To help demystify the process of psychotherapy, I have provided a thorough explanation of some of the major components of therapy as it typically occurs in my practice.
The first session will be used as an initial consultation. During the consultation, I will gather specific information about what brings you into therapy. We will try to identify the triggers, thoughts, physical feelings, and behaviors associated with the distress you are experiencing. I will also ask general questions regarding your social relationships, psychological and physical health history, and social/occupational functioning in that reducing emotional distress often includes addressing any problems that may exist in relationships, at work or school, in physical health, with sleep, with nutrition, or in finding meaning in life in general.
We will also have to go over forms that explain treatment, payment, and privacy and that release necessary information from relevant providers. Any questions and concerns regarding treatment will be answered fully at this time.
In the case that I find that you would benefit most from a treatment approach that I do not provide, I can assist you in finding more appropriate treatment providers. If requested, I will be able to provide your new provider with information from our consultation session. You are under no obligation to continue therapy at any time.
EXPLANATION OF THE GENERAL PROCESS
Case Conceptualization/Treatment Plan
The information I gather during the evaluation will be used to develop a case conceptualization, which is an initial understanding of the problems you are presenting with and factors that may contributing to your distress. The conceptualization is used to help formulate a treatment plan which will include explanations of the treatment approach and expectations for treatment. As the therapist, I will provide expertise in psychological strategies, whereas, as the client, you will provide expertise regarding your own psychological functioning, life experiences, preferences, and types of strategies that have worked for you in the past. The particular treatment approach will be tailored to your own individual needs and will vary depending on your presenting issues and concerns.
Before engaging in therapy, it will be important to come to an agreement regarding your goals in therapy. My perspective is that anxiety, whether in the form of mild unease or as an occasional anxiety attack, is likely to come and go throughout life and also that anxiety is a normal part of excitement, growth, and change. Therefore, the goal of eliminating anxiety is not possible nor is it recommended. Rather than eliminating anxiety completely, a realistic goal would be to reduce the intensity, frequency, and duration of anxiety attacks so that even if anxiety attacks were to occur, they will not be as severe, will not happen as often, and will not last as long as previous attacks. This involves chanigng your relationship with anxiety so that you are able to accept, manage, and face moderate levels of anxiety so that it no longer interferes with your valuable life experiences.
In addition, rather than just focusing on reducing anxiety, the goal should also include being able to approach situations that were previously avoided due to anxiety. The goal is to not allow anxiety to limit your ability to live life to its fullest. You can ask yourself, “If it weren’t for anxiety, what would I be able to do? What would improve my quality of life? What are my interests? What are my needs? This month, I’d like to… Within the next year, I’d like to…”
As part of setting goals, it is important to identify values that give life meaning. Meaning can come from family, intimate relationships, parenting, social life, work/career, education, leisure activities, spirituality, community life, or heath goals. Identifying those areas that give life meaning can help increase motivation for treatment and give perspective on how anxiety interferes with living a fuller, more meaningful life.
Overall Therapeutic Approach
I use an insight-guided cognitive behavioral approach with an emphasis on mindfulness and acceptance based techniques. The therapy is insight-guided in that treatment involves increasing self-awareness of factors that may be contributing to your experience of distress. These contributing factors may be biological vulnerabilities, past experiences, family relationships, personality styles, or external stressors. I will also provide information about the scientific understanding of the development and maintenance of anxiety disorders (see section on Obsessive Compulsive Disorder for an example of a thorough description of a scientific understanding of a particular disorder). The goal is to develop an understanding of how problematic anxiety developed, how it is maintained, and ways you have learned to cope with it.
Insight is important in that it can help reduce feelings of helplessness that are often associated with intense anxiety. Insight can also help prevent the reoccurrence of an anxiety disorder by developing awareness of the stressors, situations, and coping behaviors that can lead to problematic anxiety. Insight often leads to a sense of relief and hope, but it is often insufficient for reducing ongoing suffering. This is because anxiety has a self-perpetuating mechanism where, once it is established, it is able to maintain on its own, regardless of how it developed.
This is why the primary therapeutic approach is cognitive behaivoral, meaning that the focus on recognizing ways in which thoughts and behaviors can maintain a physical and emotional anxiety response. When your brain perceives danger it becomes rigidly focused on generating thoughts, feelings, and behaviors that are meant to protect you from imminent harm. The problem is that these automatic anxious responses can lead to greater problems and greater distress if there is no flexibility in your responses, such as when there is no immediate danger but your brain continues to behave as if there is.
Though our brains may generate automatic thoughts and reactive responses to anxiety, with time and practice, we are also capable of training our brain, changing neural connections or brain activity, so that alternative perspectives and new habits become part of this response system. Old patterns of responding are not necessarily bad and do not necessarily have to be eliminated, but rather you are developing a wider range of possibilities from which to choose from. The goal of therapy is to enhance flexibility in thoughts and behaviors to create a more flexible emotional system. There are many difference cognitive behavioral strategies to help with this process (See section on CBT).
My therapeutic approach is mindfulness and acceptance based in that throughout the therapy there is an emphasis on observing your emotional response as it unfolds without judgment and without immediately reacting. Mindfulness refers to observing what you are seeing, feeling, and thinking in the present moment, which can help keep you from being swept away by your powerful and automatic anxious response. The reality is that the more you to try to “control” or “destroy” your anxiety, oftentimes, the stronger it will become. Being accepting and understanding of your anxiety does not mean enjoying the experience or wanting it but rather seeing it for what it is in the moment, making amends with it, and riding the waves of emotion so as to soften its impact. Mindfulness is an attitude that can be cultivated with time and practice and there are many exercises to help with the process of shifting your attitude and approach towards anxiety.
