What Can I Expect From Therapy?

Therapy is an investment of time and money. The process may impact your life significantly. As such, it is important to select a therapist carefully. I encourage people to speak with a few psychologists before booking an initial appointment. The most consistent finding in psychological research is the importance of the therapeutic relationship. A therapist who makes you feel heard, respected, and understood increases the likelihood of a successful outcome.

You may have heard about different kinds of therapy online or from friends. The bottom line is that no one size fits all. Regardless of the type of therapy, every person is unique. Therefore, no two therapies will ever be alike (nor should they be). In the words of the famous psychiatrist Irvin Yalom, “Create a new therapy for each patient.”

I work from a psychodynamic perspective, as I find it to be the most comprehensive way of understanding human problems. Although I draw from several approaches to suit individual needs, my therapeutic work is anchored in psychodynamic theory. Some of the core principles of psychodynamic therapy are:

  • People are frequently unaware of why they feel and behave in the ways that they do.
  • People have ways of avoiding psychological pain which may result in personal difficulties.
  • Although it is often assumed that we are driven by logic, research shows that most decisions are fuelled by emotion.
  • People tend to view current experiences through the lens of past experiences.
  • Human problems manifest in relationships (including the absence of meaningful relationships).
  • The therapeutic relationship itself is a window into understanding a person’s difficulties.
  • There is a collaboration on the purpose, methods, and tasks of therapy. However, the sessions will not have a rigid agenda.

As no one size fits all, it is difficult to determine in advance how long therapy will take. The research indicates that it may take an average of 3-5 sessions for the therapeutic relationship to be established, which includes a mutual understanding about the goals and purpose of therapy (Ladany et al. 2007). It is important to be realistic about therapeutic progress, as difficulties that have been with us for years are unlikely to change in a few weeks.

It is also important to understand the difference between therapies that produce long-lasting change versus therapies that are targeted towards short-term symptom reduction. If a problem is recurring, it is usually because there are underlying dynamics that require attention. If we only attend to the symptoms – and not the cause – it is likely that the symptoms will return within a matter of months. Dr. Emily Anhalt says, “I believe the true way to healing and feeling better in the world is not about ‘whack-a-moling’ symptoms…If all you do is fix a symptom without understanding what the symptom is trying to tell you, then you’re just going to have it pop up as a different symptom later.”

I firmly believe that a successful therapeutic relationship must be an honest one. It is important that we have a clear understanding about what you expect from therapy and what I can offer. For prospective patients, I always have a brief telephone consultation (about 10-15 minutes) to begin exploring whether we might be a good fit. I want the best outcomes for people. If I believe that another practitioner would be a better fit for you, I will offer a referral. If we decide to proceed with therapy, we will become collaborators to work towards your best outcome.

Kay, J. (2006). The essentials of psychodynamic therapy. Focus; 4(2).

Ladany et al. (2007). Practicing Counseling and Psychotherapy.

Psychotherapy Networker (2022). An interview with Emily Anhalt.

https://www.psychotherapynetworker.org/blog/details/2080/the-mental-health-gym

Shedler J; Where Is the Evidence for “Evidence-Based” Therapy?; The Psychiatric Clinics Of North America; 2018.

Yalom, I.D. (2002). The Gift of Therapy.

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Pathways to Depression and Anxiety

The two most common presenting problems in therapy are depression and anxiety. In fact, I rarely see any psychological issue that does not contain aspects of depression or anxiety. Depression and anxiety are human reactions to psychological distress.

Although anxious and depressive feelings are common, there are unique ways of arriving at them. Two people may be depressed but for entirely different reasons. Person One may be depressed because they recently ended a relationship and worry that they will be alone forever. Person Two may be depressed because they are intensely self-critical and find fault with everything they do. These reasons are not incidental – they are the pathway.  In therapy, it important to explore the pathway into distress so we can chart a path out. If we focus just on the symptoms of depression – like low energy – the relief is usually short-term. Telling a depressed person to take a daily walk may provide an immediate boost. However, it rarely addresses the parts of the person’s psychology that led to depression/anxiety in the first place. Furthermore, most people have tried self-care techniques before speaking to a professional. If dealing with depression and anxiety were as simple as following a list of tips, no one would ever need therapy.

There is no one-size-fits-all when it comes to psychology. A therapist could be treating two people for depression using totally different interventions. In the example above, research has shown that Person One may need a different approach than Person Two. It goes without saying that no two people are alike; no two therapies should be, either.

