by procrastinating, pouting, or conveniently misplacing needed items of their partners. In response, partners should resist the urge to become angry but rather use a consistently direct approach.

Because loneliness is a common thread in every personality disorder, it would be convenient to have it be considered as part of the definition of the disorder. This way, the people working or living with a PD might recognize the underlying disorder sooner so a more balanced approach can be achieved.

Jennifer Rollin, MSW, LCSW-C <![CDATA[Tips for Marketing Your Private Practice: An Interview with Christopher Gerhart]]> 2017-09-19T14:29:48Z 2017-09-20T14:29:35Z Jennifer: Thanks so much for agreeing to be interviewed! What are some marketing strategies that you’ve used thus far, which have been effective in terms of generating patients for your private practice?

Christopher: Understand that Google is a verb.  Most people that search for anything “google it.”  That means that my business has a gmail address, which lets me get on the map with google business.  I also have some youtube videos.  I have a blog on google and a website on wordpress.  I do not have a personal facebook or linked in page; but, my business has both.  All of this is free.  I also have listings on yahoo and bing, also free.    Make sure that your webpage is “mobile friendly.”  Having so much test at tiny fonts will not get you many phone calls.

Jennifer: What are some marketing strategies that you tried, which did not have a good return?

Christopher: I tried advertisements in local free papers and saw no notable return on them.   I have also underwritten some programming on local public radio.  Although I have not seen any appreciable returns from that, I will probably continue to support my local public radio stations.

Jennifer: What would be your advice for someone just starting out or even someone who has been in private practice for a while, who is looking to enhance his or her marketing efforts?

Christopher: Be honest about what you do not know.  Google is a verb.  Google loves itself.  You have to be first on google to break the ice.  HARO can help; but, you have to capitalize on those links by connecting them to your facebook and linked-in pages.

Jennifer: Did you decide to enlist any outside help in your marketing efforts for your private practice?

Christopher: I spoke informally with a number of successful people.  I also learned to search myself on a computer that I do not use such as at the public library or on a friend’s phone.  If I use my laptop, there are cookies and trails back to me.  I want to make sure that someone searching for a DOT/SAP in Arkansas finds me first.

Jennifer: Looking back, what is one thing you wish you knew when you first started marketing for your private practice?

Christopher: Websites that promise to “fix” your listings don’t.  That, and many of the search engines that they promote don’t have much use.  Google is where it is at.

Jennifer: What are some ways that you schedule and manage to organize your marketing efforts?

Christopher: I keep a list of calls to make, both in person and over the phone, so that when I have a client “no show” or I am going to a training across town, I can call or stop by with a smile, a card and some pens or other swag.

Jennifer: Thanks so much for sharing your marketing tips and for taking the time out to speak with me today.

Learn More About Christopher:

Christopher is a substance abuse counselor in Little Rock, Arkansas. He offers low-cost, high value, evidence-based substance abuse counseling and education services. To ensure a greater deal of privacy, client engagement and focus on client-centered services rather than documentation, he does not accept payment from anyone other than the client served. That means that government and insurance companies influences will be limited influences on the therapeutic relationship, allowing the client and counselor to determine the most effective means and methods of change. To schedule an appointment with him, please call (501) 478-0182.


Miranda Palmer, LMFT <![CDATA[The Ultimate Private Practice Training Series: Developing Your Niche]]> http://4.984 2017-09-20T09:40:16Z 2017-09-20T09:40:16Z Developing Your Niche

Niche – it should be easy right? It’s one of the biggest things we conquered in bootcamp and now we want to help you deal with this too.

Niche by definition is simply a specialized but profitable corner of the market. Choosing a niche gives your private practice a trajectory. When you have a niche, you are able to do market research needed for business planning. You also are clear in your marketing messages about who you help and how. Your niche will also influence your training choices, for example, couples specialist going through Gottman training.

Check out this training video on developing your niche!

Miranda Palmer, LMFT <![CDATA[The Ultimate Private Practice Training Series: Business Planning]]> http://4.978 2017-09-20T09:25:52Z 2017-09-20T09:25:52Z The Ultimate Private Practice Training Series: Business Planning

Are you looking for free training on how to develop a private practice plan that inspires you, and allows you to make a great income? We have a 60-minute free training for you to watch below!

Before you try to fill out your private practice business plan, you need to clarify what you really want from your business, and how you do your best clinical work. Take this first step to creating a business plan for your private practice today by creating a clear picture.


Watch the 60-minute video on business planning fore therapists!

Jessica Dore <![CDATA[Staying in Touch with the Heart of Therapeutic Practice]]> 2017-09-19T14:29:16Z 2017-09-19T14:29:16Z If we lose touch with our core values as practitioners while doing therapy, the work can start to feel mechanical–less like an organic relational dance between two individuals and more like simply toggling back and forth between a set of techniques.

It can help to check in with ourselves every so often about what it is that we want to create with our patients and what we want our work to look like. Of course, every practitioner will have his or her own set of core values that constitute the spirit and heart of their personal work. Depending on therapeutic orientation, training, client base and other contextual factors, values will vary by individual.

Here are a few examples of common core values that many therapists share. Once you’ve read through them, consider writing down what each of these values mean to you, removing or revising any that don’t resonate and adding your own.


As we know, the therapeutic relationship is one of the top determinants of therapeutic success. A quality therapeutic relationship may look different depending on the situation, but it will always contain an element of safety and trust between the practitioner and patient.

Consider the actions you take or don’t take in the service of making your patient feel safe. Do you prioritize safety in the relationship or consider it less important than other things? How do your attempts to establish safety with them work for you? Do you see any areas where you may be able to improve?

2. Partnership

Practitioners may have different ideas about what constitutes a quality therapeutic relationship, but many will agree that partnership is a key component. When clients comes to therapy, they may bring with them a sense that the therapist’s job is to “fix” them or rid them of what ails them, but as we know, therapeutic progress takes two.

How do you feel about the idea of partnership as a core quality of the therapeutic relationship? In what ways do you establish a tone of partnership with your clients? Can you think of any ways that you may reinforce a different dynamic, for example, covertly or overtly suggesting that the client is broken, and needs you to fix them?

3. Client Empowerment

If you learned motivational interviewing in graduate school or during your clinical internships, you are probably familiar with the concept of evoking, or drawing out the client’s own wisdom about a situation rather than imposing your own interpretations, opinions or even unsolicited advice upon them.

One way to establish a therapeutic relationship that feels like a safe partnership is by resisting the urge to interpret, create meaning or dominate the conversation about the client’s experience. A person’s best shot at making change comes from his or her own experience of why it’s necessary to do so.

Do you ever notice yourself dominating the conversation in the therapy room? If so, what do you think motivates you to do that? Can you make space for clients to come to their own conclusions in their own time? If not, are you willing to examine your need to control how quickly the person comes to realize his or her own personal motivation to change?

4. Compassion

No matter what comes up, compassion should be at the heart of any therapeutic relationship. It can flow in a number of directions, including from the therapist to the patient, from the therapist to him or herself, or from the patient to him or her self.

In compassion-focused therapy, the practitioner will go to great lengths to emphasize that as humans, much of our suffering was not our choice and is not our fault. This belief doesn’t mean that we avoid taking accountability for our actions or blame everything we struggle with on others. It simply means that we maintain the stance that at any given time, we did the best we could with what we had.

This approach helps to activate the part of ourselves that sees into the nature of things, and understands. For clients who struggle with the added injury of shame and self-criticism on top of the maladaptive behaviors or mental health issues that brought them to therapy, compassion can go a long way toward helping to clear the way for healing.

In what ways does compassion show up in your therapeutic work? In what ways might you take steps to facilitate a greater flow of compassion and self-compassion between you and your client?

Consider scheduling some time every six months or so to think about your own values as a practitioner. Maybe you will see that some of your values change and evolve over time, while others endure. Either way, staying in touch with the heart of why you do this work is an important step in achieving your desired results, finding fulfillment and preventing burnout.