Overall, there is a strong educational component where you will gain knowledge to make you an expert on anxiety, its causes, and its treatment. Another important component of treatment for long lasting change will be practice. Practice is necessary for rewiring the circuitry of the brain to make it more resistant to anxiety, and some parts of the brain seem to learn best through experience, not logic or debate. Anxiety management is not meant to be a temporary change, but rather it is meant to be a life style change for life long change, and therefore, regardless of the strategy you decide to focus on, an more important aspect of treatment will be practice.
Because there are specific strategies to be taught and practiced, my style in therapy tends to be active. This means that I take an active role in shaping each session and will come to each session with a plan based on our last meeting while also taking into consideration your needs for the session. I will come prepared with strategies, worksheets, and reading material to be used in session and to be reviewed at home. At the beginning of each session, we will review how practice went between sessions, and at the end of each session, we will spend a few minutes reviewing what we have covered that day and what you might want to work on between sessions.
Such an active approach may lead to a temporary increase in anxiety at the beginning, but with time, knowledge, and practice, your anxiety should begin to subside in the long run. Therapy can be quite a challenge, but my job is to motivate, support, and coach you through the process. Do not worry if you do not feel prepared for such an active therapy, have doubts about the therapy, or have confusion over how to proceed. Part of therapy is addressing these concerns. If at any time, you find that therapy is not progressing to your satisfaction or I feel that I am not the best therapist or CBT is not the best approach to meet your needs, I will do my best to provide you with referrals to other providers.
Biofeedback is a therapeutic technique that can be used to help manage symptoms related to anxiety, stress, insomnia, and chronic pain. For some clients, biofeedback can be a useful addition to relaxation training. I use a simple heart rate monitor attached to your earlobe that allows you to see a visual representation of your heart rhythm patterns so that you can learn how to use your breathing to create those heart rhythms associated with focused attention, calm relaxation, and positive emotions. Biofeedback is not a cure or a treatment but rather a training technique that is, in a sense, a short-cut to learning deep relaxation and meditation. By getting immediate feedback on a monitor, you will quickly learn how your body responds to stress so that in the future you are more aware of your internal sensations association with stress allowing you to catch it earlier in the cycle. In addition, you will be able to learn how to implement various relaxation techniques and get feedback that it is having a positive impact on your body system.
Essentially, your heart rate speeds up and slows down in a rhythmic pattern leading to variability in your heart rate (HRV). Heart rhythm patterns associated with stress, anxiety, and anger are shallow, jagged, and irregular whereas heart rhythm patterns associated with calmness, focused attention, and positive emotions are smooth and wave-like indicating that your heart rate is increasing and decreasing in a rhythmic fashion. These smooth waves appear when your breathing and your heart rate (two powerful systems in your body) are in coherence with each other. This in turn, leads to more coherence in your other physiological systems, particularly the autonomic system that is associated with the stress and relaxation responses. The smooth waves have also been found to be an indication of health and wellness, particularly cardiac functioning.
Click here for a more detailed explanation of heart rate variability biofeedback.
Click here for research publications on the relationship between heart rate variability and both physical and mental health.
A medical evaluation is important to rule out any medical issues that may be contributing to psychological symptoms. A medical evaluation with a physician or a psychiatrist is also important for those with a complicated medical history, neurological problems, or an acute medical illness.
Consultation with a physician or psychiatrist may also help you decide whether medications would be helpful. Medications have been shown to be an important part of treatment for severe mental health problems such as schizophrenia, bipolar disorder, and psychosis, but other problems such as anxiety or depression may be effectively treated with or without medications. Therefore, consultation with a medical or mental health professional who can discuss with you the costs and benefits of specific medications may help you decide whether medication is the right choice for you. A psychiatrist or physician will be the provider who ultimately decides whether a prescription is warranted.
Click here for information regarding the use of medications for the treatment of anxiety
Click here for information regarding the use of medications for specific anxiety disorders.
After you have started to develop effective coping strategies and have begun to experience a decrease in your distress, we will discuss the next step in therapy. Some clients find that the initial course of therapy is sufficient and are comfortable ending therapy so that they may continue to develop their skills on their own. Other clients find that they have difficulty consistently implementing strategies learned in therapy and appreciate the consistency of therapy, and thus continue therapy on a weekly basis. For others, therapy sessions can be spread out to once every other week or more to help generalize the treatment to day-to-day life. Your needs will be assessed regularly to determine what is the best decision for you.
Part of ending therapy is coaching you to be able to identify your unique vulnerabilities so that when you see yourself falling back into old maladaptive patterns, you can readily utilize the strategies you learned in therapy. By the end of treatment, the hope is that you have developed a sense of independence and confidence to be able to continue to implement on your own the strategies you have learned. If at a future time, you find that old problems resurface or when life events present new obstacles, then all you need to do is call me to set up another appointment and continue to use therapy “as needed.”
Some clients find that after the immediate crisis is resolved, there are other issues in their lives that they would like to address (relationships, communication, life goals, self-esteem, fitness, assertiveness, family issues, etc.) As anxiety decreases, clients may find they are better able to tolerate other emotions that being to emerge, can explore a wider range of their emotional lives, and are more confident in their ability to handle other challenges in life. If you feel a good relationship has been established in therapy, it makes it a natural decision to continue working on different issues that will help you achieve an optimal quality of life. If therapy is continued in this fashion, reevaluation of treatment objectives will occur on a consistent basis.
I do not see therapy as providing an easy “cure” for “sick” patients, but rather as a way of motivating and coaching individuals on how to use their own resources to the best of their abilities to grow, gain insight, and solve specific problems.