WHEN I RAGE AT AN OBJECT ...

 

When I rage at an object, I personify it and thereby blot out my awareness of my own limitations. In the ascribed defective character of the object, I justify my failure and absolve myself of responsibility for the outcome of this interaction and others.

 What is it about myself I do not want to see?

 What is EMDR?

You may be told you need this therapy, but may not be told what it is or what it intended to address.  This paper is intended to help you understand what this therapy involves in order to assist you in making an informed decision about whether it is right for you.  Therapists who are contemplating EMDR training may find this paper useful in assessing whether EMDR would fit into their psychotherapy practice.

EMDR -- Eye Movement Desensitization and Reprocessing -- is a defined, advanced and its practitioners certified by an international body, EMDRIA.  EMDR therapy is a therapeutic modality that must be administered by an EMDR trained clinician or those who are currently participating in an EMDRIA-approved training. The Canadian affiliate of EMDRIA is EMDR Canada (Home - EMDR Canada). 

EMDRIA provides a brief video overview of EMDR at New "What is EMDR Therapy?"  Read on for more detail.

EMDRIA DEFINITION OF EMDR

The 2020 EMDRIA definition of EMDR, here somewhat abridged, is that EMDR is an evidence-based, clinician led, psychotherapy for Post-Traumatic Stress Disorder (PTSD). In addition, successful outcomes are well-documented in the literature for EMDR treatment of other psychiatric disorders, mental health problems, and somatic symptoms. EMDR therapy helps children and adults of all ages. Therapists use EMDR therapy to address a wide range of challenges:

•Anxiety, panic attacks, and phobias

•Chronic Illness and medical issues

•Depression and bipolar disorders

•Dissociative disorders

•Eating disorders

•Grief and loss

•Pain

•Performance anxiety

•Personality disorders

•PTSD and other trauma and stress-related issues

•Childhood abuse trauma

•Sexual assault

•Sleep disturbance

•Substance abuse and addiction

•Violence and abuse

The American Psychiatric Association, the International Society for Traumatic Stress Studies, the Substance Abuse and Mental Health Services Administration, the U.S. Dept. of Veterans Affairs/Dept. of Defense, The Cochrane Database of Systematic Reviews, and the World Health Organization among many other national and international organizations recognize EMDR therapy as an effective treatment.

EMDR is based on Francine Shapiro’s Adaptive Information Processing (AIP) model (Shapiro, 2001) which posits that much of psychopathology is due to the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences. In EMDR, trauma is regarded as a memorial process—in the fullest sense of memory: the neural networks of all the senses, as well as the meaning we have made of an experience, however incomplete that meaning-making step might be. The shock of trauma impairs the client’s ability to integrate these experiences in an adaptive manner that does not interfere with functioning subsequent to the trauma. Not integrated, the memory of these experiences preoccupies the present awareness and intrudes into thoughts, emotions and affects behaviours in the present. By contrast, when memories are integrated into our autobiographical memory, we are able to access them at will, suppress them if that is expedient, knowing their place on our time line and their meaning in our life experience. In AIP terms, there is a natural homeostatic process of incorporating experiences into long-term memory that may be interrupted when the experience is traumatic. In trauma this is interrupted and unintegrated experiences, begging to be processed, rob attentional resources from the present experience. Avoidance strategies to avoid unpleasant unintegrated memories result in recourse to a variety of tension reducing behaviours such as eating, drinking, drugging, cutting, addictions both process and physical, risk taking, etc.

Many protocols exist for delivering EMDR therapy to clients and in situations that are specialized and/or circumscribed. The Standard EMDR Protocol is an eight-phase process to facilitates the resumption of the normal homeostatic process of experiential integration into autobiographical memory. This treatment approach targets three “prongs”: past experience, current triggers, and future potential challenges. It results in the alleviation of presenting symptoms, a decrease or elimination of distress from the disturbing memory, improved view of the self, relief from bodily disturbance, and resolution of present and future anticipated triggers.

The core EMDR treatment approach to the resolution of traumatic and disturbing adverse life experiences is accomplished with a unique standardized set of procedures and clinical protocols which incorporates dual focus of attention (the traumatic past and the safe present), at the same time as alternating bilateral visual, auditory and/or tactile stimulation (BLS). This process activates the components of the memory of disturbing life events and facilitates the resumption of adaptive information processing and integration.

“Processing” is the fourth of eight phases of EMDR treatment, but the stereotype of EMDR therapy is that it is essentially if not only BLS. In fact the other seven phases of EMDR treatment are very beneficial to the client and essential to treatment effectiveness.

THE EIGHT PHASES OF THE STANDARD EMDR TREATMENT PROTOCOL

Client History Phase (Phase 1), the clinician explores targets for future EMDR reprocessing from negative events in the client’s life, prepares a treatment plan with attention to past and present experiences, and future clinical issues. It is also important to identify positive or adaptive aspects of the client’s personality and life experience. The clinician may need to postpone completing a detailed trauma history when working with a client with a complex trauma history until the client has developed adequate affect regulation skills and resources to remain stable.

Preparation Phase (Phase 2), the clinician acquaints the client with the therapeutic framework of EMDR providing sufficient information for the client to give informed consent to treatment. Also during this phase, the client learns grounding skills, practices the mindful stance of dual awareness, develops skills in self-soothing and in affect regulation that facilitate dual awareness during the reprocessing sessions and help maintain stability during and between sessions. Assessing the client for dissociative tendencies is an aspect of ensuring affective stability. Accomplishing these tasks may be supported by techniques from other therapeutic modalities. An overarching task during this phase of treatment is that the client establish a relationship of trust with the therapist that is sufficient to give the client a sense of safety and foster the client’s ability to tell the therapist what s/he is experiencing throughout the reprocessing. Some clients may require a lengthy preparation phase for adequate stabilization and development of adaptive resources prior to dealing directly with the disturbing memories. Occasionally, the therapy may temporarily return to Phase 2 if in assessing or processing more sensitive target memories, it is apparent that more stabilization is needed.