Christine Hammond, MS, LMHC <![CDATA[Florida Teachers: Beware of Post-Hurricane Stress in Students]]> http://5.1668 2017-09-17T17:17:28Z 2017-09-17T17:17:28Z After being closed for over a week due to the devastating effects of Hurricane Irma, some Florida schools are attempting to return to normal operations. While the schools may be fully-functional, the teachers and students might not be. Educators should be properly equipped to handle basic first-aid for mental health care as many students will be in need of assistance. Here are a few potential problems that may happen in the classroom and some possible solutions:

  • Shared Common Experience. Tragedies that effect entire communities, let alone those that change an entire state, are shared common experiences. It is very helpful and therapeutic for students and teachers to tell their own unique story of how the hurricane effected them. However, too much sharing could traumatize or re-traumatize students who had a mild experience compared to those whose loss was significant.
    • Solution: Have a bellwork assignment (either written or drawn) asking students to share their experience with the hurricane. After completion, encourage students to voluntarily share their story. Ideally, the teacher would go first as an example. Limit the overall time to no more than 15 minutes as well as individual time to a couple of minutes. Because some students have a tendency to “one-up” each other, maintain a tight control on sharing the unnecessary extremes. Remember, this is not group therapy. However, the bellwork assignment is essential information for teachers who have students still without shelter, water, food, power, phone/cell service, transportation, and/or internet.
  • Secondary Trauma. Many Floridians have extended family members in other parts of the state, Puerto Rico, and the Bahamas. While the student’s individual experience may not be as traumatic, their relatives and friends may not have done as well. This is a form of secondary trauma where the student doesn’t experience directly, instead they feel it indirectly. For sensitive people, this is equally traumatizing as having gone through it themselves.
    • Solution: Avoid showing pictures of the hurricane damage to students unless the teacher is certain that no students have any extended family or friends in the most devastated areas. Talking about the storm is one matter while viewing videos or photos is an entirely different experience. Any regular assignments that involve trauma happening to others such as war, might also activate secondary trauma. Teachers should be sensitive to this issue and offer alternative assignments to students who seem to be experiencing additional stress.
  • Increased Anxiety. Younger children and some teenagers have a difficult time discerning between a major storm like a hurricane and a smaller thunderstorm. Unfortunately, this is still the rainy season in Florida so there are and will be severe thunderstorms till the end of October. Even mild storms can increase anxiety when this was not an issue on the past. It is a form of hyper-vigilance where a student becomes highly sensitive to even the slightest indication of danger.
    • Solution: When a person is in a hyper-vigilant state with increased anxiety, trying to tell them that everything is fine doesn’t work and can make things worse. Instead, normalize their experience by agreeing with the reason for the anxiety. Remind them that anxiety is good, it is a warning indicator that something is not right. It is normal for their warning light to be overactive now. In the future, it will settle down.
  • Students in Shock. After a traumatic event, it is common for a person to be in a state of shock for a period of time. This is foggy-like confusion can last from weeks to months depending on the person. Children have a natural tendency to block out difficult situations so sometimes those who experienced significant damage will appear to be the most well adjusted. However, this only temporary and has a rubber-band effect usually when their environment has fully returned to normal.
    • Solution: Set aside the bellwork assignments that reveal the most trauma. In a couple of months, these students may show signs of increased anger, anxiety, arguing, withdraw, and depression. Once discovered, refer these students to a safe coordinator or guidance counselor to get them the help they need to process their experience. Due to state of shock that some students are experiencing, many will have a difficult time diving right into schoolwork. It is good to go a bit slower for a few days to allow time to readjust before unleashing the week’s worth of missed assignments.
  • Stages of Grief. Anytime there is a significant change in a person’s environment such as a death, divorce, move, or natural disaster, a person experiences the stages of grief. These stages are not done in order, especially when young children are involved. Rather, they are experienced in a ping-pong like fashion: one day it is one stage the next day it is something else. The stages are: denial (“It wasn’t that bad”), anger (“I’m mad at everyone”), bargaining (“Why didn’t this happened instead”), depression (“I can’t stop crying”), and acceptance (“I’m OK”).
    • Solution: Knowing that nearly every student and teacher might experience the stages of grief at varying times, degrees, and durations, means extra grace needs to be extended to all. It is essential that teachers be aware of their own processing of grief first before trying to see it in their students. Most students are highly sensitive to changes in their teachers so this is the time for teachers to set an example of healthy processing of their own experience before assisting their students.
  • Post-Hurricane Stress. Children and some teenagers are unable to identify stress in themselves. Usually stress in children presents itself in physical complaints, obsessive/repetitive behaviors, anger outbursts, problems sleeping, nightmares, loss of interest in fun activities, withdrawal from friends, and defiant behaviors. The big key here for teachers is to be observant of a shift in behavior from the previous month to now. Any dramatic changes are likely indications of increased stress due to the hurricane.
    • Solution: It is important to remember that new changes in behavior are stress-related and not defining characteristic of the child. Children need to be taught how to handle and release stress properly. This could be as simple as having a box where children put in a writing or drawing about anything they want without consequence. Or creating a safe corner of the classroom where an anxious child can sit or stand. Or encouraging more physical activity (such as jumping jacks or going outdoors) to help release some steam. Again, it is important that teachers model proper stress management because sometimes this is the only place a child sees it done well.
  • Post-Traumatic Stress Disorder (PTSD). It is far too early to diagnose anyone with PTSD. The official diagnosis requires a passage of six months from the incident, ongoing anxiety/panic attacks, continued nightmares, random flashbacks, and mild to severe depression. Rather, panic disorder and adjustment disorder is very common now. Panic appears as heightened anxiety, mixed with intense fear, usually generating a freezing, fleeing, or fighting response. Adjustment disorder means a person is struggling with their new normal and experiences anxiety and depression due to the change in environment or circumstances.
    • Solution: Do not diagnosis students. Rather, use this information to be aware of potential problems that might need to be addressed by a mental health professional. Children don’t know that they need help and usually are uncomfortable asking for it. Not addressing these issues early on could result in the activation of PTSD later. PTSD is a much more difficult recovery than panic or adjustment disorder. Teachers should reach out to parents, a safe coordinator, and/or guidance counselor if they see these symptoms in their students.

This article only covers the basic first-aid care of students experiencing post-hurricane stress and are not met to be a replacement for therapy. Therapy should not be done in classroom, it should be left for those trained in handling children and the disorders. However, teachers are frequently the first-line of support in helping students to fully recover from their post-hurricane stress and should be seen as a valuable asset in this process.

Bret Moore, Psy.D. <![CDATA[4 Simple Steps to Help Your Patients Manage Anxiety]]> 2017-09-16T23:06:57Z 2017-09-17T13:06:38Z Anxiety is as commonplace in our daily lives as cellphones, microwavable food and drive-thru coffee shops. If your patients are like everyone else, they worry about paying their bills on time, the health and welfare of their loved ones and advancing in their careers.

But, does that mean anxiety is bad? No, not at all. In fact, some degree of anxiety is healthy for us. Without it, we would have a tough time getting motivated to do things we don’t like such as showing up for work on time or registering for college courses. It also helps us find solutions to difficult problems by forcing us to consider the outcomes of multiple courses of action.  In other words, it helps us plan the steps needed for effectively solving problems.

Unfortunately, many people associate anxiety with psychiatric illness and believe that professional help is the answer. This perception is, in part, the fault of media.  It’s also because of  what we’ve been taught in graduate school, which is that we are the best source of comfort and relief for our patients. The reality is that not all of our patients need to see a shrink and be put on medication or endure months of talk therapy to manage their anxiety.

In fact, unless their anxiety keeps them from going to work or enjoying life, all they need to do is use some basic and straightforward techniques. And you can encourage them to do so.

Which techniques?  Well, the most successful techniques often are based in common sense, not some abstract psychological theory. Here are four sure-fire techniques for helping your clients beat back the annoying anxiety that hides in every nook and cranny of their psyche.

1.Stay in the present.  A popular movement in the professional and secular areas of psychological wellness is mindfulness, or the intentional direction of one’s focus to the present moment. If your clients are able stay in the here-and-now and avoid labeling and judging what’s going on around them and allow themselves to just “be,” then their mind will be unable to create anxiety.  There are various schools of psychotherapy based on this core principle. However, individuals can use basic mindfulness techniques on their own schedule and within the context of their own understanding.  Maybe all you need to do is teach them the proper use of mindfulness over one or two sessions.

