Choosing a Therapist

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There are many factors at play in choosing the right therapist for you. The most obvious are logistical, such as location, cost, insurance coverage and appointment availability, but there are a number of other important issues that are vital to consider before making that first appointment.

Relationship

Research shows that the relationship between the client and therapist is the most crucial piece that makes therapy “work”. Ensure that you feel your therapist understands you and has patience and respect for you. If you don’t feel that in your initial phone contact, it’s unlikely you will in person, so shop around until you find someone who makes you feel that it’s okay to be you.

Area of specialty and preferred treatment approach

All therapists, regardless of their type of licensure, differ in their treatment approach and areas of specialty. In the same way that you wouldn’t ask an acupuncturist for a deep tissue massage, it’s important to respect a therapist’s expertise and preferred methods of working.

Some therapists are excellent at treating anxiety while others are better at treating depression. Some therapists are excellent with couples, while others do much better with individuals. Some therapists use EMDR, hypnosis or somatic experiencing, while others stick with talk-therapy. Talk-therapy may vary from a psychodynamic approach (where your childhood experiences are considered as important in shaping who you are as an adult) while others work with a cognitive-behavioral approach (which is generally shorter and more tool-based).

Ask your potential therapists what they consider to be their areas of expertise and what issues they have most success with. If there isn’t a match, or if they give you an exhaustive laundry list, look elsewhere.

Do your homework

Good therapists rarely have time to offer “free consultations”. Do your research up-front by asking friends, colleagues or other therapists for recommendations and by talking with therapists on the phone. Pay attention to the details, such as how soon you receive a call back and whether the therapist conveys that they have time to chat with you.

While therapists can be notoriously difficult to reach, you should expect your phone messages to be returned on the same day, or at least within 24 hours. If the therapist has a website, read what they say about themselves and see how that leaves you feeling. Of course, if your first meeting with your therapist doesn’t go well you are under no obligation to return, but if you’ve done your homework properly, that shouldn’t happen.

Good things come to those who wait

Finding a therapist who can get you in as soon as possible might not always be the best option. Most therapists book at least two weeks out and many have waiting lists. Since therapy is a medium to long term process, calling someone you’ve never met and demanding to get in by the end of the week may convey that you are looking for a quick fix and are not ready to engage in the necessary work ahead of you. While therapists vary in their scheduling flexibility, the adage “good things come to those who wait” may be appropriate here. If a therapist can’t get you in right away and you don’t want to wait, ask for referrals.

Couples therapy

All good couples therapists agree that couples counseling is one of the hardest modes of therapy to pull off well. Yet many therapists who have not been formally trained in couples work still claim to offer this expertise, often with devastating results. Insisting on finding a couples therapist who is in your insurance network may be a false economy. Good couples therapy is priceless – and a LOT cheaper than the divorce process. Don’t scrimp. Ask for referrals, see if the same names keep coming up, get on their waiting list, and drive across town if you have to.

Make time in your life

For therapy to be effective, the time between sessions must be considered as important as the time spent in-session. At a minimum, the brain needs space and rest to integrate the new learning and insights of the therapy process. If you are so scheduled that you can barely make your appointment-time work, this might not be the right season in your life to start your therapy journey. Since good therapy doesn’t come cheap, it’s worth waiting until you can invest the time as well as the money to do it well.

Decide what’s most important and what you’re willing to let go of

Finally, be a little flexible. While it would be wonderful to find a highly reputable therapist two miles from home who specializes in what you’re looking for, is in your insurance network and can get you in tomorrow, it’s unlikely that you’ll get all those things. Decide whether it’s worth it to drive a little further, wait a little longer or pay a little more to see the best therapist available to you.

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EMDR therapy explained

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All living bodies are predisposed towards healing. If we have a cut or a bruise or even a sprained ankle, our bodies will usually be able to repair themselves, whether or not we understand how. Sometimes, with more serious injuries, our bodies need help to start the healing process – wounds need to be cleaned; stitches, splints or plaster-casts may need to be applied; physical therapy may be necessary. Yet even with all the astounding facilitation that modern medicine provides, it is still our own bodies that do the actual healing.

It is a long held belief that psychological wounds take much longer to heal than physical wounds. Bruising sustained during an assault may disappear within a month, while the memory of that assault and associated fear may remain with a person for a lifetime. Yet treatment with EMDR suggests that this does not have to be the case. The brain too, it seems, is predisposed to heal itself as quickly as the body does – but it some cases it needs help facilitating the healing process. EMDR provides that help.