Assessment Phase (Phase 3): Significant issues, incidents identified in Phase 1 are reviewed with the client.  There may be several incidents that are thematically related, such as being bullied at various ages and in various contexts. Once a specific representative experience has been identified (the target), the clinician asks the client to select the image or other sensory experience that best represents it. A negative belief (the Negative Cognition or NC) is elicited that expresses the client’s currently held maladaptive self-assessment related to the experience. Sometimes the NC emerges organically in the client’s account of the experience. The client is asked about the emotions evoked when pairing the image or other sensory experience and the negative belief, and to identify the location of the physical sensations in the body that are stimulated when concentrating on the experience, as well as to rate the level of disturbance utilizing the 0 to 10 Subjective Units of Disturbance (SUD) scale. Finally, the therapist elicits a positive belief (the Positive Cognition or PC) connecting the experience to more adaptive memory network(s), with the client rating and felt validity of the positive belief, utilizing the 7 point Validity of Cognition (VoC) scale.  Sometimes the PC emerges organically in the client’s account of the experience.

Desensitization Phase (Phase 4): The memory is activated and the clinician asks the client to notice his/her experiences while the clinician provides alternating bilateral stimulation. The client then reports these observations. These may include new insights, associations, information, and emotional, sensory, somatic or behavioural shifts. The clinician uses specific procedures and interweave other content if processing seems blocked. The desensitization process continues until the SUD level is reduced to 0 (or an ecologically valid rating), assisting the client throughout in maintaining an appropriate level of arousal and affect tolerance.

Installation Phase (Phase 5): the therapist first asks the client to check for a potential new positive belief related to the target memory. The client selects a new belief or the previously established positive cognition. The clinician asks him/her to hold this in mind, along with the target memory, and to rate the selected positive belief on the VOC scale of 1 to 7. The therapist then continues alternating bilateral stimulation until the client's rating of the positive belief reaches the level of 7 (or an ecologically valid rating) on the VOC Scale.

Body Scan Phase (Phase 6): The therapist asks the client to hold in mind both the target event and the positive belief and to mentally scan the body. The therapist asks the client to identify any positive or negative bodily sensations. The therapist continues bilateral stimulation when these bodily sensations are present until the client reports only neutral or positive sensations.

Closure Phase (Phase 7): This occurs at the end of any session in which unprocessed, disturbing material has been activated whether the target has been fully reprocessed or not. The therapist may use a variety of techniques to orient the client fully to the present and facilitate client stability at the completion of the session and between sessions. The therapist informs the client that processing may continue after the session, provides instructions for maintaining stability, and asks the client to observe and log significant observations or new symptoms.

Re-evaluation Phase (Phase 8): At this stage the stability of treatment effects on targets previously processed. As Leeds (2016) points out, the stability of treatment effects needs to be assessed at the micro level – the specific impact of the previous session -- and at the macro level – re-evaluation of the work as the treatment plan is nearing full implementation. At the micro level, the treatment plan is adjusted session-wise as a Phase 8 step, based on new memories, present triggers and anticipated future challenges arising for the client; for each, Phases 3-8 are repeated. In addition to assessing the overall stability of treatment effects, systemic influences are also assessed as a macro level consideration.

Focus on present triggers and anticipated future challenges relates to an overarching principle of standard comprehensive EMDR treatment: the three-pronged approach that encompasses past events, present triggers, and the exploration of adaptive outcomes for related anticipated future challenges.

Here-and-Now Approach:  The above description of the eight phases of the standard EMDR protocol outlines the structure of EMDR treatment which may give the impression that EMDR is a mechanical process as the word protocol may suggest to some. However, for any EMDR protocol to be effective, elements more akin to art, essential to any successful psychotherapy, must be present:

• an alliance of trust between the client and therapist and a feeling of safety within the session 
• ongoing informed consent, even if implicit 
• crafting of the interventions and cognitive interweaves, and pacing of the work to dynamically changing capacities of the client 
• an attunement by the therapist to:

• the client’s moment-to-moment readiness to proceed, groundedness in their dual awareness of their memories and the present context in the therapist’s office. This includes situations where the client says they are ready to proceed with processing but the therapist’s assessment of them in the session is that they are not (e.g., too tired, already outside their window of tolerance due to recent events in their life) 
• specifically in EMDR and also in CBT and narrative therapy, the exact words of client’s description of their memory which make it compelling to them. These words must be reflected in the NC and PC and adjusted as the client refines these ideas during treatment.
• in EMDR, Gestalt therapy and sensori-motor psychotherapy, the client’s somatic and behavioural tells that may signify changes in autonomic arousal and depth of connection to memories to which the client is not mindfully aware in the moment.
• non-verbal, non-narrative, non-cognitive aspects of the memory that are stored in other senses– visual, auditory, tactile, olfactory – and/or in movement, gesture or context.

Innovation, Flexibility and Clinical Judgment as Applied to Particular Clients or Special Populations:   As a psychotherapy, EMDR unfolds according to the needs, resources, diagnosis, and development of the individual client in the context of the therapeutic relationship. Therefore, the clinician, using clinical judgment, emphasizes elements differently depending on the unique needs of the particular client or the special population. EMDR treatment is not completed in any particular number of sessions. It is central to EMDR that positive results from its application derive from the interaction among the clinician, the therapeutic approach, and the client. In treatment tailored to the client’s history, the three-pronged basic treatment protocol (past events, present triggers possible future triggering situations) may need to be altered in order to address all three prongs in a manner suited to the client’s stability, readiness and situation. There may be situations where the order may be altered or prongs may be omitted, based on the clinical picture and the clinician’s judgment.

ADDITIONAL RESOURCES

In addition to Francine Shapiro’s seminal work (2001), an excellent, current summary of standard protocol  theory, practice guidelines and protocols is provided in Leeds (2016). In recognition of Francine Shapiro’s lifetime contributions to trauma treatment, EMDR practice and research, EMDRIA has established the Francine Shapiro Library as an online resource. Marilyn Luber has authored several volumes to assist in the tailoring of EMDR treatment to special situations and specific populations (Luber, 2009, 2010, 2013, 2015, among others). Ongoing developments and new research are reported in the Journal of EMDR Practice and Research, published by Springer on behalf of EMDRIA.

THERAPY OR TECHNIQUE?