2. Think of pleasant childhood memories.  No, this technique is not the same as having your patient connect with his or her inner child. All it requires of them is to conjure up some positive moments from their past. As you are aware, a person’s mind is really bad at deciding whether what’s going on in their head is in the past or is happening now.  As a result, the person can trick his/her brain and body into reliving the positive emotions and thoughts that come from reconnecting with their younger self. Yes, there are some people who will believe that they have no positive childhood memories.  However, with gentle exploration, most everyone can identify at least a few.

3. Practice acceptance. There is age-old wisdom that directs us to change the things we can and accept the things we can’t. This guidance is perfect when it comes to dealing with day-to-day anxiety.  For many people, the inability to let go of things that are out of their control fuels chronic and disruptive anxiety. If you have a client in this siutation then it’s time to help him or her let it go.

4. Practice avoidance. I know.  Generally speaking, avoidance is not a healthy strategy for dealing with anxiety. But in some instances, staying away from people, places and things that make you anxious can be the best medicine. Ask your client to identify those triggers in his or her daily life and practice some evasive maneuvers.

*A previous version of this article was published in Dr. Moore’s column Kevlar for the Mind, which is published in Military Times.

Marie Hartwell-Walker, EdD <![CDATA[The Importance of Therapist Silence]]> 2017-09-16T23:07:16Z 2017-09-16T23:07:16Z In a 2009 study of 10 languages from five continents, Tanya Stiver and her associates found that the amount of time between turns when people are in conversation is remarkably brief and surprisingly universal. On average, the gap between speakers is about 200 milliseconds. That’s milliseconds! Just about the time it takes to say a syllable.

In order to keep the conversation flowing then, people have to start planning their replies in the middle of whatever the speaker is saying. Does that mean we’re only planning our responses and not listening? Not really. The researchers found that people who are engaged in conversation are aware of multiple nuances in our choice of words as well as the rhythm and tone of speech. When talking to each other, we are exquisitely tuned in to each other and do understand each other’s content and intent.

The study also identified two universal rules in conversation:

1) Avoid speaking at the same time as a matter of courtesy and to give the speaker time to complete a thought.

2) Avoid silence between turns. When the gap between speakers is lengthened, it has generally the same meaning across cultures: Either the listener is in disagreement or she is unwilling to give a definite answer.

The first rule is easy to follow because it is a rule we have been taught from childhood. Most of us were admonished by our parents, teachers and elders not to interrupt; to let people finish. Most young therapists therefore know better than to talk over their patients. Most understand that interrupting a patient’s thoughts or ignoring their feelings is not therapeutic.

But a challenge for many beginning therapists is that most schools of therapy require us to break the other fundamental rule for ordinary discussions. To be effective, the therapist must both tolerate and use silence as a therapeutic tool. Despite the fact that this approach is so central to effectiveness, it is often overlooked by training programs as an essential skill that needs to be taught.

Breaking the universal rule around turn-taking in conversation is anxiety provoking. We are conditioned from the time we first learned to communicate to keep talking. When conversation lapses for more than that 200 milliseconds, most people feel compelled to relieve mounting tension by filling in the gaps. A new therapist’s task is to work through whatever anxiety he or she has about letting conversation lag.

Stretching out the gap between a patient’s statements and our responses doesn’t come naturally. But, in therapy, our silences are as powerful as whatever we might say.

The Benefits of Therapist Silence in Session

 Therapist silence can help the client stay in charge of the session. When we don’t jump in with an agenda, the client will often take more responsibility for setting the goal of the session and for deciding what is most important.

Comfortable silence can provide what D.W. Winnicott referred to as a “holding environment.” In such a silence, the client can feel safe. It indicates that there is space in the therapy hour for the person to do serious introspection. Further, they can experience our lack of immediate responses as confidence in their ability to deal with their distressing issues.

Silence can slow things down in a productive way. A patient who is anxious to solve a problem may land on a solution prematurely or settle on a decision that is borne of that anxiety, not on new understanding. The therapist can suggest that they both take a few minutes to sit quietly and think about the usefulness of such a decision before coming to conclusions.

Done supportively, silence can exert some positive pressure on the client to stop and reflect. Non-verbal signals of patience and empathy by the therapist can encourage the client to express thoughts and feelings that would otherwise be covered up by too much anxious talk.

Sympathetic silence can signal empathy. When the therapist responds to accounts of tragedy, traumatic experiences or emotional pain with non-verbal cues of kindness and understanding, it can mean more than awkward attempts to verbally express sympathy. For some things, there really are no words that are adequate to the situation– at least at first.

Attentive silence can help us when we feel “stuck.” Carl Rogers, a master at kind and supportive silences, often stated that when in doubt about what to do, listen.

Not so finally, silence can give the therapist time to think. It reduces patient anxiety about our silence if we mark it by saying something like “Let me think for a moment about what you just said.” Such a remark signals respect for the client’s ideas and feelings while we take the time to sort through what is best to say.

On the Other Hand:

Remember, our silence breaks a universal conversational rule. It’s therefore essential that we educate our clients about the difference between ordinary conversation and therapy. Conversation requires rapid turn-taking to keep the social gears turning. Therapy requires slow, thoughtful consideration of feelings and ideas as we work toward a goal.

Even having been told and retold that silences are useful in therapy, they can be anxiety-provoking for the client.  If the client feels threatened by our lack of response, therapy won’t go anywhere. An anxious reaction needs to be met with a reassuring response.

The patient may not be ready to manage the feelings and thoughts that come up in lengthened conversational spaces. Fewer or shorter silences may be required for awhile to help the patient develop trust in our process. As the client develops that trust, he may become more comfortable with spaces that prompt him to feel uncomfortable feelings and to talk about painful events.

As the researchers noted, silences can be read by the client as disapproval, rejection or withholding. A brief verbal explanation or non-verbal cues like a head nod or hand gesture can make the space feel supportive instead of dismissive.

 Silence as an Oasis

Silent moments in therapy serve as an oasis from the chatter that fills most of our lives. Like an oasis, supportive silences can refresh, nurture and strengthen those around it. Because such spaces in conversation are outside usual human interactions, they can let something different happen. They are a powerful tool that we each need to develop thoughtfully and purposefully.

For more information about the study of conversational gaps, see:

Stiver, Tanya, N.J. Enfield, P. Brown,, Universals and cultural variation in turn-taking in conversation, Proceedings of the National Academy of Sciences of the United States of America,  Vol. 106, No. 26



Christine Hammond, MS, LMHC <![CDATA[Hurricane Survivor Reveal: What Are You Made Of?]]> http://5.1663 2017-09-15T12:15:17Z 2017-09-15T12:15:17Z Hurricane Irma tore though Florida five to seven days ago, depending on where a person lived. Since then, in the Orlando area alone, there are still nearly ½ million people, businesses and schools without power, even more without any internet service, and countless others without land-line phone service. Some businesses are fully operational while others are partially or completely shut-down.

Our local coffee store still has no dairy products which means no lattes. A neighborhood restaurant chain offers customers paper menus with limited selections. Many grocery stores have bare shelves and a small number of frozen or refrigerator items. Gas stations near the major interstate roadways have lines that wrap around the corner. Schools are still out.

Last night while driving home in an unexpected torrential rainfall, the streets flooded. Already high lakes overflowed and in some cases spilled out onto neighboring streets. Debris from downed trees which lined the streets in anticipation for garbage removal shifted into the road clogging drains. Flooding in some parts of the city from the hurricane expanded rapidly to others making driving nearly impossible.

Life is not normal. Tensions have mounted. Anxiety is pushed to the limit. The desire to go back to way things operated a couple of weeks ago before Irma was a known threat is felt by all. Yet it is precisely in these moments, that the real character, specifically the unhealthy parts, of a person is revealed.