The brain’s information processing system

The brain is such a complex organ and there is much that we do not understand about it. But we do know that sleep is highly important to our wellbeing, and that there are different cycles of sleep. One of these cycles is known as REM (Rapid Eye Movement) sleep. Research suggests that this is the brain’s means of processing, filing and storing information for later retrieval. Indeed, several studies on both humans and animals have shown that if a subject is deprived of REM sleep after learning a new skill, the skill will no longer be retained*. In short, it seems that all the information and experiences of our everyday lives are processed and integrated into our overall life story during REM sleep – whether we remember dreaming or not.

The problem of trauma

Yet some data is too disturbing or upsetting to be properly processed by REM sleep – which is often the cause of nightmares that wake us before processing is finished. Such data can include major traumas – such as a violent assault, a car accident or a hurricane – or it can include a series of smaller life events that serve to undermine our sense of wellbeing, security and peace with the world. Other data never actually makes it to the Thalamus – the part of the brain responsible for taking all of our sensory information and weaving it into an integrated, cohesive experience. Instead, the data exists in the form of unconnected, fragmented images, sounds or sensations that occurred right before the traumatic event, which become the “cues” that alert the brain to potential danger in the future. If one of these cues is triggered by something similar, the thoughts, feelings and bodily sensations associated with the past can come flooding back, causing us to overreact to the current situation.

In many cases, we may not associate the original event with what is happening in the present, but will find ourselves suddenly overwhelmed by feelings of hopelessness, powerlessness or fear. We may react in ways that are inappropriate and damaging – by “losing it” with an incompetent boss, a rude child or an unsupportive partner – not  understanding why they have such an effect on us. We may find ourselves paralyzed with fear by the thought of public speaking, flying or visiting a doctor’s office. Someone in our lives might seem to bring out the worst in us, causing us to behave in ways that we dislike but can’t seem to do anything about. Any of these situations could be the result of unprocessed, improperly stored data from our past that needs reprocessing.

What EMDR does

By using eye movements that mimic REM sleep, EMDR stimulates the brain’s natural processing mechanism so that the fragments of disturbing material from the past can be accessed, processed and integrated into a cohesive experience and then into the overall life story. In the case of a recent, single incident trauma such as a mugging or a hurricane that occurred in the past couple of months, the disturbance can usually be cleared up within a few sessions of EMDR. When there are a number of traumatic incidents, or the same trauma was repeated multiple times (as in the case of physical or sexual abuse), EMDR therapists create a “target sequence plan” that lists all of the traumatic events and memories to be covered in the course of therapy. Generally, by starting with the first chronological event on the list and moving to the worst, the disturbance level of all of the memories on the plan will be brought down significantly, again enabling improvements relatively quickly.

At the end of treatment with EMDR, memories still remain, but feel distant and inconsequential. Most importantly, they are no longer associated with the emotions and bodily sensations that can be so debilitating in the present, and the cues that caused the over-reaction will be desensitized. Nightmares and flashbacks should clear up all together, and it’s not unusual for clients to report a significant decrease in physical ailments such as aches and pains, coughs, colds and allergies. Most importantly, clients typically find they have a new sense of peace with the world and with themselves which their loved ones can’t help but notice.

 

*Karni, A., et al. (1992), cited by Shapiro F. and Silk Forest, M. (2004). EMDR: The Breakthrough Eye Movement Therapy for Overcoming Anxiety, Stress and Trauma. New York, NY: Basic Books, 92.

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Symptoms of trauma and PTSD

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Nightmares, flashbacks, hyper vigilance and insomnia are all typical symptoms of trauma and post traumatic stress disorder (PTSD). But while most sufferers believe that there must be something “wrong” with them, the symptoms are actually part of the human survival system.

Allow Jane to explain.

If a truck ran over our foot, we would expect it to hurt. We would spend time in hospital having the bones reset, sit for weeks in plaster or a hard boot waiting for it to heal, and then undergo a painful exercise regime to rebuild strength. It may be months or years before we would be able to walk on it again – if ever. We hope such accidents won’t happen to us, but sometimes they do, and when they do we deal with the consequences.

Symptoms of our humanity

What we often dismiss, however, is that the brain can get hurt too. If we witness or experience something devastating, ugly or horrific, it will – and should – affect us. In fact, if it didn’t affect us then there’d probably be something wrong with us. We’d be considered hardened, inhumane, a psychopath, or – at the very least – out of touch with our feelings. The symptoms of PTSD happen not because we are weak, but because we are human, seeking to survive like all human beings. Unlike other human beings, however, we have undergone ordeals no-one should ever have to face.