Although EMDRIA describes EMDR as a comprehensive psychotherapy, Marich (2011) suggests that empirical examination of how EMDR is applied by practitioners shows that that it is also used as a) an adjunct to other approaches, b) a technique in an eclectic practice of psychotherapy, or c) as a framework to inform and shape other therapeutic modalities. More specifically Marich’s four faces of EMDR can be summarized as follows:

Face 1. protocol oriented EMDR – the Standard Protocol described above: EMDR as a therapeutic modality

Face 2. flexible EMDR – such as Parnell’s Attachment Focused EMDR: EMDR as a therapeutic modality

Face 3. EMDR as a technique – introduced in the context of some other super-ordinate modality

Face 4. EMDR-informed interventions - such as EMD (Keissling)

The question conceptual framework hinges on whether EMDR or some other modality is primary.  The author’s orientation is Face 1. above, but would argue that other modalities can inform the Preparation (Phase 2 of EMDR) as well as some cognitive interweaves during Phase 4 Processing and Phase 8 Future Template work.

One controversial side issue with Face 3., is the practice some therapists to farm out EMDR treatment of their long-term clients to an EMDR specialist, like a dentist sending a patient to an endodontist for a root canal. Treating EMDR as an adjunct technique provided by a specialist called in on an ad hoc short-term basis is a problematic practice because the client’s sense of safety in the dual awareness of EMDR processing necessitates a strong therapeutic alliance between the client and practitioner that cannot easily be created in a drop-in context, and may be undermined if the client is expecting to be back with long-term therapist after a few sessions. In addition, a trusting therapeutic alliance may be very slow to develop for deeply traumatized clients who do not experience safety and trust easily.

OTHER PROTOCOLS

1. Variants on the Standard Protocol

• the inverted standard protocol (Hoffman, 2010): begins with the future and present prongs of focus rather than the past (Standard Protocol)
• EMDr, EMD (Keissling) - used to restrict the scope of memories access in Standard Protocol processing
• A-TIP (Keissling) - restricted individual processing in acute, very recent trauma; not considered EMDR by EMDRIA 
• R-TEP (Recent Traumatic Episode Protocol) for use in disaster situations (Shapiro & Laub, 2008) 
• EMDR-PRECI (EMDR Protocol for Recent Critical Incidents. - Jarero & Artigas, 2014) 
• G-TEP (Group Traumatic Episode Protocol) (Shapiro, 2014 – see Shapiro & Moench, 2018) 
• G-TEP RISC (G-TEP for Remote Individual and Self Care) for delivery of remote individual treatment, for example, as is necessary during the corona virus pandemic. (Shapiro, 2020)

2. Attachment Focused EMDR (Parnell, 2013)

3. Addiction protocols

• dTUR (Popky,2010)
•  FSAP (Miller, 2012)

4. Imaginal Nurturing (Steele, 2010) – working with the wounded inner child

5. The Progressive Approach (Gonzalez & Mosquera, 2012) - using BLS when the client is not ready for trauma processing

6. (others too numerous to mention)

REFERENCES

Gonzales, A., & Mosquera, D. (2012) EMDR & Dissociation: the Progressive Approach. (selfpublished, available on Amazon)

Hoffman, A. (2010) The inverted EMDR standard protocol for unstable somplex post-traumatic stress disorder. In M. Luber (ed.), Eye movement desensitization and reprocessing (EMDR) scripted protocols: Special populations, pp. 313-329. New York: Springer.

Jarero, I., & Artigas, L. (2014). The EMDR protocol for recent critical incidents (EMDR-PRECI). In M. Luber (Ed.), Implementing Early Mental Health Interventions for Man-made and Natural Disasters:  Models, Scripted Protocols and Summary Sheets (pp. 217-232). New York: Springer.

Keissling, R. - https://www.emdrconsulting.com

Leeds, A. (2016) A Guide to the Standard EMDR Therapy Protocols for Clinicians, Supervisors & Consultants. New York: Springer.

Luber, Marilyn (2009) EMDR Basics and Special Situations. New York: Springer.

Luber, Marilyn (2010) EMDR Scripted Protocols: Special Populations. New York: Springer.

Luber, Marilyn (2013) Implementing EMDR: Early Mental Health Interventions for man-made and natural disasters. New York: Springer.

Luber, Marilyn (2015) EMDR Treating Anxiety, Obsessive-Compulsive, and Mood-Related Conditions. New York: Springer.

Marich, J. (2011) EMDR Made Simple: 4 approaches to using EMDR with every client. Eau Clair, WI:  Premier Publishing & Media

Miller, R. FSAP – Feeling-State Addiction Protocol.   New Hope Counselling.

Miller, R. (2012) Treatment of behavioral addictions utilizing the feeling-state addiction protocol: a multiple baseline study. Journal of EMDR Practice & Research, 6(4), pp. 159-169.

Parnell, L. (2013) Attachment Focused EMDR: Healing Relational Trauma. New York: Norton.

Popky, A. J. DeTUR for EMDR Therapy:  EMDR Professional Training

Popky, A. J. (2010) The desensitization of triggers and urge reprocessing (DeTUR) protocol. In M. Luber (ed.) EMDR Scripted Protocols: Special Populations (pp. 489-511). New York: Springer.

Shapiro, E. & Laub, B. (2008) Early EMDR Intervention (EEI): A Summary, a Theoretical Model, and the Recent Traumatic Episode Protocol (R-TEP). Journal of EMDR Practice and Research 2(2), 79-96.

Shapiro, E. & Moench, J. (2018) G-TEP (Group Traumatic Episode Protocol, 7 th ed.)

Shapiro, E. (2020) G-TEP RISC (G_TEP for Remote Individual and Self Care)  earlyemdrintervention.org

Shapiro, F. (2001) EMDR: Basic principles, protocols and procedures (2nd ed). New York: Guilford.

Steele, A. (2010) Imaginal Nurturing, Ego States & Attachment: an integrated approach to early deficits. (EMDRIA approved) Self-published. www.april-steele.ca.

CLIENTS WHO LEAVE THERAPY WITH NO CLOSURE: Reducing Its Incidence By Continuous Affirmation Therapeutic Objectives

Sometimes a client precipitously leaves therapy with no explanation. They may ghost the therapist, or it may be done with elegant finesse such as suspending therapy for a foreign trip of indeterminate duration from which they seem never to return. Either way an anticipated confrontation involved in going through the exercise of closure is avoided. Such subterfuge is a Pyrrhic transferential victory because the client is taking baggage away from the ruptured relationship, however delicately they engineer their disappearance. The reasons behind such ruptures are wide-ranging, including unstated transference, embarrassment, unstated plateauing in the ability to further confront phobic material, feeling unsafe or insufficiently supported, and so on. These are actually opportunities to advance the therapy if the therapist is quick to recognize what is happening, but in a busy practice, such situations are easily overlooked before the critical moment has passed.