  • “It’s all about what I’m going through.” Even knowing that the lack of power, internet, and limited cell service is a communal experience, some find ways to make it about them and their agenda. The selfish demand for attention doesn’t stop because of the storm, rather it escalates. In some cases, the arrogance is so intense, that it generates it’s own mini hurricane within the overly stressed family unit.
  • “Why is this happening to me?” The victimization of the storm into a personal experience instead of a statewide experience, causes some to complain non-stop. This drains much needed energy resulting in a lack of productivity. This victim mentality frequently paralyzes a person which in turn generates even more issues.
  • “If I was in charge, things would be different.” In an effort to prop up one’s ego, some use this opportunity to be overly critical of businesses, school districts, and governmental officials. Their oversimplification of complicated issues, most of which has not been discussed with the public yet, creates a superiority attitude. Those who need to feel better by putting others down are really bullies at heart and not team players.
  • “Get out of my way.” Unfortunately for some, anger is the only emotion expressed during stressful times. Instead of using the full range of an emotional experience, sadness, fear, anxiety, and frustration are lumped into anger. This raging intensifies as circumstances change very slowly separating neighbors at a time when unification is far more beneficial.
  • “I’m fine. Everything is fine.” Denial is a powerful defense mechanism every bit as destructive as anger. Those who choose to pretend that life is OK at a time when it clearly is not, miss out on the opportunity to connect more deeply with others. This lack of intimate connection isolates a person from others who don’t feel valued or needed in the relationship.
  • “It’s all your fault.” When tension are high, some people look for others to blame rather than to take personal inventory of their contribution. This blame shifting is a way of not taking individual responsibility. For some, admitting their shortcomings is too vulnerable so they go out of their way to point out the flaws in others as a way of hiding their own. Eventually this wears others out and causes them to leave or abandon the blamer.
  • “Just leave me alone.” Rather than lash out on others, some chose to withdraw completely from others for large periods of time. The flood of emotions from within is so overwhelming and uncomfortable that they retreat instead of reaching out to family or friends. It is a shutting down of sorts that is hard to bounce back from if not addressed soon. The more a person isolates, the easier it becomes, until they find themselves completely alone.
  • “There is so much to do.” Some respond to the stress by busying themselves with unnecessary activity. In an anxious effort to distract from the real problem at hand, some obsess over things that are insignificant. This nervous energy is difficult to be around and most run for cover when they see it. As a result the anxious person takes on the runner’s tasks resulting in a rapid burn-out from all the unnecessary work.
  • “There is nothing I can do.” At a time when extra volunteer resources are needed to help with the clean-up, some choose to remain inactive. Rather than seeking out opportunities to engage within the community, they hibernate claiming that their help is not really needed. This is an unfortunate waste of human effort which only compounds isolation.

The antidote to all of these unhealthy responses is balance. While it is good to stay active during stressful times, too much activity or complaining is exhausting. Releasing some pent up emotions such as anger is important but doing it in a way that harms others is hurtful. And while connecting honestly and openly with others is essential, overwhelming or blaming others is destructive. Even when life is unbalanced on the outside, there can be balance on the inside.

The Carlat Psychiatry Report <![CDATA[Understanding the Dangers of Designer and Club Drugs]]> 2017-09-14T18:33:03Z 2017-09-14T18:33:03Z cannaboidCATR: This is a great topic because it’s been in the news lately and it is one that a lot of people don’t know much about. We’ve heard about designer drugs; we’ve heard about club drugs. I’m not sure if most of us really know if there’s any difference between the two or how they are defined.

Dr. Weaver: Designer drugs are derivatives of other drugs, some of which occur naturally. Designer drugs in a specific category can be referred to by brand names or by individual or street ones. One category of designer drugs are synthetic cannabinoids, which are laboratory-produced versions of the THC (tetrahydrocannabinol) found in marijuana. Some brand names of synthetic cannabinoids that you may have heard of are K2 and Spice. Then there are the bath salts, which are similar to ecstasy and gaining in popularity. Bath salts is kind of a catch-all name for the various cathinone and cathinone-derivative products. Cathinones originate from the khat plant, which is grown in the Middle East and is often chewed there and used as a mild stimulant, similar to a cup of coffee. But bath salts are concentrated formulations and are much more potent. One of the newer stimulant/hallucinogens most similar chemically to bath salts is called Flakka. Around the Texas area it is also known as gravel. Some of its other street names are Vanilla Sky and Ivory Wave. Another group of designer drugs that have recently emerged are synthetic versions of other synthetic drugs. A fairly popular synthetic hallucinogen called 25i-NBOMe, known on the street as N-bomb or Smiles, is a derivative of LSD. Ecstasy (methylene dioxy-methamphetamine, or MDMA) which contains both stimulant and hallucinogen-type properties, is another type of designer drug. It often goes by the street name molly and can also be categorized as a club drug.

CATR: What are club drugs?

Dr. Weaver: The classification “club drugs” was coined by the National Institute on Drug Abuse (NIDA) to identify drugs commonly used on the club scene, or at dance parties, raves, and circuit parties. Although there is some overlap between designer drugs and club drugs, club drugs tend to be more established ones that include things like methamphetamine and ketamine. Club drugs also include the “date rape” drugs such as GHB and flunitrazepam. Unlike designer drugs, club drugs are not necessarily made up of new chemicals that are derivatives of something else. An exception to this is ecstasy, which is an example of both a club and designer drug.

CATR: In a typical psychiatric practice, are these drugs in fairly common use?

Dr. Weaver: They tend to be used by teenagers and young adults. Child psychiatrists will definitely be seeing these patients, but the age range goes up to 40 or so. Among young adults where I have the most information, synthetic cannabinoids are second only to actual marijuana in terms of popularity. Someone who is using marijuana regularly may use synthetic cannabinoids periodically. Younger users and newer users may opportunistically try some of these drugs if they are available, or they may seek them out because of their trendy names and colorful packaging. Designer drugs are marketed as “legal highs” since they may not yet monitored or enforced by any local or federal laws. Currently, there is no specific urine test for designer drugs. Patients with the most to lose from a positive drug test outcome may gravitate towards these drugs because they are harder to detect. This could be a teenager on an athletic team, a professional athlete, a person on parole or probation, or a member of the military.

CATR: In the context of an outpatient setting where we may be seeing patients that are using these drugs, should we be approaching them differently? Do we now have to go down a long checklist and say, “Have you taken this?” “Have you taken that?”

Dr. Weaver: I think, for a clinician, awareness is one of the most important things. Forewarned is forearmed. So it’s good to be aware that these drugs are out there, that they are widely used, and that a negative drug screen doesn’t mean that the person isn’t using. And the usual sorts of things in a psychiatric interview: asking open-ended questions. Lists aren’t a bad thing necessarily. Knowing what some of the names for these drugs may help you establish some street cred. If you can ask them about bath salts, Spice, Scooby Snacks, N-bomb, they are more willing to open up.

CATR: Certainly with younger patients they have a feeling of invulnerability. We often talk to them about how dangerous drugs are, and they sort of say, “Yeah, yeah. We’ve heard this before. You’re a doctor. You’re supposed to say this.” How can we get around that attitude?

Dr. Weaver: Well, one of the ways I talk to patients about this is “buyer beware.” You don’t always know what you’re getting. Someone may be willing to cheat you with a cheaper, more dangerous substitute, or you may not know exactly what it is that you’re getting. Letting them know that there is a very real risk even if they do have that kind of immortal, invincible mindset. At best they may get a very bad scare and at worst a life-changing event that could impair their ability to finish school or get a job—to say nothing of potential legal consequences down the road as the laws do catch up with these drugs.

CATR: Are these drugs truly medically dangerous?

Dr. Weaver: Yes, these kinds of newer substances can have severe medical consequences. There are cases of people who have used just once or twice and have had life-changing problems: strokes and cardiac arrhythmias. These effects aren’t necessarily common, but they also are not as uncommon as we would like. There is a young lady here in Texas, not too far from Houston, who spoke recently at a summit on synthetic marijuana. She had used just a couple of times when she was 17 or 18 and ended up having a pretty severe stroke and is now in a wheelchair. In fact, the synthetic cannabinoids, the synthetic hallucinogens, and the bath salts have all had deaths attributed to them.

CATR: We’ve talked about some of the dangerous physical side effects. I imagine that these kinds of compounds can produce some pretty significant psychiatric effects as well. What might we see in patients?

Dr. Weaver: Most common are agitation, paranoia, anxiety, and varying degrees of delirium and hallucinations. Patients could also be experiencing something fairly similar to a psychotic break with some of these drugs, especially with the more stimulant-based ones like the cathinone derivatives—the bath salts. They are like taking amphetamines, and they can be pretty potent. It can be challenging to distinguish these symptoms from manic episodes or psychotic breaks, especially because oftentimes they will not show up on a standard drug screen. You might need to look for other clues.

