The most common way to assess the outcome of therapy is to gather information relating to well-being, functionality, and problems that brought someone to therapy, and to do this both at the beginning of therapy and again at the conclusion of therapy. This allows a therapist, and the person attending therapy, to see the progress they have made and determine what areas may still need to be addressed in the future. Unfortunately, this outcome measure is rarely accurate, because a large number of people who receive cognitive therapy or talk therapies drop out prior to therapy conclusion.

Therefore, Slawomir Czachowski of the College of Medicine at the Nicolaus Copernicus University in Poland recently led a study utilizing a revised outcome tool. Czachowski altered the Psychological Outcome Profiles (PSYCHLOPS) tool to include questions pertaining to problems that could arise during therapy, not just those that were present when therapy began. Further, Czachowski repeatedly administered the revised PSYCHLOPS throughout the therapy process to gauge progress along the way.

Using a sample of 238 clients, Czachowski administered pre-therapy, during therapy, and post-therapy surveys. A total of 135 people completed all three assessments. The results revealed that those who experienced valid change increased from 56% to 81%. This suggests that the revised PSYCHLOPS method captured more accurate data than the traditional delivery method, or more change occurred because PSYCHLOPS was repeatedly administered.

Czachowski also discovered that 60% of the completers reported new problems during therapy. However, these problems were not more severe than any that they presented with and the level of change that occurred with respect to these new problems was equal to that that occurred for the prior existing problems.  In fact, completers were more likely to have new problems arise during therapy, or at least admit them, than those who did not complete therapy.

Another interesting finding was that during therapy PSYCHLOPS allowed Czachowski to recognize that non-completers had the lowest PSYCHLOPS scores before and during. This could help therapists identify and take steps to help those most at risk for early drop out. In sum, these results support intermittent PSYCHLOPS to measure therapeutic outcome. “A large proportion of outcome data is lost when outcome measures depend upon completed end of therapy questionnaires,” said Czachowski. “The use of a during-therapy measure increases data capture.”

Reference:
Czachowski, S., Seed, P., Schofield, P., Ashworth, M. (2011). Measuring psychological change during cognitive behaviour therapy in primary care: A Polish study using ‘PSYCHLOPS’ (Psychological Outcome Profiles). PLoS ONE 6(12): e27378. doi:10.1371/journal.pone.0027378

I was not far from the shore in the fickle, warm Gulf of Mexico, a place I love. I was swimming, enjoying the sun, feeling deeply at peace. I loved the smell of the water, the feel of the air. I was carefree and at ease, like a butterfly on honeysuckle.

Then I was ambushed by a whirlpool, kidnapped from my reverie. I wasn’t paying attention, and I swam right into it, caught before I knew it was there. I’m a strong swimmer, and expected to swim out of the vortex and get back to shore, but I couldn’t. Each time I made it to the edge of the circle, I was forced back by the whirlpool. Each time I thought I was making my escape, I was sucked back in. I kept trying, but I couldn’t get out. I was getting scared. What if I drowned?

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I didn’t know it then, but built into every whirlpool is a backdoor, a path to survival, but when you’re in the middle of a whirlpool you can’t see it—you need someone outside, someone standing on the shore, to see you’re in trouble, to help find the solution, to show you the path so you’ll survive.

Lucky for me, there was a lifeguard standing on the shore; I screamed to him for help and he saw what was happening. I expected him to swim to me and rescue me, carry me out of the ocean like you see in the movies. I was prepared to be grateful—but that’s not what happened at all. Instead, he waded in a bit, careful not to get caught in the whirlpool himself, and pointed at something. I was angry; why didn’t he save me? I didn’t know what he was pointing at, but he insisted that I pay attention and pointed again until I saw the path out of that swift, inexorable current.

He was showing me how to escape, how to save myself.

This is like the therapist/client relationship, like what happens when I’m helping a client. I have a different perspective on what’s happening, even if I had a similar experience sometime in the past, in my own life, but to help I will stay slightly apart, so as not to get caught in the whirlpool. I will feel for you, but I’ll keep those feelings in check. It’s almost like being in two places at once—feeling close to your experience but a bit apart, too.