There are clients who leave therapy for less overtly avoidant reasons. Sometimes a client gradually drift away, appointments become less and less frequent, and then the client stops booking, or even fails to show up and doesn’t respond to enquires. Perhaps the therapist closes the file and thinks nothing more of it. “Perhaps their benefits ran out or they weren’t ready for more therapy.” Imagining reasons when there are no explanations is tempting, but the truth may be very different from what we imagine. It is better to tolerate the ambiguity of not knowing than to engage in projection and judgement based on circumstantial evidence.
Simpler territory is the situation where the therapy has achieved its goals, but sessions continue with no mention by either the therapist or the client that the objectives of the therapy need redefinition. Continuing therapy with no explicit reason creates what is sometimes called false alliance—a collusion of motives that do not advance the client’s mental health. Two situations frequently arise:

• It is useful to make a distinction between tactical problems and strategic problems. A tactical problem might be recent job loss, recent bereavement, illness or relationship failure. Strategic problems include recurrent job loss, recurrent relationship failure or developmental trauma. If therapy has supported client through a tactical problem which was the stated reason for coming to therapy, and the client continues to want to come to therapy, there needs to be a clarification and redefinition of the reason for continuing the therapy.
• While they would actually prefer to quit, the client continues for fear of offending therapist (transference issue) or has insufficient confidence in their capacities to cope without the regular visits with the therapist. Eventually, the sessions feel sufficiently pointless the client quits, and what could have been a good ending is turned into one that leaves a negative feeling that could prevent the client from seeking to resume their therapy at some later date when they may then need it.

What the client may need in both of these situations is encouragement and support to undertake deeper work.

In all of these ambiguous circumstances, it is best to follow up with the client rather than to make assumptions. Better still is to prevent such inconclusive endings. Having clients complete the Miller-Brown brief questionnaires [Scott D. Miller & Duncan, 2000, Outcome Rating Scale (ORS) / Session Rating Scale (SRS)] to bookend each session has the potential to catch misalliances early before other defences of the client are activated. Implicit in the use of the ORS and SRS is the reaffirmation of the consent from the client to receive treatment. If the therapist is not inclined to use questionnaires, explicitly returning to the matter of ongoing informed consent* is another approach.

As part of the intake process, a psychotherapist solicits from the client their objectives for therapy, preferably in writing. A comprehensive history taking, including previous therapy and its outcome, would include goals for the current therapy. Ethically, if the therapy proceeds to address the stated objectives, even if the therapist is aware of other or deeper issues, the client cannot claim to be ill served. Unfortunately, clients sometimes are unhappy with their therapy when their stated reasons for seeking help are at variance with their willingness to follow through. They may have bitten off more than they can chew and are embarrassed to say so. If the therapist doggedly pursues the original objective for therapy, irritation, resistance and dropping out of therapy may result.

There are instances where the client claims to have a particular problem, leaves therapy because their resistance is aroused by the therapy, and then seeks counsel elsewhere for something less triggering.  They may not see that their problem is that they set the goal of therapy to be jumping to the top of the mountain. Instead they find another practitioner who will address more superficial issues, and then the client claims that the original therapy was misdirected or mishandled. “You should have known that all I needed was Treatment X.”. The client may not be aware that the vulnerability required to do the deep work they asked of the first therapist may be at odds with their control issues or other psychological defences. For example, a client reports marital breakdown because of a history of childhood sexual abuse by close relatives, leaves therapy with no notice or explanation because the developmental trauma work is too challenging, and then claims better results and takes up umbrage against the original therapist when a subsequent therapist treats only the symptoms of the developmental trauma such as anxiety, addiction or eating disorders. Neither therapist is wrong because both are treating what they were asked to treat, but the client may complain against the first therapist even though they did as they were asked.

In this example, it may seem that a potential malpractice issue is arising—not from improper actions of the therapist who acted on the client’s requests and offered what was requested, but that turned out to be too much for the client, or another therapist who offered them a less challenging treatment—but from the changing perceptions and emotional comfort of the client.

The mistake that the therapist may make is to fail to restate and reconfirm frequently the objectives of the therapy. While it may seem pedantic to periodically repeat back to a client their reason for seeking help, there may be practical and legal reasons for doing so. This revolves around the principle of ongoing informed consent*. Unfortunately, there may be few indicators that the therapist’s understanding of the objectives of the therapy and the client’s emergent desires for the therapy are diverging, especially if the client is inclined toward pleasing others and is therefore hesitant to interrupt the therapist’s approach to treatment.

In summary, it is never a bad time for the therapist to clarify what is going on with the client, and there is never a good time to make assumptions about the shifting dynamics in the therapeutic relationship. It is better for everything to be on the table all the time, which for many clients may be unique experience missing from problematic relationships in their lives.

*Ongoing Informed Consent

Informed consent in the context of a professional service means that nature, purpose and risks of a therapeutic procedure are explained to and understood by the client receiving the service. Having a client sign a document alone may not stand up legally as there is no determination of the client’s understanding unless there is a verbal verification and preferably a discussion with the client.

Regulatory organizations require that mental health practitioners maintain ongoing informed consent from their clients for the treatment they are receiving. It does not mean signing a legal document every time the therapist seeks to reaffirm doing something that has been  done before. It does mean asking, are you still OK with (treatment X), or are you up for doing a little more work on problem Y today. For various reasons, the answer may be No, perhaps because the client it too tired today, too anxious, has other present needs or other more urgent matters to discuss. Leading by following is the principle here. While some clients may welcome the therapist leading the therapy and that may accord with the therapist’s personality, it sidesteps ongoing informed consent and may be colluding with client’s issues such as, passivity, pleasing, reticence, unassertiveness, taking personal responsibility or making decisions.

Another take on ongoing informed consent is that it is not so much about consenting as it Is about checking in on refusing. The client may agree in principle about certain activities in therapy, but they may not want them on a particular day. There may be things that the client has done in previous sessions that they do not wish to do today, and checking in may be more about the timeliness of the intervention then it’s overall acceptability. The only way for the therapist to be sure is to ask.