Sharie Stines, Psy.D <![CDATA[Ten Rules Found in Narcissistic Homes]]> http://7.1380 2017-09-19T21:19:01Z 2017-09-14T05:28:37Z  

In a dysfunctional household there are some specific rules which are passed down from generation to generation. These rules are severe and uncompromising.  If you have been raised in a narcissistic family you may find that you have been raised with some, if not all, of the following rules:

  1. Children are taught that someone must be blamed for the mistakes that occur. There needs to be a scapegoat.In a healthy family, ownership is taught. Apologies and amends are made. When an injustice occurs, the perpetrator makes it right.
  2. The narcissist always gets his or her way during decision-making. There is no cooperation, collaboration, or compromise (at least on the narcissist’s part.) Only the non-narcissistic family members are called to compromise their wants. In a healthy family you will find cooperation and even the type of compromise where each person must give a little.
  3. The narcissist is allowed to have his or her feelings and “dump” them on other family members. In healthy families every family member is free to experience their emotions; however, no one is allowed to dump their emotions on another family member. Rage attacks are not tolerated.
  4. Family members other than the narcissist must justify why they feel the way they do, and the narcissist will never validate anyone else’s emotions.  In healthy families emotions are expressed in healthy ways; family members are allowed to talk about their feelings and other family members will listen to them.
  1. “Discipline” of children is harsh, shame-filled, destructive, inappropriately expressed, and hurtful. In healthy families, discipline is thoughtful, productive, intentional, and not a method for the parent to “work out” his or her own emotional issues. Discipline is meant to teach children, and is mainly expressed through role-modeling.
  2. Family members are conditioned to meet the needs of the narcissist. All family members learn this expectation. In healthy families, one’s needs are not always going to be met by others, but they can be properly articulated to others. Validation of emotions occurs.
  3. Children are taught, not to look within themselves, but to constantly scan the horizon in order to determine the narcissist’s mood prior to making a decision. This teaches children not to trust their own thoughts, feelings, or intuition; and to “walk on eggshells.”In healthy families each individual is allowed to experience his or her own reality. Even when people disagree, it does not mean that anyone is going to be punished for having an independent thought. Individuals learn to trust their intuition.
  4. Everyone in the family learns that making mistakes is shameful. On top of that, “mistakes” seem to be arbitrary, based on the narcissist’s state of mind. The culture of a healthy environment teaches that mistakes are how we learn. There is no shame involved.
  5. Narcissistic homes have rigid rules. Flexibility is not encouraged. Changing one’s mind is not permitted.  In a healthy family, changing one’s mind is evidence that people can grow and rethink based on new information.
  6. Image is the highest priority. In healthy families, relationships are what matter.

Reference:  Donaldson-Pressman, S., and Pressman, R.M. (1997). The Narcissistic Family – Diagnosis and Treatment. San Francisco, CA: Jossey-Bass.

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Christine Hammond, MS, LMHC <![CDATA[Post-Hurricane Stress Recovery]]> http://5.1657 2017-09-13T13:57:32Z 2017-09-13T13:57:32Z The real devastation and triumph of Hurricane Irma lies in the personal stories of loss and survival. While the extent of the catastrophic property damage in the State of Florida is just now coming to light, the people of Florida have rallied around each other in simple acts of kindness.

Since this was the largest evaluation in the United States history, many Floridians down south headed for northern or central parts of the state unaware that the storm would soon follow them. Due to the unpredictable nature of this hurricane, both coasts were under mandatory evacuation orders. Family members and friends living in safer areas of the state took in their coastal neighbors. Some people carpooled to conserve on gas and keep one less car on the two north bound clogged interstate highways.

Once the rain and winds died down and residents began to survey the damage, the realization hit that nearly 70% of Floridians were out of power. Some residents lost their homes, boats, roofs, trees, farms, and water. Our downtown Orlando neighborhood which is known for the 200+ year old oak trees that line the streets, had several huge trees fall (roots and all). But the neighbors gathered around and in a few days, the road ways were cleared making it easier for the power to be restored.

The adrenaline that pumped through bodies prior to the storm had plenty of time to reboot as the massive storm lasted for several days over the entire state. But now the attempt at normalization begins for some workers while schools remain closed for a few extra days or indefinitely depending on the damage. Not only is the recovery physical, but the mental and emotional aspects of the storm need to be addressed as well. Here are some tips:

  • Write it down. Florida has a population of approximately 19 million residents and each has a unique story to share. For some the storm did only minor damage while others lost everything including someone they love. The act of putting it down on paper helps to focus on accurate memory while reminding a person that they did live through one of the most devastating storms.
  • Talk to neighbors. This is a time to reach out to neighbors to make sure that they are OK. Many Floridians are elderly so this is especially important because phone service, power, and water have not been restored in all areas. Shared common experiences are far better than trying to handle this alone. Take time to talk to neighbors and form a bond.
  • Be cautious. Already, there are several news stories of unnecessary electrocutions, carbon monoxide poisonings, injuries from power tools, and many car accidents. Even though the work seems overwhelming, go slowly and carefully. Take time to do even the simplest of tasks with full awareness of the environment. Avoid all standing water and downed power lines.
  • Stay present. There is a temptation to relive the past preparations and worry about the future. This can drain precious energy needed for the present day. Instead, make an effort to accomplish only what can be done today and not be anxious about tomorrow. Tomorrow’s worries will be enough for that day.
  • Listen to others. One of the best gifts to offer others is that of listening. Listen to the stories, fears, hopes, and sorrows. Those tempted to give advice during this time are doing a disservice to others, most people just want and need to be heard. If they want advice, they will ask for it. For those seeking advice, please DO NOT look for it from a person who has never gone through a hurricane. This is the equivalent of getting parenting advice from a person who has never parented.
  • Begin to grieve. The grieving process for any loss of a person, property, or community is the same. It is denial, anger, bargaining, depression, and acceptance. The duration varies depending on the significance of the loss. For instance, grief over a minor piece of property can take a few weeks, while grieving a community can take years. Expect to ping-pong from one stage to the next in a random order.
  • Release emotions. One of the best ways to release emotional stress is to cry. Crying releases sadness, anger, frustration, anxiety, and stress. Physical activity is another good method to let off some stem. This is not the time to unleash onto family members, the power company, or others trying to help. This only generates hostility and increases isolation.
  • Do normal activities. As soon as possible, try to reengage in normal routines and activities. Even if the only possibility is a morning shower, it is better to start with something that is even slightly familiar. Try to stick to regular bedtimes and wake times. This allows the body to reset and feel healthy. Eating normal foods and drinks can also help during this time. The last thing a nervous stomach needs is strange foods.

The most important thing a person can do now is to give thanks for what they do have instead of what they have lost. While the loss might be catastrophic, it is helpful to discover even the little things that a person can give gratitude for experiencing. Lastly, please stay safe.

Jessica Dore <![CDATA[The Four Processes of Motivational Interviewing]]> 2017-09-11T21:46:19Z 2017-09-12T13:46:02Z According to its founders William Miller and Stephen Rollnick, motivational interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation to change in a counseling setting.

By steering conversations with patients in a certain way, motivational interviewing aims to help the person to realize his or her own personal and genuine motivation for changing problem behaviors. Though the clinician still guides the work in a particular direction, motivational interviewing should aim to inspire the patient to create and formulate a plan for moving toward appropriate therapeutic goals for him or herself.

Motivational interviewing (MI) is not in itself a psychotherapeutic modality but rather a tool to be used in conjunction with other comprehensive approaches to counseling ”for inspiring change in clients who may otherwise feel neutral about their situations or even reluctant to change. MI consists of four key, client-centered processes that work together to help the individual define his or her goals and begin to move toward them. These processes work together to guide patients toward their motivation for change and to move forward accordingly.

The following represent a limited explanation of each of the four processes. For more in-depth information about MI, there are many wonderful resources available, including a newly revised edition of Motivational Interviewing in the Treatment of Psychological Problems.


Establishing a solid therapeutic relationship is a foundational component of motivational interviewing. Qualities like empathy, acceptance, a focus on client strengths and mutual respect create the foundation for such an alliance.