Inside your own whirlpool, you just can’t see. You don’t know what’s happening. Maybe you’ll even have the feeling that you’ve been through something like this before, but you don’t know what to do about it. With relationships, for instance, the kind where you split up and make up, over and over again. Each new breakup feels like other breakups in the past—you keep on breaking up/making up with the same person, and never make it to shore.

I will stand with you but a little to the side. We’ll find your path together, but then you must swim out yourself. I’ll help, but you have to do the work.

Sometimes people get very angry about that: If I know the answer, why don’t I just tell you? If I really cared I would rescue you, right?

I remember when I was in therapy myself. I was about 30 years old, recently divorced, mother of an infant, full-time social worker, and struggling financially. I did not know how to get out. I was stuck. I could not believe how I had arrived in such a miserable place, so I started treatment. I was almost completely hopeless.

My therapist listened to me, felt for and with me, showed me some of my less healthy habits, expanded my ways of thinking, and adjusted my vision. She loved me. She did not quit on me and did not let me quit on myself, either. She did not carry me out of my misery, but she was a positive example and helper, and I emerged, eventually, with a better understanding of the world and my place in it, so I could find my path and make it to shore. You can, too.

Most people enter therapy wanting something. They seek relief from debilitating symptoms. They want help making a life-changing decision. They long to heal past hurts. Couples need tools for communication. Some want better self-control. Others search for the ability to reach their potential. The list goes on.

If their therapy has the right formula of therapeutic competence, perseverance, compatibility, and good fortune, those individuals will likely reach those goals. They’ll learn what they need to learn, internalize the therapist’s message or voice, and charge into the next challenges of their life.

But many people find that therapy also provides some unexpected benefits. When they leave, they realize they’ve gotten more than they bargained for—sort of a bonus for engaging in the experience. Here are four unexpected benefits of therapy I’ve seen in my own practice:

Depth: In polite society, we’re accustomed to having mundane conversations revolving around the weather, bullet points from work, some celebrity/sports highlights, and the story we just heard on NPR or Fox News. We skip along the surface because doing so is safe and universally accepted. Therapy pushes beyond the superficial to deeper introspective questions of personal experience, historical precedents, deep feelings, and drives—a variety of topics that would never end up on a Facebook status update. When people realize talking on this level is not just interesting, but also productive and healing, they want to recreate this depth in other relationships.

Empathy: It’s kind of ironic: The majority of people come to therapy wanting to understand their own problems and why other people impact them the way they do. But once they delve into their own issues, they discover insights that help them understand their lovers, their friends, their co-workers, and their bosses on a whole new level. A light bulb goes off and they may think, “Oh, that person’s worst experience was when he was abandoned by his dad. I understand why he reacted so strongly when I bailed on our plans.” People often learn to understand the people who inhabit their lives nearly as much as they understand themselves. Or maybe they become curious and ask a few more questions, which leads to this deeper understanding.

Contagion: I can’t count the number of individuals who came to therapy to learn more about themselves and before long, their friends were interested in finding their own therapist. It happens all the time. People feel empowered and excited about growing. Their mood, attitude, and/or behavior changes, and their friends are intrigued. Occasionally, individuals in an entire friend circle will seek their own help and everyone relates on a deeper, more functional level. Fixing your friends is not a reason to seek therapy, but it sure can be rewarding when this is the outcome.

Listening: When a person spends significant time with a professional listener, that person often develops the ability to listen. They sit for many hours with someone who keeps eye contact, pays attention, and indicates reflecting or recalling past information. People in therapy know how good it feels to be on the receiving end of that kind of attention and are more likely to replicate that for their loved ones. They’ve reaped the benefits of close focused attention, had it modeled for them, and can now show it to others.

At the risk of sounding too pro-therapist, the common thread here is that therapy helps people learn to adopt some basic therapeutic characteristics. They learn to talk on a deep level, to empathize with others, to discover the thrill of self-knowledge, and to listen well. This is to be expected, as we humans often take on the characteristics of the people we spend time with, from attitudes to behaviors to communication styles.

Like I said, these are the bonuses of therapy. The main objective is helping people relieve their symptoms and underlying issues. But if they can resolve their problem while becoming better listeners and empathizers with an ability to discuss deep issues in a way that positively impacts their inner circle, what’s the problem?