Some may argue that the therapist can sometimes proceed on the basis of implicit consent because of the inter-subjectivity -- essential to any effective psychotherapy -- exists with the client. Has the therapist failed to obtain consent if they proceed on the basis of an intuition based on the therapist knowing the client well enough to sense of what is OK and what is not on a particular day, and doesn’t say anything about this awareness? The lack of explicitness may fail legal metrics, but consent may be there implicitly. The problem is that there is no objective attestation, even though there is attunement between the therapist and the client. Parallels exist in medical situations where a nod of the head, or the blink of an eye may have to substitute for a signature or an affirmative verbalization or refusal.

CASE CONCEPTUALIZATION

CASE CONCEPTUALIZATION: Therapist Compass, Clarifying Lens, Medical Model Envy ... or a Jumping-off Point for Something Completely Different

A discussion paper by Don Edwards, Ph.D., Jude Johnston, MSW, Julia Balaisis, Ph.D.,Valeri Belyanin, Ph.D. & Inese Gravlejs

CASE CONCEPTUALIZATION (CC): an assessment of the client and their presenting concerns in order to devise a treatment plan or treatment approach. This assessment includes client skills, environmental stressors and supports, cognitive, emotional and behavioural patterns. According to Padesky & Greenberger (1995), case conceptualization consists of identifying the issue or concern with the most leverage in the context of all other contributing and mitigating factors. This issue or concern may not be one that is initially figural for the client, but if not correctly identified by the therapist, the direction of therapy and its outcome may be compromised.

A well-prepared case conceptualization is intended to facilitate communication between professionals, systematize client records, and may help the therapist maintain a consistent frame of reference as well as track and review progress with the client even if the CC is not shared with the client. CC can also link the facts of the case to therapeutic interventions and may suggest areas of psycho-education as well as a session direction if the client does not raise areas of concern. In this era of heightened 'accountability,' 'cost effectiveness' and 'managed health care,' treatment plans, which are more and more demanded by non-practitioner administrators and professional regulatory bodies, are predicated on CC. However, as we will explore, CC's are not without their limitations.

FACTORS INFLUENCING HOW A CASE IS CONCEPTUALIZED:

• therapist's theoretical orientation:
  The theoretical focus of a therapy shines the spotlight on aspects of the client's psychological functioning that the therapy seeks to improve. Every therapy is based on a set of assumptions about what is important. These assumptions manifest in the case conceptualization. For example, a therapy such as Psychoanalysis, based on a developmental stage model, will seek to address developmental arrests. A relational therapy such as Gestalt Therapy will seek to improve the relational skills of the client – the ability to create and experience contact in Gestalt terms. CBT seeks to correct cognitive distortions that affect the emotional functioning and behaviour of the individual and might consider factors such as “schema interference” that would not figure in conceptualizations based on other therapeutic models. Bound up in the theoretical orientation are other fundamental premises that become reflected in how a case is conceptualized:
  • CC is a solution-focused notion that fits in the medical model. CC can be 'diagnosis lite.' Not all therapies embrace this view of the nature and purpose of psychotherapy. Gestalt therapy in its purest form, for example, regards the client's concerns and blocks as emergent. The client is not treated according to some assessment or diagnosis conceived by the therapist in the early stages of therapy.
  • notions of where the 'neurosis' is held: in the body (Maté, 2004) as reflected in Reichian (Totton & Edmondson, 2009) and other somatic therapies and those that focus on energetics
  • the definition of healthy or wellness inherent in the therapist's theoretical orientation
  • the influence of culture as part of the individual's field (Lewin, 1952), lived experience, meaning making, imposed identities or identifications as reflected in an existential stance (e.g., Yalom, 1980) or an anti-oppression orientation (e.g., Aguinaldo, 2008)
• type of therapy (brief/depth): Clearly conceptualizing a case is limited by the amount of data that can be collected. If the therapy is single session as in a drop in centre, the presenting data is shallow and may be the only basis for conceptualization other than the therapist's intuition and professional acumen. Also elaborate conceptualizations have questionable utility of the therapy is going to be of short duration.
• therapeutic method, not to be confused with theoretical orientation: to paraphrase, If all you have time for is a hammer, every problem is a nail. These days due to heavy case loads most psychiatrists reach for the prescription pad. If you cannot prescribe medication, medication will only be part of your treatment plan if a prescribing physician is part of the treatment team. Without these medical resources, case conceptualization will be limited to psychodynamic, cognitive and behavioural elements. If you are an ardent CBT practitioner, the whole person may not figure as large in the conceptualization; body language may be noticed and conclusions drawn about it, but interventions are not likely to begin with the body as movement-based therapists would. A Reichian practitioner would begin with somatic energy blocks.
• presence of medical issues, addictions, trauma, pervasive disorders, psychosis. The DSM IV-TR multi-axial system is one way or organizing this set of criteria into an efficient heuristic or checklist:
  • Axis I: All diagnostic categories except mental retardation and personality disorder
  • Axis II: Personality disorders and mental retardation (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)
  • Axis III: General medical condition; acute medical conditions and physical disorders
  • Axis IV: Psychosocial and environmental factors contributing to the disorder
  • Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia.

Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.

Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

(source: Wikipedia)

LIMITATIONS:

CC is not without limitations and drawbacks. The above factors influencing how a case is conceptualized are also potential limitations:

• within the therapist's paradigm of practice, a blindered view of the case is a considerable risk
• inherently a CC is imposed on the therapeutic relationship and fosters hierarchy in the relationship
• if the CC is not allowed to evolve over the course of therapy, it may become out-dated, and the therapy is at risk of becoming sterile, non-organic and irrelevant. Even if the CC evolves, it remains narrowing, though some may think of this as 'focusing.' This focusing can either help or hinder the therapeutic process by either making more figural those aspects that are truly influential or alternatively limit content and vocabulary or and narrowing perspective.

CAN WE DO BETTER? BEGINNING CONSIDERATION OF A TRANSCENDENT VIEW OF CC

A case conceptualization is a snap-shot of the client from the perspective of a therapist or treatment team. Even if it evolves and is rethought from time to time, we still will have only a set of snap-shots that are static rather than process-based and not matrixed in the larger context of the client's experience which includes the therapy itself. Some criteria for next generation CC that is less susceptible to the above noted limitations might include:

• shift toward a process orientation: patterns and dynamics versus labels and static facts
• added focus on relationality: include the impact of therapeutic relationship, by abandoning the car mechanic model of therapy and recognizing that the therapist is person, not just a technical resource, in the client's social matrix, notwithstanding all the tried and true wisdom concerning the maintenance of professional boundaries.
• more openness to cross-disciplinary integration by including professionals using other modalities or disciplines:
  • know when to bring other practitioners onto the team. Psychotherapy does not address everything that may be contributing to the client's presenting concern and we do the client a disservice trying to make therapy into a panacea.
  • special focus: explore (with the assistance of other practitioners if necessary) the important role of food and diet
  • know when the client's problem does not fit within the therapists frame of reference: recognizing when the limits of one's training and expertise have been reached
• integration the influence of culture, including religion, ceremony and ritual
• shift the professional attitude of the CC as a plan (somewhere the therapist is taking the client) to a biography (therapist as more respectful observer or co-traveller)

 

REFERENCES

 

Aguinaldo, J. P. (2008) "The social construction of gay oppression as a determinant of gay men's health: homophobia is killing us." Critical Public Health, 18(1), pp.87-96.