Mutual respect is made possible in part by the establishment of a quality of collaboration between the counselor and patient so that the client-centered approach is not stymied by power dynamics. Encouraging a tone of equal partnership in a counseling relationship requires that the counselor be willing to not only acknowledge, but lean on the patient’s strengths, knowledge, wisdom and values throughout the process of doing the work.

Engaging also involves four client-centered skills that are abbreviated by the acronym OARS. OARS involves asking open questions, affirming clients’ strengths, reflecting to clients what they may wish to express but have not yet spoken aloud and summarizing what has occurred in the therapeutic interaction.

2. Focusing

While some therapeutic situations will come with some obvious focal points or goals–as in the case of court-ordered counseling, for instance, many will not.

Some clients will come in with material they are immediately ready to go to work on, while others may lack insight and direction regarding the next steps to take. Focusing is about helping the client determine what is truly important to him or her and using that information to set the tone for the work.

The goals should, of course, be mutually agreed upon by both client and therapist, but the focus in MI is on encouraging the person to do the work of identifying his or her own area of stuckness, ambivalence or struggle and setting goals accordingly.

3. Evoking

Once a focus has been identified and is mutually agreed upon, evoking involves discovering the client’s personal interest in and motivation to change. Being able to recognize when  clients say something that suggests they may be willing or ready to move toward change is an important part of the evoking process.

Patients may make a statement that expresses their desire to change, that they know they are able to change, that they are concerned about consequences if they don’t change or that change is absolutely critical to their ability to move forward. Such statements hold important information about whether or not the client is open, willing or ready to change.

But knowing how to invite this sort of “change talk” is an important part of MI. Open-ended questions are a useful tool for evoking this sort of talk and better understanding the client’s relationship and attitudes toward change. Asking for clients to share examples or elaborations on their responses to your open-ended questions about change is another good way to gather information. Once the individual is engaging in change talk, be sure to reflect and summarize, as mentioned in the OARS acronym above.

4. Planning

The important thing about the planning process in motivational interviewing is that the plan comes from the clients and is based on their unique values, wisdom and self-knowledge. Each of the four processes are geared toward fostering and building the clients’ motivation to change, and any attempts on behalf of the counselor to “take the reigns” during the planning process may undermine or reverse the client’s sense of empowerment.

That said, as a counselor you are responsible for inserting your expertise when warranted. For example, clients may express clearly that they want to change, have to change or even that they are ready to change, but they may be stuck on how to go about doing so. This situation is where your expertise comes in. As long as your advice is wanted, your input can be a valuable part of guiding the client toward creating a plan that they feel great about and motivated to stick with. If you’re not sure whether or not your advice is wanted, you can always ask.

For more about motivational interviewing in counseling, check out Motivational Interviewing in the Treatment of Psychological Problems.  

Jennifer Rollin, MSW, LCSW-C <![CDATA[Private Practice Management Tips with Meghan Renzi, LCSW-C]]> 2017-09-11T21:45:44Z 2017-09-11T21:45:44Z Does Psychotherapy Work?Jennifer Rollin’s latest Q & A interview is with Meghan Renzi, LCSW-C.

1.What are some of your favorite systems and ways that you keep your practice running smoothly/organized?

Having an electronic medical record seriously changed my practice. I was able to keep track of my notes and all patient information in a secure place. I also was able to store credit card info so there was not the awkward payment exchange that most therapists dread. Finally, I could bill for insurance through my EMR which saves so much time and energy! I use Theranest but I have heard good things about Simple Practice as well.

2. What do you outsource in your practice?

I outsourced my website to Brighter Vision. I am not tech savvy at all. I was able to participate in the artistic process of building the website without having to know how it all worked! They have great customer service and give me tutorials on how to use WordPress. I email them about things I would like to change and usually it is done by the end of the day.

3. How did you learn how to effectively run your business? Did you have a mentor ?

I had no idea how to run a business when I started my practice. I had worked in outpatient clinics and a few hospital programs before I decided I wanted to start my practice. I had a few sessions with a private practice coach. I also joined an online Business School Bootcamp through Zynnyme, which I felt was well worth the investment. Lastly (and this is the free one), I contacted several private practice therapists in the community who I had been in touch with over the years and reached out to people through LinkedIn. People were so kind and willing to help. I would ask any question no matter how silly I felt it was. It truly was amazing.

4. If you could go back and do something differently in terms of business management and organization, what would you have started right away?

 I would have invested in an EMR and website right away. Without these two things, I would have a very different practice and would feel lost most of the time!

5. How many clients do you typically see in a day and how did you make this decision?

I usually see five or six, however, there have been days where I have seven or more on the schedule.

For my own sanity, I try to make six my max and I try my best not to schedule back to back. Summer is much slower so I typically will see fewer clients on any given day.

6. What are your boundaries around answering work email?

 I used to get email alerts on my phone when I first started my practice. I felt like if I did not answer right away I was going to lose clients. I quickly realized that I was creating too much anxiety for myself. Now, I will check my work email a few times a day but try not to look on weekends. I have a message/ signature that informs patients that email is not 100% secure, and letting them know that I will typically take 24 hours to respond to an email. I also note that email is not a place to share clinical information. This message also advises clients to go to the ER or call 911 if this is an emergency.

One helpful tool for email has been Boomerang- you can schedule your emails ahead of time in case you want to compose an email but not respond right away.

7. Tell me about some of your favorite self-care practices during your workday and on the weekend.

Essential oils, yoga, music, talking to other therapists or psychiatrists in private practice. I love spending time with family. I also am part of wo peer supervision groups which I find immensely helpful.

8. What are some of your best tips for work/life balance as a self-employed therapist?

I must admit I am still learning. Sometimes, I get super excited about revamping my website or putting on a workshop. I have to remember that I do not have to do everything right now. I teach my clients mindfulness practices and I often have to remember the power of pausing and recognizing when I need a break myself.

 Learn More:

Meghan Renzi, is a therapist in private practice in Bethesda, Maryland, who offers therapy and mindfulness services for teens and adults. Check out her website.


Bret Moore, Psy.D. <![CDATA[Many Emotions Follow Trauma]]> 2017-09-08T13:19:25Z 2017-09-10T13:19:09Z It has been estimated that roughly 1,000,000 veterans from the recent wars in Iraq and Afghanistan are struggling with some type of mental health concern as a result of their deployment(s). This situation is particularly true for those who experienced a traumatic event.

In the days, weeks, months and even years following a traumatic combat experience, many veterans struggle with a variety of strong and difficult feelings.  Some experience sadness and grief.  Others struggle with panic attacks and rage. Some deal with guilt or blaming themselves for what has happened. And then others experience almost every one of the aforementioned emotions.

People experience these emotions in different ways. Anxiety comes in many forms and goes by many names, such as “worry,” “stress” or “fear.” Just the simple act of teaching your patient how to label their anxious feelings may seem impossible, but the label is not so important. What is important is helping them recognize that what they are experiencing is anxiety.  When you do that then you can help them deal with it.


Sadness or depression is easier to identify. At some point, each and every one of us has gone through a period in which we were down, depressed, blue or just felt plain “blah.” Sadness is a part of life.  However, after trauma, sadness may become a part of your patient’s daily existence. It can keep them from getting out of bed in the morning or it can keep them sitting home alone when their family or friends are out enjoying life.  In other words, their quality of life suffers.  And those around them, especially loved ones, suffer.


Anger has often been labeled as depression turned outward or toward someone else. As a psychologist, I appreciate the simplicity in this explanation. However, anger is a complex emotion and a powerful one. It can lead to a variety of physical, emotional, relationship and even legal problems. Rage, an extreme form of anger, is even more destructive.  Anger is the emotion that is most often noticed by other people.  It is hard to disguise as the affect, behavior, and posture of an angry person are obvious.


Guilt is also a complex emotion. Guilt is how you feel when you believe, whether rightly or wrongly, that you have violated some personal moral standard.  For example, a Marine who kills a child combatant on the battlefield may experience grief because of his actions. Even though he was trained to shoot the enemy, he still has a difficult time accepting the fact that he killed a child. It goes against his beliefs about what is right and wrong.

As you can see, there are a number of emotions that can overwhelm a person following trauma. And these are just a few of the feelings your veteran client may experience. At times, it may seem like they are drowning in their own feelings. They may feel frustrated that the traumatic event happened so long ago, yet they are still struggling.