Blatt, S. J. (2004). Experiences of depression: Theoretical, clinical, and research perspectives. American Psychological Association. 

Shedler, J. (2021). The personality syndromes. In R. Feinstein (Ed.), A Primer on Personality Disorders: Multi-Theoretical Viewpoints. Oxford: Oxford University Press.

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February is Psychology Month!

The goal of psychology month is to raise awareness about the role that psychology plays in our lives, including our communities and workplaces. To that end, I wanted to write about a topic that is critical for those seeking help: What promotes psychological change?

There is heated debate about which approaches will best address depression, anxiety, and relationship problems. Rather than arguing, I would rather focus on where we can find consensus. What helps people to change in therapy? The following principles have been associated with psychological change (adapted from Goldfried, 2019):

  1. Providing the client with hope that therapy can help.
  2. The establishment of a bond between the therapist and client, along with a shared understanding about the tasks of therapy.
  3. Helping clients to become aware of what is contributing to their difficulties.
  4. Encouraging clients to have corrective experiences. That is, experiences that are different from what they have known before.

The decision to enter therapy is a leap of faith. It is no easy feat to explore our minds, our behaviors, and to contemplate real change. If one chooses to embark on this journey, I encourage them to do so thoughtfully. It is important to understand the differences between mental health professionals, so you may find one who best suits your needs. To learn more about mental health professionals and psychology in Alberta, please visit:

https://psychologistsassociation.ab.ca/do-you-know-the-differences-between-mental-health-professionals/

Goldfried, M. (2019). Obtaining consensus in psychotherapy: What holds us back? American Psychologist, 74 (4), 484-496.

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Mental health is health

Mental Health Awareness Week runs October 3-9, 2021. As a practicing psychologist, every week is mental health week. When the spotlight is on psychology, I feel a professional responsibility to highlight some important issues:

  • Mental health is health

There is a health care disparity in Canada. For physical health issues, people are treated until they get well. For mental health issues, a lower standard of care exists. You are placed on a waitlist for services. In the meantime, you receive little support. When you finally do access services, they are often time-limited. While this may work for some, it fails many. To achieve mental health parity, people should receive care until they are well.

  • Long-term support is becoming harder to access

As the demand for mental health services grows and funding is stagnant, it becomes more difficult for people to receive the support they need. Both patients and therapists are being asked to do more with less.

  • Ignoring mental health is expensive

It is estimated that mental health issues cost the workplace about 51 billion per year (Canadian Mental Health Association, 2020). Further, untreated mental health issues often end up in expensive emergency room visits.

The Psychologists’ Association of Alberta has long advocated for mental health parity. Currently, we have a two-tiered system: Those who can afford timely service through a private psychologist, and those who cannot afford it despite critical need. All Albertans, regardless of income, should have access to psychological services.

I would also like to note that if short-term therapies have not worked for you, this is not a personal failing. You are not alone. It takes time to develop a trusting relationship with a therapist. Very often, people would fare better if they were given a little more time. The bottom line is that no one knows in advance how many sessions a person will need. For some, a single-session can be effective. For others, perhaps a handful. In many cases, people will do best with 10 sessions or more. As a society, we need to understand that human connections and healing cannot be rushed. I am hopeful that our advocacy will help Albertans get the support they need.

Dr. Norman Doidge, a Canadian psychiatrist, emphasizes the importance of the therapy relationship.

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Does therapy work?

The answer is yes. The research clearly shows that people who participate in therapy have better outcomes when compared to those that do not (Karyotaki et al., 2016). Approximately 80% of people who receive therapy derive benefit from it (American Psychological Association, 2016). There is also evidence to indicate that people who receive in-depth counselling experience longer-term gains, even after the therapy has ended (Abbass et al., 2006). The most important elements in successful therapy are the relationship between client and counsellor, along with the client’s expectations and contributions to self-improvement (Wampold, 2015). The options for improving mental health can range from low commitment (such as self-help books) to higher commitment (like medication and/or therapy). I would encourage everyone to speak honestly about what they are looking for, regardless of whether they are talking to a family doctor or a psychologist. You are the expert on your life.

Abbass AA, Hancock JT, Henderson J, Kisely S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews, Issue 4.

American Psychological Association. Understanding psychotherapy and how it works. 2016. http://www.apa.org/helpcenter/understanding-psychotherapy.aspx

Karyotaki, E.; Smit, Y.; Holdt Henningsen, K.; Huibers, M.J.H.; Robayse, J.; de Beurs, D.; Cuijpers, P. (2016). Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. Journal of Affective Disorders.