Lewin, K. (1952) Field Theory in Social Science. London: Tavistock.

Maté, G. (2004) When the Body Says No. Toronto: Knopf/Vintage.

Padesky, C. & Greenberger, D. (1995) Clinician's Guide to Mind Over Mood. New York: Guilford.

Totton, N., & Edmondson, E. (2009 ) Reichian Growth Work: Melting the blocks to life and love. London: PCCS Books.

Yalom, I. (1980) Existential Psychotherapy. New York: Basic Books.

MINDFULNESS & MODELS OF AWARENESS

Awareness Served Four Ways

The Buddhist notion of sati or mindfulness can be translated loosely as awareness, but encompasses many subtle meanings other than the western notion of awareness as focused attention. Mindful awareness is non-evaluative, non-goal-directed, present moment experiencing without accompanying internal dialogue (Mahathera, 1990). Mindfulness is awareness refined: it abstracts observation from concern about outcome. One simply observes whatever is happening without judging it to be good, bad or otherwise—to the extent that that is possible—and without reacting. When mindful, one is attentively observing without an agenda, rather than vigilantly watching for something. Though one may observe that one has intention, one does not observe with intention. As Daniel Siegel (2011, p.86) describes it, “mindfulness is a form of mental activity that trains the mind to become aware of awareness itself and to pay attention to one's own intention.” The ideas of non-evaluative observation and awareness of awareness seem to capture much of what is meant when mindfulness is used outside a Buddhist context. To be aware of one's awareness, focusing on moment-to-moment changes of one's state both internally and with respect to one's environment, mindful activity represents a high degree of attunement within and outside oneself.

Mindfulness is a process not a state of being. David Wallin (2007, p.6) describes mindfulness as “attend(ing) to the process of experiencing.” Most familiar processes are in the service of goals that are external or consequent. One eats to satisfy hunger. One works to make money. The “goal” of the mindfulness, if can be said to have a “goal,” is mindfulness itself. One does it as an end in itself; one does not arrive there or achieve it.

Mindfulness is thought to promote development of new neural pathways in the pre-frontal cortex (PFC), the area of the brain responsible for impulse control, emotionally self-regulation, empathy, moral sensibility and our ability to relate to other people. In early life, circumstances associated with insecure and disordered attachment are thought to hinder the normal development of the PFC. Mindfulness practice has been shown to be effective in treating depression, mania, anxiety, bipolar disorder and borderline personality which may be related to the individual's attachment history.

The concept of awareness has a developed history in western psychological discourse along the lines of being the activity of focusing attention. In this framework, various types of awareness have been distinguished based on the target of attentional focus. In a therapeutic context, this is useful in that many of the problems for which people seek therapy are the result of habits of attending so some things and not others.

The concept of zones of awareness in Gestalt therapy (Canes, Trier-Rosner & Rosner, 1987, pp.28-29) is a model of awareness with three levels or areas to which attention is focused:

Outer Zone – what is perceived by the five senses (sight, hearing, smell, touch and taste)

Middle Zone - thinking, analyzing, planning, remembering, imagining

Inner Zone – feelings, emotions, body sensations

Siegel (2011) groups things differently, modelling awareness in three broad categories and making an important contribution by distinguishing relational awareness as distinct from the rest:

Body Awareness: contact with the environment (objects, air flow, wetness, heat, cold, etc.--the province of the five senses), internal states (breath, pain, pressure, pleasant sensations, internal changes – proprioception).

Mental Awareness: synonymous with the Gestalt Middle Zone plus feeling

Relational Awareness: our mental model of our relation to others in our social world

Wallin (2007) offers us the four concentric rings of awareness pointing out that attachment theory deals only with our development in terms of the first three rings. The fourth, innermost ring of awareness is the province of mindful practice which may be the key to the remediation of difficulties rooted in one's attachment history.

External reality (the outermost ring): physical and social stimuli in one's environment

Representational World: one's interpretation of perceptual data based on previous experience

Reflective World: one's reflective stance about the meaning of our experience

The Mindful Self (the innermost ring): one's ability to be aware of, observe and think about one's engaging in the other three rings of awareness. This gives rise to our sense of self, which even if it be a fiction as Buddhist psychology contends, is a persistent and useful one.

This model maps best onto distinct areas of the brain responsible for specific functions of which Wallin (2007, Ch.5) gives an excellent account.

REFERENCES

Canes, M., Trier-Rosner, L., & Rosner, J. (1987) Peeling the Onion. Toronto: Gestalt Institute of Toronto.

Mahathera, Venerable H. Gunaratana (1990) Mindfulness in Plain English. High View, West Virginia: Bhavana Society

Siegel, D. (2011) Mindsight: the new science of personal transformation. NewYork: Bantam.

Wallin, D. (2007) Attachment in Psychotherapy. New York: Guilford Press.

THE SERENITY PRAYER EXTENDED EDITION

The Serenity Prayer, so named by the Rev. Reinhold Niebuhr (1943) and attributed to many back to Roman times, begins with the familiar words:

God grant me the serenity to accept things I cannot change

Courage to change things I can, and

Wisdom to know the difference.

These well known words are a life line for many coping with loss, depression or addiction.

Niebuhr chose to unpack his message by adding the Christian exhortations to humility, poverty, penitence and divine redemption:

Living one day at a time;
Enjoying one moment at a time;
Accepting hardships as the pathway to peace;
Taking, as He did, this sinful world as it is, not as I would have it;
Trusting that He will make all things right if I surrender to His Will;
That I may be reasonably happy in this life and supremely happy with Him
Forever in the next. Amen.