The purpose of nightmares and flashbacks

When nightmares and flashbacks occur, the brain is trying to learn everything it possibly can from a bad experience so that it can spot the signals and keep us from ever having to undergo something like that again. But sometimes this survival system goes into overdrive and prevents us from identifying the true level of threat in front of us. In many of these cases, the brain’s natural information processing system – REM sleep – is unable to place the information into long term memory, either because we’re not sleeping, or because we wake before processing is finished.

How EMDR can help

EMDR therapy facilitates a process that is similar to REM sleep, which takes all of the information about a traumatic incident (including images, sounds, smells and body sensations), combines them into one cohesive experience and files them away into long term memory. At the end of treatment, the memories remain, but they feel firmly in the past. And, if something happens that looks, sounds, smells or feels like the original trauma, we can notice the similarity without feeling as though it is happening all over again.

As a result of this reset, EMDR therapy gives us back our uninterrupted sleep, clears out the flashbacks, and enables us – amazingly – to feel normal again.

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Understanding Trauma and PTSD 

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Although PTSD (posttraumatic stress disorder) is a condition typically associated with returning military personnel, it is important to recognize that many of us suffer from the impact of trauma, whether or not we realize it or know where it originated.

Understanding trauma

Trauma can occur through any situation that threatens our safety or sense of integrity. If we have ever been caused to feel intense humiliation, fear or powerlessness, we have experienced a traumatic event.

The most obvious trauma-originating situations include being involved in (or witnessing) an incident like a mugging or car-crash where we are powerless to protect ourselves or somebody else. Secondary trauma occurs through hearing the traumatic story of another person and being unable to get it out of our head.

The vast majority of trauma, however, occurs during childhood when we do not have the voice, the choice or the power to intervene in whatever situation we find ourselves – be it an abusive, alcoholic or otherwise shaming family system, being bullied at school or being forced to suffer painful medical and dental procedures without the necessary information, understanding or support.

As we undergo a traumatic experience, our brains remember the cues – such as sounds, smells, images or sensations – associated with the event that harmed, shamed, threatened or frightened us.

If a similar cue is ever experienced in the future, the higher cognitive and emotional functions of the brain automatically shut down to enable the most primitive, instinctive part of the brain to take over and cause us to fight, flee or freeze and so avoid being harmed again.

Frequently, however, the brain may over-react to the cues it believes are harmful, causing us to behave in ways that are out of proportion or unnecessary in the current situation. This, in a nutshell, is a traumatic reaction.

Traumatic reactions can be debilitating and lifelong.

They can keep us from being intimate in relationships. They can develop into phobias that keep us from visiting the dentist, seeking the medical help we need or from driving in certain conditions or on specific roads.

They can cause us to explode angrily towards a spouse, a co-worker or a boss who might have tripped our shame-wire. They can cause us to feel fuzzy in the head with an overwhelming urge to run.

They can manifest in dissociative flashbacks and nightmares that prevent us from sleeping or even having an idle moment. They can reduce us to a state of perpetual vigilance or anxiety, rendering us incapable of relaxing or enjoying life.

The good news is that the impact of PTSD and other trauma does not need to be permanent. EMDR (Eye Movement Desensitization Reprocessing) is an empirically validated therapy that can help reprocess traumatic memories, taking away our flashbacks, nightmares and unexpected body sensations, allowing us to live in the present.

Understanding Panic Disorder

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“Everything that happens once can never happen again. But everything that happens twice will surely happen a third time”.

Paulo Coelho, The Alchemist

Panic disorder is an extremely debilitating condition. Many sufferers report symptoms of heart palpitations and hyperventilation, the fear of being out of control and an impending sense of doom.

For many sufferers, panic attacks may be triggered by elevators or airplanes, traffic jams or movie theaters. Others are triggered by shortness of breath – whether through exercise, humidity or being in a stuffy, confined space with lots of other people.

Most sufferers are extremely embarrassed about their panic attacks and wish they could “just get control of themselves”. Many have undergone excruciating treatment using a systematic desensitization approach which involves gradually exposing the sufferer to what they most fear – with limited results.

Rather than a set of random, unexplained symptoms, Jane believes that panic attacks are triggered by subtle cues that look like, smell like, sound like or feel like a life-threatening situation to which the sufferer has been exposed before – not once, but twice.

The brain is usually very good at dealing with a one-time traumatic event – particularly if it occurs when we are young – and is usually able to tuck it away as an isolated experience that is unlikely to happen again.

Should a similar experience occur later in life, however, the brain suddenly kicks into overdrive, recognizing that the same experience could occur again and again and being ultra-sensitive to any cues that may resemble either of the previous events. Often the sufferer has no idea what the original event may have been; in many cases it may have been something that occurred pre-natally or pre-verbally and is stored as “lived experience” in the limbic system but there is no explicit memory of the event. Other times there may be knowledge or explicit memory of the underlying event, but the sufferer has never connected it with the panic attacks.