Wampold, B. (2015).  How important are the common factors in psychotherapy? An update. World Psychiatry, 14 (3), pp. 270-277.

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Stop – Step Back – Observe

Negative thoughts have a way of taking over. In recent months, most of us have a lot fewer distractions and a lot more free time. Due to COVID-19 restrictions, we are missing many of the fun, positive activities that help to refocus our energies. These days, many people find themselves caught in an endless spiral of negative thinking.

Cognitive defusion* is one strategy for managing negative thinking. Cognitive defusion is the process of distancing ourselves from our thoughts – seeing them as words and passing sensations, rather than as facts. It is important to remember that thoughts are not facts; your thoughts can lie to you.

Some cognitive defusion strategies include seeing your mind as a separate entity. For example, some people tell themselves: “There goes my mind worrying again.” Or: “I notice that my mind is really criticizing me today.” Cognitive defusion can also include visualization techniques, such as picturing negative thoughts as text messages or pop-up ads. To distance yourself from these thoughts, you might say: “I am not reading that message right now.”

It is normal to have negative thoughts sometimes. During a global crisis like COVID-19, they might come around more often. If negative thinking is interfering with your ability to live, work, and function, then it may be time to seek professional support.

Adapted from Hayes and Smith (2005). Get Out of Your Mind and Into Your Life – The New Acceptance and Commitment Therapy.

  • * Adapted from Hayes and Smith (2005). Get Out of Your Mind and Into Your Life – The New Acceptance and Commitment Therapy.

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Can therapy help me?

The answer: I am not sure. You may feel uncertain, too. This is normal. In the beginning, the path of therapy is unknown to the client and to the counsellor. We need to explore what is wrong, how things got this way, and how you hope therapy can help. The only way to figure it out is through mutual dialogue, driven primarily by the client. In the first session of therapy, my job is to listen. I am not going to learn anything about a person if I assume the role of teacher (e.g., lecturing, giving advice immediately, assigning tasks). It all begins with listening. From there, we can answer the question: Can therapy help me?

There has always been debate about what kind of therapy is “best.” Not surprisingly, this debate is still raging. There is no debate, however, that a strong client/counsellor alliance is critical for success. If you are seeking support, it is important to find someone that makes you feel heard, understood, and respected.

In a culture of instant feedback, we may hope that counselling will be fast acting. I certainly understand feelings of impatience and urgency. Whatever your concern may be, it is impacting your life and you want it fixed now. However, I cannot promise anyone a quick-fix or guarantee any particular outcome. What I can promise is listening, working with you to understand the problem, and answering the question: Can therapy help me? If we believe it can, then we can discuss what therapy might look like. Some examples of this: How often will you come in? What kind of approach do you think will be helpful? These kinds of questions can best be answered after listening, followed by collaboration on the goals and purpose of therapy.

I offer all prospective clients a brief telephone consultation (usually about 15 minutes), so that they can explore the question: Can therapy help me? Although each conversation is different, some of the questions I typically ask are:

  • What do you feel is wrong?
  • In your opinion, what has contributed to the problem?
  • What has led you to seek therapy now?
  • Have you ever been to therapy before? If so, what helped and what didn’t?
  • What do you hope to get from therapy?

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5 Tips for Making the Most of Online Counselling

The COVID-19 pandemic has forced all of us to adapt to the new normal. For psychologists, this “new normal” has included bringing the in-office counselling experience to the virtual world. For all of its conveniences, it is not without challenges. After fourteen years of practicing face-to-face, I am deeply attached to what is known as the therapeutic frame. The therapeutic frame includes things like a regular appointment time, the chair the client sits in, and the privacy of the office. The frame provides a set of implicit rules, boundaries, and expectations. It creates a sense of continuity and safety for the client, from which they can explore difficult topics. This frame, and the security it provides, is fundamental to the counselling process.

In virtual counselling, many elements of the traditional therapeutic frame are absent. The counsellor and client are not sharing the same space. The client may not feel as safe speaking about difficult issues from their own home. The visual cues that are obvious in-person may be invisible over the internet. As a psychologist, I consider these obstacles that need to be overcome. To have successful virtual counselling, I believe that we need to recreate the therapeutic frame as much as possible. 