Whether one is of faith or agnostic, there are in the opening lines of the Serenity Prayer, a message of importance in psychotherapy. The consequences of neurosis include confusion and the paralysis of action. The opening lines of the Serenity Prayer give us the conditions for taking effective action in our lives. A humanistic psychotherapist might substitute for Niebuhr’s religions completion something more existential. Beyond knowing when to act and when to rest, we also need maturity in being able to delay gratification, the wisdom to take the long view and not get lost in the details of the moment, as well as the perspective to understand our own (relatively small) place in the scheme of things. And thus we might add the following three lines to the original three of the Serenity Prayer:

The patience to accept that things take time to work out

Letting go of asking “why” because I may not be ready to understand the answer, and

The detachment to realize that whatever my problem is, it involves more than me.

PSYCHOTHERAPY BASICS Q&A

How do I get started in therapy? What are the steps?

At All of You Wellness Centre, your initial enquiry by phone or e-mail will result in booking a free 15 – 20 minute telephone interview (usually at a later time) during which you will be asked to give a rough outline of your reasons for seeking help. In addition during that call, the parameters of treatment will be discussed (confidentiality, fees, insurance coverage, office locations, appointment time preferences, 24 hour cancellation, policy, missed appointment fees, etc.). If the intake coordinator feels that an All of You therapist can help you, and you accept the terms of service, an initial face-to-face appointment will be booked. You may be requested to complete a personal history form and complete some online questionnaires prior to this first appointment.

Is therapy ever complete? Does it just go on forever?

The stereotype of psychoanalysis is that you lie on a couch forever as you talk to yourself endlessly in the presence of the analyst who tries his/her best to be nothing more to you than a blank screen for your projections. Today this is as untrue of psychoanalysis as it is of other forms of therapy, many of which are designed to be brief, targeted and mindful of the economic cost involved.

The duration of therapy cannot be separated from the manner in which a client integrates the changes that arise from therapy. In practice, clients achieve a plateau in their development which must be explored before they are ready to move on to the next stage. During these stages of exploration of new ways of being in the world, therapy may continue and appear to “idle” as the therapist provides only support while the client gathers their forces to move forward again. At this stage, apparent relapses may occur, but usually are quickly overcome as the client's newly acquired coping mechanisms are brought to bear. Sometimes, is may be desirable to interrupt therapy when things plateau if the experience of being self-supporting without the therapist is part of the therapy. We are speaking here of what might be termed “strategic therapies” aimed at personal growth and correction of problems with deep, old roots. Other therapies are tactical: crisis, goal or results-oriented. These types of therapy typically have a short course and may be the entrée to longer term strategic therapy. In practice, most courses of therapy begin with a crisis of some sort –the “presenting problem” that causes the client to seek therapy. With the therapist's help, a new perspective, recognition by the client of existing strengths they can apply and provision by the therapist of information about other supports available within the client's environment, help shift the initial problem from crisis toward being a manageable symptom and it begins to become apparent that the initial reason for seeking therapy is underlain by a more strategic long-standing perhaps pervasive issue.

In principle, therapy is never finished because we are continually in the process of evolving and growing. However, if you have gotten what you wanted from a course of therapy, then, for the time being, you are finished. It is time now to live what you have learned and the feeling that you need help to make your life better may never come up again. If at some time in the future you have a sense that you are getting stuck again, it may be time to do more therapy.

I'm mad at my therapist. Should I quit therapy?

While it is possible that a panel of experts might also disapprove of whatever action of your therapist has upset you, it is far more likely that your therapist has hit upon a core issue that brought you to therapy. One of the most common patterns is to seek approval from people we look up to. Likely you look up to your therapist; otherwise you would have chosen a different one. If you therapist shines a light on something uncomfortable to you, it feels like disapproval. And the most common defensive responses to perceived disapproval and criticism are anger and flight. Why not tolerate your discomfort and hang around for the discovery that will change you? Wasn't that the result you were seeking?

What role do transference and counter-transference play in psychotherapy?

As definitions and lengthy discussions of these terms are available from many sources, we will not repeat them here other than to say that it is perhaps more profitable to look at transference as a naturally occurring process in all relationships, not just in therapy, rather than pathologizing it as Freud did in describing transference as a infantile neurotic pattern. Phenomenologically, we understand new experiences as a function of past ones –it cannot be otherwise –and thus the projective aspect of perception is pervasive. In that sense, transference is just one of the mechanisms by which we find our way in relationships. By learning about ourselves, we may become mindful of our transference, but it is debatable that we can be cured of it or operate without it.

Transference is what makes the therapeutic relationship non-hypothetical. When transference arises (whether the client is aware of it or not), the energy tied up in the patterns that trouble the client is being brought online. This creates an opportunity for new awareness and growth.

Counter-transference is rooted in your therapist's own life experience and is partly what enables him/her to be of assistance to you, to relate to your problems non-hypothetically, provided that your therapist is able to remain mindfully self-aware, recognizing that their own emotional response to your story implicates their own unresolved issues.

I want to end my therapy but can't face my therapist with my decision. Should I just make excuses and disappear?

At the risk of sounding redundant, your relationship with your therapist is just like any other relationship you have: it's a relationship. And such, it deserves a proper ending. It is more than a commercial transaction that ends with a cash register tape in your pocket.

One of the disservices we do ourselves is neglecting endings everywhere in our lives. Like most errors of omission, they go unnoticed. We break off with people without ever having an open discussion that goes beyond the anger of the breakup; we don't say good-bye to people who are dying; we leave jobs/ parties/community groups without saying good-bye, because we say “it doesn't matter,” but the real reason we do it is that we are not courageous enough to be open about our decision. Ending therapy has a impact on both you and your therapist. The (silent) damage occurs on both sides: you may feel the hollow weight of a lack of integrity; your therapist is confused about your disappearance; and both of you lose out on the opportunity for growth that having closure could bring. By disappearing, you miss yet one more opportunity to become comfortable with bringing about closure without which the accumulated unresolved experiences of life create an emotional backdrop of inauthenticity tinged with a bit of shame. Disappearing isn't a crime.   It's just a lost chance to grow as a person.