A common example is in the case of an infant who stops breathing. Panic usually ensues – not only for the caregivers but for the infant herself as she fights to stay alive. While the caregivers may remember the event and become especially vigilant and anxious, the infant may grow up to be largely unaffected – that is, until being smothered by an elder sibling in a game of rough and tumble at age 7, or running out of breath on the sports field at age 11. Both events could trigger a panic attack – where the body recognizes the cues as being similar to those it felt when it stopped breathing as a baby – but the child usually has no idea what the root cause might be. To make matters worse, nobody else connects the two events either, and the child is labelled as anxious, sensitive or otherwise unpredictable. Not surprisingly, the child grows up perpetually fearing another attack – not only because stopping breathing is so terrifying, but because it’s embarrassing and everyone else is often puzzled and unsympathetic.

By the time the child grows up to get on an airplane as an adult,  they’re the one having the meltdown as soon as the door is closed, delaying the plane and inciting impatient glares and tuts from all the other passengers. Most simply stop flying, avoid driving on freeways, or always take the stairs – and may often be labelled as controlling or neurotic by others around them. But when flying, driving and elevators are impossible to avoid, sufferers have no choice but to seek help.

Treating panic disorder

Jane uses a combination of Thought Field Therapy and EMDR Therapy to treat panic disorder. The beauty of EMDR is that the sufferer doesn’t have to know which events might be triggering the panic attack – rather, EMDR will find them.

She starts by taking a thorough developmental history, paying careful attention to issues of prenatal, birth or preverbal trauma, which sometimes highlights possible areas where the original trauma may have occurred. She will also ask the sufferer about the most recent panic attack, and using that as an entry point, will ask the client to float back to any times when the body may have felt the same way before.

By building a chronological list of contributing events, Jane will use EMDR to target the first, worst and most recent events of panic, before using a Future Template technique to target future events where panic could potentially occur.

The crucial ingredient, however, is teaching clients to have compassion for themselves, and engendering a sense of wonder at the body’s amazing ability to keep us safe.

Understanding Phobias

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Understanding phobias

If you have a phobia – be it of needles, heights, snakes or public speaking – you have likely learned to keep it to yourself. That probably has something to do with the fact that on the one occasion you quietly disclosed your intense fear of needles, everyone in the room thought it entirely appropriate to regale you with their 10 worst blood-draw experiences.

Similarly, if you disclosed your fear of flying, you probably discovered too late that the room was full of Delta’s most elite customers, all of whom had multiple tales of close-calls and near-crashes while earning their frequent-flyer miles.

But even if you’ve never experienced the who’s-got-the-worst-story-about-the-object-of-your-phobia competition, you’ve almost certainly met the well-meaning yet completely clueless individual who tells you just how irrational your fear is and why.

Given the significant lack of understanding of phobias by those who don’t suffer from them, it is no wonder that those who do often feel intense shame on top of their already excruciating and debilitating fear.

Furthermore, since the traditional treatment for phobias involves gradually exposing the phobia-sufferer to what they fear most, the vast majority of phobia-sufferers would never dream of seeking treatment. It is only when the object of their fear becomes completely unavoidable, or when their attempts to avoid it become so untenable, that initial (and brave) enquiries about treatment might be made.

In an attempt to honor the significant courage of phobia-sufferers who do dare to research treatment options available, Jane has written this page to explain how she conceptualizes and treats phobias in her practice.

The different types of phobia

One of the reasons why there is so much insensitivity around the phobias is the basic misunderstanding that they are all the same and all equally irrational. But this is not the case. In fact, there are different categories of phobia, and all are quite rational – since it is indeed quite rational to be concerned about one’s survival.

Jane believes that there are three core categories of phobia, all of which need to be treated differently. They are:

  1. Ancestral phobias
  2. Trauma-based phobias
  3. Anxiety-organizing phobias

 

Ancestral phobias

Fascinatingly, there are many phobias that come down the generational line. If your mother is terrified of cats, the likelihood is that you will learn (by observing your mother’s reaction when Smokey from next door comes wandering through the garden) that you should be afraid of cats too. But generational phobias can go back much further than your mother, and may even form part of our biological instincts.

A great example is the fear of snakes. Most people who fear snakes have never encountered one in the wild, let alone suffered a life-threatening snake-bite. So where does this fear come from? If we consider that those who maintained a healthy fear of snakes in years gone by were more likely to survive long enough to bear children, we can start to speculate that over thousands of years, fear of snakes became a dominant trait passed down the generations that helped to enable survival.