Whether your veteran patient is in the immediate days following a traumatic event or have suffered repeated traumas over their lifetime, it is important to help your client understand that experiencing difficult and powerful emotions is expected. However, it is equally important to let them know that they do not have to live with them forever.  In addition to mental health professionals, your clients can find assistance from clergy, family and friends.  In particular, family and friends are good at helping us put things into perspective. And the ability to recognize and label how they are feeling is the first step in allowing them to help themselves gain control over their past in order to lead a more fulfilling future.

*A previous version of this article was published in Dr. Moore’s column Kevlar for the Mind, which is published in Military times.


Christine Hammond, MS, LMHC <![CDATA[Overcoming Pre-Hurricane Storm Anxiety]]> http://5.1652 2017-09-09T14:50:08Z 2017-09-09T14:50:08Z The shifting projections for Hurricane Irma have caused resulted in the largest evacuation for the State of Florida. Those of us who choose to stay behind watch each update with anxious anticipation wondering which forecast will be correct. Having survived other storms in the past, I have come to appreciate the difficulty in accurate predictions.

As the storm approaches, the roadways are bare, the shops are closed, and many homes are boarded up wondering when the electricity and internet will stop working. The hurricane causes families and neighbors to unite and hunker down expecting the worst but hoping for the best. But the topic of choice remains the latest updates on the storm and the damage that has already occurred.

This creates an atmosphere of severe anxiety as tensions mount and miscommunication increases. Here are a couple of ideas to calm the inner storm so the focus can remain on the outer:

  1. Be aware. Anxiety can manifest in different ways. There are physical symptoms such as rapid heartbeat, difficulty breathing, sweaty palms, tightness in the chest, and a knot in the stomach. And there are mental symptoms such as foggy thinking, confusion, obsessive thinking and racing thoughts. Become aware of the early signs of anxiety before it reaches a full blown attack.
  2. Welcome the feeling. Instead of becoming anxious about being anxious which only increases the tension, see the anxiety as a normal part of pre-hurricane stress. The uneasiness is there to warn a person of a potential danger which is very real in light of the hurricane. This is a perfectly normal time to feel anxious, embrace the anxiety instead of fighting it.
  3. Become present. One of the tools of mindfulness is learning how to become present in a given moment. Focus on breathing deeply, filling the lungs up with air, and releasing every drop of breath. Allow the breath to travel throughout the body finding areas of tension. Focus on releasing that stress with each breath. Most likely this will need to be done with every hurricane update and news story.
  4. Good self-talk. As the breathing slows the heart rate, channel thoughts to sayings like, “This moment will pass,” “I can handle this,” and “I’ll figure it out after the storm.” Taking a break from any analysis frees up the mind to focus on reducing the anxiousness. Distraction is another effective method as is taking a few moments alone periodically to rest. Think of a calming place and imagine being there.
  5. Return to moment. As soon as the anxiousness passes, quickly return back to the moment and become aware of the surroundings. Reengage in activities or conversation so the disruption is minimized for now. Most likely others won’t even notice the anxious moment which is good when there are children or elderly in the house that might already be feeling overwhelmed by the storm.

It is impossible to eliminate anxious responses about the hurricane; the danger is real as the storm is large and powerful. But what is possible is to learn to embrace the anxiety and not escalate the already aggravated tensions. This will benefit everyone while they wait out the storm.

Bret Moore, Psy.D. <![CDATA[Gambling Addiction is Not Uncommon in Veterans]]> 2017-09-08T13:18:55Z 2017-09-09T13:18:40Z specialization in addiction: a person-centered approachIt has been estimated that upwards of two percent of service members struggle with gambling issues. Two percent may not sound like much. However, when you consider that the military has about 2.5 million people on the rolls, that adds up to tens of thousands of troops whose daily lives are impacted by this particular addiction. If you factor in spouses, children, parents, siblings and other loved ones, the number of people affected by gambling is huge. Indeed, gambling does not occur in a vacuum.

Gambling is typically not an isolated condition. A major issue for military gamblers is the severe depression that often occurs along with it. Prior research on service members seeking treatment at military gambling treatment facilities found that between 20 and 50 percent had seriously considered suicide or had attempted suicide because of problems that arose because of their gambling. Often, the depression that accompanies a gambling problem is linked to work and relationship stress, feelings of hopelessness and financial strain.  Anxiety also closely follows.  The life disruption that follows gambling addiction often leads to chronic worry and stress as a well as panic attacks and substance use disorders.

The military views gambling as an addiction much like alcoholism and drug dependence. The official website of Gambler’s Anonymous provides 20 questions for individuals to determine if they might have a gambling problem. The general guidance is that people with serious gambling problems will say yes to seven or more of the following questions.

If you believe your veteran client may be struggling with a gambling addiction, the first step is to have him or her answer the questions below. This process is the first step to helping them get the assistance they need.

Questions to Ask

Did you ever lose time from work or school because of gambling?

Has gambling ever made your home life unhappy?

Did gambling affect your reputation?

Have you ever felt remorse after gambling?

Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?

Bottom of Form

Did gambling cause a decrease in your ambition or efficiency?

After losing did you feel you must return as soon as possible and win back your losses?

After a win, did you have a strong urge to return and win more?

Did you often gamble until your last dollar was gone?

Did you ever borrow to finance your gambling?

Have you ever sold anything to finance gambling?

Were you reluctant to use “gambling money” for normal expenditures?

Did gambling make you careless of the welfare of yourself or your family?

Did you ever gamble longer than you had planned?

Have you ever gambled to escape worry, trouble, boredom or loneliness?

Have you ever committed, or considered committing, an illegal act to finance gambling?

Did gambling cause you to have difficulty in sleeping?

Do arguments, disappointments or frustrations create within you an urge to gamble?

Did you ever have an urge to celebrate any good fortune by a few hours of gambling?

Have you ever considered self-destruction or suicide as a result of your gambling?

Again, as noted above, if you think that one of your veteran clients has a gambling problem, it is important to get them the help they need. Unlike formal programs for alcohol or drug problems, gambling programs are more difficult to find on military installations. In fact, they are more difficult to find for all types of clients.  However, your local mental health clinic or chaplain at your local base or post can assist you in finding help for those patients who are on active duty and the VA can help with veterans  You can also find national and state gambling hotline numbers on the Gambler’s Anonymous website.

*A previous version of this article was published in Dr. Moore’s column Kevlar for the Mind, which is published in Military times.


Marie Hartwell-Walker, EdD <![CDATA[Why a Therapist Needs a Theory]]> 2017-09-08T13:18:16Z 2017-09-08T13:18:16Z I’m concerned. Although some of my early career supervisees graduated from programs that provided a solid theoretical base, that isn’t always the case. Some master’s programs seem set up to introduce their students to a little bit of this, a little bit of that; a course on child development, a course on pathology, a statistics course, etc. but with no unifying theory. The goal of such programs seems to be to prepare their students to pass a licensing exam, with little thought to the importance of giving them an organizing structure for their thinking.

From my point of view, this situation is a serious problem. I really don’t care what theory my supervisees have learned, as long as they learned one. With the exception of treatment for a few diagnoses (e.g. Dialectical Behavior Therapy for Borderline Personality Disorder; Cognitive Behavior Therapy for Anxiety), there is no conclusive evidence of overwhelming superiority of one theory over another.

But without a theory, these new clinicians are relying on their good intentions, a few techniques learned in school and good listening skills to be helpful to people who may be experiencing complicated and painful issues. They don’t have the compass and guide for their assessment and treatment that a unifying theory provides.

What is a Theory?

A theory is simply a set of principles that a therapist adopts to explain people’s thoughts, feelings and behaviors. Included are ideas about what causes those thoughts, feelings and behaviors and what techniques will help people change them so they can live more productive, satisfied and happy lives. In practice, the theory we adopt helps us assess a patient’s strengths as well as the nature of their distress and informs how we plan our goals and interventions to help the patient heal. Practicing therapists each discovers or develops a theory about the human condition that we feel is both congruent with our own ideals and beliefs and helpful to those in pain.

It’s inevitable that a therapist’s attachment to any theory will change over time as we become more experienced and more sophisticated in our work. That being said, it’s important to settle on the construct from which we work at any given time. Yes, it’s possible to become “eclectic” but it’s important to be purposeful in our eclecticism. (See related articles.)