Sounds like a bonus to me.

Ryan Howes, PhD, ABPP, is a clinical psychologist in Pasadena, California, the founder of National Psychotherapy Day sponsored by GoodTherapy.org, and a writer for the Psychotherapy Networker Magazine.

Art therapy is a specialized area of mental health that uses art materials and the creative process to explore emotions, reduce anxiety, increase self-esteem, and resolve other psychological conflicts. The American Art Therapy Association states that art therapy can be an effective mental health treatment for individuals who have experienced depression, trauma, medical illness, and social difficulties. Making art in therapy can be a way to achieve personal insight as well as healing.

There’s more to art therapy than simply “drawing your feelings.” Art therapists are trained to lead people through the creative process in a therapeutic way. Just as your doctor may prescribe a medication or behavioral change to aid your physical healing, your art therapist offers art-based therapy interventions that are tailored to your needs. As with every aspect of therapy, the choice to engage with specific types of materials will ultimately be up to you.

“Art washes from the soul the dust of everyday life.” —Pablo Picasso

In this article, we’ll take a look at some of the top questions people have about art therapy.

Q: Do I need art training or experience to participate in art therapy?

A: No art experience is necessary for you. Your art therapist is highly trained in visual art as well as psychology, and he or she will guide you in the process of creating art using specific types of materials. All you need is a willingness to experiment and explore.

Q: What kind of training should my art therapist have?

A: Art therapy is a profession that requires at least a master’s degree in a program with specific art therapy components.[fat_widget_right]While expressive arts therapists are trained in art therapy, there is also the designation of art therapist whereby the therapist studies only art therapy. There are also associations that offer certification as a supplement to your education, rather than a degree. Many art therapists have an art therapy credential called an ATR that indicates they are registered with the national art therapy credentials board.

Q: What kind of art will I make in art therapy?

A: It depends on your interests as well as the therapeutic benefits of certain types of art for your situation. Art therapy can include a wide range of art materials and processes. Your sessions could potentially include activities such as working with clay, painting, making a mask, creating a visual journal, and assembling a collage. Most often, the focus will be on the process rather than creating a finished art product.

Q: Do I get to keep the artwork that I make in art therapy? Will the art therapist show it to anyone else?

A: Your artwork is your creation and always belongs to you. Some people choose to keep the finished artwork, while others may decide to leave it in the care of the art therapist. Your art therapist will not show your artwork to anyone without your permission. The code of ethics followed by art therapists specifies that an art therapist must safeguard a client’s art creations the same way he/she would protect any other privileged information.

Q: Why are some art materials more appropriate for my situation than others? What does it mean to have an art therapist prescribe an art process for me?

A: Art materials have inherent healing qualities, but some are more appropriate for certain types of situations. For example, there is a therapeutic difference between using colored pencils, which are very dry and controlled, as opposed to watercolor paint, which is extremely wet and difficult to control. Your art therapist has specialized training in assessing which materials to suggest based on the issues you are facing, your frame of mind during the session, and other factors. Art therapists also have an extensive personal background in studio art, making them personally familiar with the use of specific types of art materials so that they can guide you through any difficulties that may arise in the creative process.

Q: Will the art therapist “interpret” my artwork?

A: Art therapists can use a variety of approaches, just as counselors or psychotherapists may utilize different approaches. It is not customary for a therapist to interpret your art. In a humanistic or transpersonal approach to art therapy, the focus will be on the personal meaning that you find within your own creative work, rather than an arbitrary meaning imposed by the therapist. You are the expert on your own artwork and creative process, and the art therapist’s role is to facilitate explorations of your work rather than to analyze or interpret it.

Reference:

Pablo Picasso Quotes—Art as Therapy. (2010, October 10). Retrieved May 6, 2013, from quotes: http://www.arttherapyblog.com/c/art-quotes/#ixzz2SYtZgGua

On more than one occasion, previous clients have asked if we could remain friends during or after our therapy sessions. While I could envision being friends with some of my previous clients if circumstances were different, I usually refrain from doing so and explain why I don’t encourage it.