In order to give online sessions a frame, I have set up my virtual office to mimic the in-person experience. I angle my camera so that clients can see me from the waist up, much as they would in the counselling office. If clients are able to do the same on their end, this helps me a great deal. To make the most of a virtual session, I suggest the following to my clients:

  •  Do everything possible to ensure that you are in a private, quiet space during your counselling session. You should feel safe enough to share very personal information. If you worry about being overheard, it will negatively impact your counselling experience. If a private space is unavailable to you, in-person counselling may be necessary. Remote sessions are not for everyone and can potentially be risky, such as for those experiencing domestic violence. To maintain privacy and COVID-19 safety, a counsellor may be able to direct you to a secure space to conduct remote sessions.
  • Although I do not wear headphones during virtual sessions, I encourage clients to do so if it helps them to feel a sense of privacy on their end. If possible, please use a larger device for virtual sessions (such as a laptop).
  • During face-to-face meetings, people regularly take ‘micro-breaks’ by averting their gaze. On video, however, many people feel compelled to maintain eye contact by staring into the web camera. This is very unnatural and, thus, very tiring. I encourage my clients to focus on the content that they are sharing and not to worry about maintaining eye contact.
  • If possible, please test your microphone and camera prior to the session starting. As well, please be comfortable with the position of the camera so that you do not feel self-conscious during the session. Some clients opt to remove the image of themselves at the bottom of the screen.
  • Prior to the session, consider writing a list of your key concerns and goals. If there is a technical issue or some other interruption, it will be easier for the session to get back on track.

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The Symptoms, the Story and Slowing Down

My clients usually tell me about the symptoms first:

“I can’t sleep.”

“I worry all of the time.”

“I can’t focus.”

The symptoms are certainly important. They tell me about what is happening in the here and now. They tell me something about the client’s everyday life. However, the symptoms are not the story. The story may have started recently, or a long time ago. The symptoms represent a turning point in the story, and that old coping mechanisms are no longer working. The clients arrive at the end of their rope, feeling overwhelmed and out of ideas.

The first task of counselling is to slow things down. We need to take a step back from the symptoms and see what exists around them. This is the story. The problems that people experience are embedded in a complex history that contains memories, thought patterns, habits, and ways of relating to others. This goes far beyond the symptoms, and usually reveals the client’s background and enduring ways of relating to the world (the personality). By slowing down, we can examine personality patterns of acting and reacting. This acting and reacting is often automatic and outside of conscious awareness. This is why people feel that the same things always happen to them –  over and over again. By slowing down and examining the story, the automatic moves into conscious awareness. From there, we can work towards establishing new patterns and making different choices.

A good outcome is defined by the client. It usually involves the alleviation of symptoms, but most people want something more. The research indicates that when counselling focuses just on symptom relief, clients might experience short-term improvement but often relapse (and usually pretty quickly). Most researchers suspect this is because the enduring patterns (the personality) were not addressed in the first place. These enduring patterns often prevent people from living the life they truly want. Although every client has a different aim for therapy, the most common goals are: 1) A strong sense of self-worth and identity; 2) To improve the quality of relationships, and; 3) To understand their own feelings and behavior. Obviously, goals like these require a trusting relationship with a counsellor and a commitment to change. 

There are many people who want to change, but there are obstacles in the way. Cost. Waiting lists.  Difficulty accessing services. The Psychologists’ Association of Alberta is currently advocating for increased funding and public support for mental health services: (https://psychologistsassociation.ab.ca/about-paa/).

We believe that all Albertans, regardless of income, should have access to psychological services. To protect the public, we believe that psychotherapy should only be provided by a regulated health professional (e.g., Registered Psychologist; Psychiatrist). I am hopeful that our advocacy efforts will improve the lives of all Albertans and make accessing psychotherapy much easier. All Albertans deserve a chance to make positive change, supported by a regulated professional committed to ethics and competence. As it stands, it is far too difficult for most people to share their story. Many Albertans do not have the extra money to establish a trusting relationship with a psychologist. They feel rushed because they have finite resources or a limited benefits program. In psychotherapy, this has been referred to as the “tyranny of time” (Shedler & Gnaulati, 2020). In fifteen years of practice, I have yet to meet anyone who wants to be hustled through their story. We need to give people a real shot at change and connection. 

References:

Lambert, M.J., Hansen, N.B., Finch, A.E. (2001). Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects. Journal of Consulting and Clinical Psychology, 69, 1590-172.

Shedler, J., &  Gnanulati, E. The Tyranny of Time: How long does effective therapy really take? (Psychotherapy Networker, March/April 2020).

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