If you are a therapist who graduated from a program with a strong integrated theoretical orientation, you can skip the rest of this article. But if your program did not ground you in a particular theory, I suggest you think about the following reasons to devote yourself to in-service education that will give you one.

If you are considering a career in therapy and are researching graduate programs, I urge you to look for one that has a strong, integrated theoretical orientation. Here’s why:

Why We Each Need to Settle on a Theory

To ground us: To be constantly questioning the basis of our thinking makes it impossible to come to any conclusion about anyone or anything. Sloppy eclecticism results in sloppy thinking. Deciding  on a theory that works for us lets us both assess and treat our clients with clarity and consistency. That alone often provides grounding for the client as well.

To organize our thinking: Patients who enter treatment are overwhelmed by their thoughts and feelings and can easily overwhelm the therapist. A theory provides a structure for sorting and organizing all the information. Whether a therapist adopts the work of the psychodynamic thinkers, the behaviorists, the cognitivists, or the post modern school of family therapy, the theory provides a structure for inquiry and guidance for developing interventions.

To develop a mutually understood language with our clients: Each school of therapy has beliefs and values that are expressed in a unique way. Therapists teach their clients the vocabulary of their theory so they can co-evolve an understanding of what has caused and/or maintained the client’s distress and what needs to be done to address it.

To serve as the basis for assessment: Each theory has a different point of view for the cause of the problem or for the behavior that supports it. Simply put as examples: Psychoanalysts see pathology as the outcome of unresolved internal (intrapersonal) conflicts. Carl Rogers defined pathology as incongruence between an individual’s real self and ideal self.  Family Systems therapists look for dysfunctional patterns of relating among family members (interpersonal conflicts) while narrative family therapists separate individuals from their problem., Behavioral therapies reject a causal point of view and instead focus on carefully defining the present issues. Narrative therapy was created as a non-pathologizing approach but does include guidance for observing a family’s struggle with their own story.

To set treatment goals: Assessment always drives treatment. To continue with the above examples: Psychoanalysts focus on resolving those unresolved intrapersonal issues. Rogerians help their patients bring their real and ideal self into alignment so they can work toward self-actualization. Family therapists work on healing family relationships. Behaviorists identify discrete behaviors that need to change. Narrative therapy aims to transform the effects of the problem.

To determine who should be in the session: Intrapsychic theories confine therapy to the individual so rarely include other people in the treatment. Interpersonal family therapists generally see the family as a whole as well as members of subsystems (parents, siblings, etc.) within the family.

To determine the type of intervention: Theory also determines methods (techniques) a therapist uses. Psychoanalysts work with the client to create “transference” with the therapist (a recreation of a historic relationship) so it can be understood and corrected. Rogerians provide unconditional, positive regard within sessions to re-establish congruence between self and experience. Behaviorists develop interventions that positively or negatively reinforce behaviors. Many family therapists prescribe homework assignments to give the family experience in interacting differently. Narrative family therapists support the family in using their own competencies to create a new story.

To measure progress: Most therapists rely heavily on their own clinical judgment and client self-reports. Psychodynamic therapists assess the client’s report of symptom relief. Rogerians look for client progress in becoming a fully functioning person (as defined in Rogerian terms). Behaviorists keep data to determine if change is occurring. Family therapists of all stripes rely on the family’s report of change in their dynamics. Narrative therapists observe an increase in the family’s use of their own skills to guide them toward a more successful life.

I do think all therapists would benefit from using concrete measures for determining progress although, with the exception of behaviorists, few do. But that’s another conversation.

To help when we’re “stuck”: Therapy rarely proceeds in an orderly way from identification of the problem to resolution. When therapy seems “stuck,” when little or no progress is being made, it is often helpful to go back to our theory to review our thinking about our assessment, goals and interventions. Often, thoughtful reconsideration of the case within the construct of our theory provides guidance for getting through the impasse.

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Christine Hammond, MS, LMHC <![CDATA[What is Pre-Hurricane Stress?]]> http://5.1647 2017-09-08T13:08:37Z 2017-09-08T13:08:37Z As Hurricane Irma, with shifting center winds of 150 – 185 miles per hour, heads for Florida, anxiety in residents builds with every shifting forecast. The topic of conversation at check-out isles in grocery stores is which storm have you lived through. Those who have survived the many storms have already completed their shopping several days ahead of the arrival. While others who discount or minimize the storm mockingly comment on the over-response of others.

There is a great divide between survivors of previous storms and observers of storms. Survivors know of the unpredictability of storms. The best forecasting still falls short of accuracy when unsuspecting turns and either increasing or decreasing winds determines the fate of cities forever impacting lives. Observers use the unpredictability as their evidence for not properly preparing preferring instead to “roll the dice”. Some observers inaccurately use previous storms as determining factors for how to prepare, failing to understand that each storm is as unique as an individual.

The skies clear, the humidity dries up, and the wind stands eerily still as the hurricane pulls all moisture from surrounding areas to add to its intensity. This calm before the storm adds to the tension for survivors as their anxiety and fear begins to build just before landfall. Last minute decisions to leave clog highways and drain gas stations as even more stories are recounted, more preparations are done, and more storm tracking is followed. This pre-hurricane stress infects everyone as road tensions mount and desperate searches for generators/batteries/water intensify. Here are some of the other symptoms.

  • Increased anxiety. Several days out the anxiety was like lukewarm water, but as the storm draws closer and the news of its damage to surrounding areas is revealed, anxiety turns into a boil. In reality, the predictions of potential damage have been consistent all along, however the anxious response by others fuels some into a panic. The key to countering the anxiety is to distract with some normal activity and conversation that does not involve the storm.
  • Group anxiety. Watching others become panicky about the storm frequently causes those who were not previously anxious to become anxious. It becomes a type of group anxiety that can feed irrational thoughts and behaviors. Watching too much news or too many updates on the storm contributes to this group anxiety. Instead, select times to review the storm, limit the amount of news watching, and avoid anxious places or people.
  • Fearful premature reactions. The premature firing of survival instincts prior to a storm hitting can deplete the much needed survival response after the storm. Take a clue from nature, just before a massive storm, everything is calm. There is no wind, no rain, and no chirping birds. All of nature seems to take a deep breath in anticipation of the hurricane. Use this time to turn off the TV and meditate, pray or take several deep breaths. This will calm the fearful premature reactions that are best reserved for after the storm.
  • Obsessive thinking. In some regards it is necessary to think about all of the possible outcomes in order to minimize the damage. However, obsessively thinking about the worst possible scenarios can drive a person into a frenzy. This is very dangerous as rational thinking is replaced with irrational fears. At a time when careful planning can literally make the difference between life and death, irrational or obsessive thinking must be eradicated. Ask: “Is this realistic? Has this happened here before?” For instance, those on the coast of Florida must prepare for storm surges as this is a real possibility. While those inland do not need to worry about the impact of high waves.
  • Heightened tensions. As if the pending storm is not enough, some turn their anxiety into anger. This is frequently seen on the roadways as distracted, frustrated people try to complete the last minute errands. The sense of hurry drives some to literally push others out of their way in an effort to accomplish their objective. This disregard for others in interest of self-preservation increases car accidents, verbal lashings, and aggressive behavior. Walking from my car into the grocery store, I was almost run over by two separate drivers who were so focused on their task that they forgot to watch for pedestrians. Be intentional about slowing down so more focused thought and less angry responses can be achieved.

I walked the perimeter of my house this morning looking for any loose articles that could transform into dangerous projectile objects. This is my fifth hurricane in Florida, and not likely to be my last. With the outside all taken care of, now the work on the inside begins as laundry, dishes, and cooking (all which require electricity) begin knowing the likelihood of no power in a short time. My family is safe and at the moment stress free which is my prayer for other families across Florida.

Miranda Palmer, LMFT <![CDATA[The Ultimate Private Practice Training Series: Website 101]]> http://4.975 2017-09-07T07:18:24Z 2017-09-07T07:18:24Z You need a website that works!

However, you need a website that is effective, and not all are created equally. We have talked to too many therapists who built a website expecting it to help grow their practice- to met with silent phones. We see psychologists and therapists spending SO much money on websites that don’t even have the most basic functionality you can find on a free platform.




Click down below to watch the website 101 video training!