People terminate therapy for many reasons. They don't like their therapist; they tell themselves can't afford it; the stress and discomfort of change is too much, at least for now; the change that has been achieved suffices for what they think they want out of life, at least for now. Therapy seldom ends with a mutual realization that the client has arrived at perfection, both client and therapist being exceedingly glad and a grand graduation takes place. In most therapeutic relationships, the client and the therapist do as much as they can within the time and other resources that are available. Movement occurs, hopefully, but perfection remains “out there.” Despite such limitations, one of the things that makes the therapeutic relationship relatively unique is that it is a forum where nothing is outside the relationship: we should be able to tell our therapist anything, including good-bye. When we quit therapy without closure, we are putting that decision outside the relationship, and thereby violating one of the premises of that highly unique relationship.

How do I know if my therapist isn't doing a good job? Sometimes I feel worse after therapy. That can't be right.

There is no comprehensive list of signs against which to check. Egregious misdoings by your therapist are identified in professional codes of ethics and conduct. If you think your therapist is failing you, the best approach is to confront your therapist –which is different from complaining to a friend –knowing that you will grow from the experience even if you are have been mistaken—e.g., you discover your are getting upset because your therapist is doing his/her job in challenging your resistances –or your therapist takes a position where you have to agree to disagree. In any event, if you don't like the answer you get, at least the issue is out in the open and any decision you make is based less on assumption and more on fact.

Is it OK to see more than one therapist at a time?

In principle, different therapeutic approaches should not conflict, but in practice might e.g., a cognitive approach which encourages you to mentalize thereby focusing your awareness away from bodily sensations versus a somatically focused approach which encourages you to “get out of your head.” Some clients might find two simultaneous therapies overwhelming. Even if you can encompass different approaches concurrently, you are adding stress to the stress that brought you to therapy in the first place, not to mention potentially unnecessary expense and perhaps reducing the benefit of each approach. At All of You Wellness Centre, our policy is not to begin therapy with clients who are still receiving psychotherapy elsewhere, with the exception of clients who are being seen by a prescribing psychiatrist or family physician who monitors the client's psychological well-being as a necessary part of psycho-active drug therapy but are not actively engaged in psychotherapy with the client.

Am I getting value from my sessions? Is my therapist doing enough? It seems to me that I am doing all the work.

The real question is would you do this work if you were not seeing your therapist or would your life go on in the same familiar patterns you wanted to change by going to therapy? Some people expect that transformations will occur during the therapy hour. Actually at least half of the change that results from therapy takes place later, after each session, and in the six months following the end of a course of therapy. This makes sense: in the therapy room, you are talking about your life. The living of your life takes place outside the therapy room. The second part of this is who does the work in therapeutic change. Some clients, thinking along the lines of medicine, expect that something will be done to or for them in therapy, that some procedure will be applied, when in fact change is the client's response to the therapeutic relationship. Therapy is a relationship and it is through relationship that human beings change.

Why is psychotherapy expensive? It's just talk!

Like any business operation, your therapist has to pay rent, heat, electricity, ongoing profession development costs to stay current, along with other normal business expenses in order to provide you with an appropriate environment –in this case a safe, quiet and comfortable space in which to hold your sessions. In addition your therapist has to make a living in order to be available to you. If your therapist cannot make a living from their work, they will likely have to work at some other profession.

Psychotherapy is health care. Why do I have to pay for it?

Unfortunately public health care dollars are not equitably distributed across the health care system. The necessity to attend to mental health concerns is still an emerging priority in public health care funding.

I have benefits at work. Why aren't psychotherapy services fully covered?

Benefit plans cover psychotherapy in varying ways, sometimes separately with a separate limit per session and per annum, sometimes additionally restricted by being bundled in with a set of supplemental health care services all taken from the same annual total reimbursable sum. In addition psychotherapy may be reimbursable only if provided by particular practitioners. Read your plan details and do the math on the total cost of your therapy when selecting a therapist. For example: suppose your plan reimburses $50 per session for a max of $500 per annum.

CASE I: Suppose the therapists on the approved list on average charge $175/session. In order to collect the full annual limit from the insurance ($500 at $50 per session over 10 sessions), you will be paying $125/session over and above the amount reimbursed by your benefit plan, a total of $1250 for 10 sessions.

CASE II: You select a therapist whose services are not reimbursable by your benefit plan but charges $100 / session. Over the course of the same 10 sessions, your outlay would be $1000, AND you would have the luxury of choosing the therapist you feel is most suited to your concerns and personality.

I can't afford to pay for therapy every week. Can't we do something in one session?

There are two pieces here: 

1. What can be accomplished in one session and what is accomplished in longer courses of therapy?
2. What is therapy worth to you?

2. Let's deal with the second question first. Before starting anything, asking whether you can afford it is one of the first considerations. Are you already spending what therapy would cost on other discretionary purchases? Can you truly not afford therapy or do you just not want to spend the money? Is your reluctance to invest in your well-being and your future happiness really about money? Or is money a front for your resistance to confront issues in your life? Do any of these questions have resonance for you? If you really cannot afford therapy, there may be options like student clinics (lower cost but not likely free), or community agencies offering free counselling provided by volunteers (usually a waiting list). Neither of these options is likely to be highly specialized.

1. Brief therapy or single session/drop-in therapy deals with crises and tactical issues. Deeper issues such as the origins of patterns in your life cannot be addressed in one session and may not even be focal if the first session is devoted to addressing a crisis. The aim of such a session is shift the client's perspective on their presenting issue (reframing), increase the client's awareness of the resources they can draw on both within themselves and in their social circle and community to support them in dealing with their presenting issue, and ascertain whether other agencies or services should be involved. It is helpful to your therapist to know that it is your intention to see them only once.

As a final note, therapy need not be weekly, or may begin at that frequency, later shifting to a longer inter-session interval. The time between sessions is as important as the sessions themselves because change has to be lived, not just talked about. In addition, you are not helped if you become dependent on your therapist. Therapy is intended to support you in your life, not become your life. The frequency of sessions must be based on keeping that perspective as well as on cost and other practical considerations.

Some therapists offer a sliding fee scale. How do I get that?

At All of You Wellness Centre, fee reduction and pro bono consultation is at each Member Therapist's discretion. You may be asked to complete an Application for Reduced Fee. Reduced fees are a made possible by other clients paying the full fee for the services rendered. Therefore, there is a maximum number of clients who can be seen on a reduced fee basis at a given time. Availability and the factors below are weighed in determining reduced fee eligibility. Filing an Application for Reduced Fee does not imply a guarantee that a fee reduction will be approved. Reduced fee eligibility will be reviewed if there is a change in your circumstances. Any personal information you provide is strictly confidential.