Similarly, fear of heights, tarantulas, water and flying – all of which may have helped preserve the survival of our predecessors – could fall into the category of an ancestral phobia, provided the sufferer has never undergone a traumatic experience with one of these stimuli. Because there is no direct trauma, ancestral phobias frequently respond well to treatment with systematic desensitization, where the person with the phobia is gradually exposed to the feared stimulus until they are able to tolerate it without undue stress.

 

Trauma-based phobias

Trauma-based phobias are typically much more severe than ancestral phobias due to the fact that the sufferer has a first-hand experience of the feared stimulus. If you were mauled by a dog when you were four years old, it would be entirely appropriate and understandable if you then developed a life-long fear of dogs.

Similarly, if you were forced to undergo painful and frightening medical or dental procedures as a child without the necessary explanation, care and respect, you could well develop a fear of doctors, dentists, needles or hospitals.

Even if you didn’t have a traumatic experience of the medical kind, the powerlessness of lying back – often in a state of undress – while someone else gets to look, poke and prod can often evoke the memory of other unwanted physical or sexual attention that may have occurred in childhood or adolescence, making routine healthcare a significant ordeal.

Unfortunately, because the traumatic nature of many phobias is so frequently misunderstood,  trauma-based phobias become more embedded every time they are confronted.

Sadly it’s not unusual for healthcare staff to be unsympathetic towards those who fear blood-draws, fillings or pap-smears, which not only causes significant shame to the traumatized patient, but also validates their fear of the procedure. Furthermore, if treatment has been historically approached from a systematic desensitization standpoint, clients often end up being re-traumatized, rather than helped, by their therapy.

For treatment of a trauma-based phobia to be effective, it is extremely important that past traumatic encounters are appropriately addressed BEFORE the feared stimulus is introduced in the present.

Anxiety-organizing phobias

The third category of phobias is possibly the least understood.

These phobias manifest in issues such as fear of driving, fear of vomiting, fear of germs, fear of death, any many more ways that serve to limit the sufferer’s ability to “do” life. Typically, such phobias serve as a “hook” or “container” to help manage anxiety that would otherwise be completely pervasive and incapacitating. Often such phobias can be quite metaphorically ingenious, for example, a fear of vomiting (emetophobia) may relate back to never having been allowed to express emotion and always needing to be perfect, resulting in a persistent fear of the rejection or punishment that might happen if the real self, with all its ugly (and disallowed) feelings, were to force its way out.

It is extremely important for the treating clinician to understand the function that the phobia is serving, and to work on the underlying anxiety BEFORE tackling the phobia itself. By targeting only the phobia, the treatment might inadvertently take away the “hook”, resulting in an explosion of completely unmanageable anxiety in every area of life, or alternatively, causing the phobia to evolve into something even more debilitating – such as turning a fear of driving over bridges into a fear of driving all together.

Generally, the phobic symptoms will reduce as the underlying anxiety is treated, often serving as a useful gauge of the treatment’s success. Only once the underlying anxiety has reached manageable levels is it appropriate to tackle the incident that caused the phobia to be linked with the underlying anxiety in the first place, and work on uncoupling the automatic response.

 

Treating phobias in therapy

Jane’s treatment of phobias in her practice starts in the same way as any other issue brought to therapy – a genogram. This provides a significant amount of context to what the client grew up with and is bringing to life – including places where anxieties may have been set in. She will then seek to understand – in detail – how and when the phobia came about, what was the worst incident of dealing with the phobia, and how it manifests in day to day life.

Treatment starts by providing the client with a number of tools to use to manage the daily manifestations of the phobia – including Thought Field Therapy (Tapping) and learning how to identify and tolerate feelings of anxiety in the body.

Because phobic reactions are stored in the limbic system and not in the cognitive, rational part of the brain, treatment then proceeds with EMDR Therapy which looks a little different depending on whether the phobia is trauma-based or anxiety-based.

Broadly, anxiety-based phobias require greater examination of the early life of the client, including prenatal and preverbal anxieties that are felt in the body but do not have a narrative memory attached to them. Trauma-based phobias focus more specifically on the traumatic event.

Jane is extremely careful to pace the therapy so that treatment is not overwhelming or re-traumatizing for the client.

She also seeks to engender in the client a respect for the ingenuity of their phobia and how it is organized around issues of protection and survival. Not until the very last phase in the process is the client asked to imagine being faced with the phobic situation, in order that a new template may be created to deal with it.

While there are no quick fixes in working with phobias, the majority of clients see significant improvement over the course of their treatment.