As clients, it’s wonderful when your work with therapists has developed a strong sense of trust and safety over time. You have successfully been able to open up, gain more insight, and work through the primary issues for which you initially chose therapy. Perhaps you saw the evolution of talking about intimate details to a virtual stranger who then became what feels like a friendly confidant.

Good therapists with appropriate boundaries often do not view the evolution and closeness of the change in the therapeutic relationship with the potential for a friendship after therapy concludes, as some clients may. It is not that therapists wouldn’t like there to be a friendship in some instances. Nor does it mean they don’t care about or are indifferent toward their clients.

Therapists are usually not friends with their clients for two reasons:

1. To maintain objectivity in the clients’ best interests
2. To avoid conflicting dual relationships.

While some dual relationships are inevitable, ethically and legally therapists must evaluate and avoid dual relationships that harm or hinder the work with their clients. Therefore, other types of relationships that evolve during or after the therapeutic relationship are not normally encouraged. As an example scenario, let’s say you are hosting a dinner and wine tasting party at your home, and invite your therapist to meet your new significant other. Your therapist declines, and you feel angry. How will this affect your next session? Will it affect whether you decide to show up or not?

In another scenario, maybe you have successfully terminated your sessions, and somehow remained friends with your therapist. But what if another issue comes up for which you would like to resume therapy? The nature of the relationship would then be clouded and the boundaries unclear.

The therapeutic relationship is not a symmetrical relationship where there is mutual sharing on both sides. There is a natural imbalance. While a good therapist is a caring and empathetic person who you feel became a friend, he or she is also an authority figure to whom you are choosing to turn for professional help and support.

In friendships, there is normally a two-way dynamic in which both parties get to know each other and can mutually share vulnerable information about themselves over time. In the therapeutic relationship, the client primarily holds the role of sharing vulnerable information with the therapist. The therapist does not usually do so in turn, especially on the clients’ time. When personal issues come up for therapists, they will often seek consultation, supervision, and even their own therapy when needed.

The role of therapists is to serve their clients through listening, empathizing, mirroring, offering a different perspective, and assisting their clients gain more insight into their situations and their reactions. They help their clients with coping skills and equip them with tools to deal with their situations or relationships in a healthier manner. The therapist focuses attention on the primary issues a client is struggling with, rather than the other way around.

It is never the responsibility of the client to take care of the therapist or to solve an issue a therapist is struggling with in his or her personal life. This is one of the primary reasons developing a friendship with your therapist outside the appointed session time is not highly encouraged.

Most good therapists generally care about their clients tremendously and want to genuinely see them improve. In order to do so, they will keep the therapeutic boundaries clear and intact.

Premature termination with people in therapy happens with both seasoned and newly licensed therapists. In a study that talked about the therapeutic relationship and psychotherapy outcome, it shows that 20 to 57 percent of people in therapy do not return after the initial session (Lambert). Another 37 to 45 percent only attend therapy a total of two times (Schwartz). Sometimes these people leave without warning, but sometimes they do give some signs they won’t be returning, even if they do not directly explain them. Some will contact the therapists by email, will leave phone messages, or simply will not show up for their appointments. These people may come back much later, or not all. Many will also find a new therapist when they want to resume their therapy work.

There can be many reasons for this. I have had some people and personal contacts share some of their reasons with me. Here are some common reasons I’ve heard:

The ‘Can of Worms’

People realize therapy opened a bigger “can of worms” than they were prepared to handle. They say hindsight vision is 20/20. I wrote in my previous article, Helpful Tips to Make Therapy Most Effective for You, that one of the things to keep in mind during therapy is what you want to achieve or gain in therapy. Sometimes we don’t always know, even when we are posed that question. We can identify that we are struggling in some area of our life, or we are in some pain either emotionally or mentally, and we want some relief. We find the therapist we have a good connection with, make the appointment, and go in for our sessions.

Sometimes, we never know what to expect. Some have really good results; others have light-bulb moments with increased insight. Some, however, are taken aback by the depth of therapy, and they realized they didn’t want to go further at that time. One particularly candid response I heard from someone in this position was, “it was just too hard and painful at the time, and I just didn’t want to see what else was there.”

Subconscious Resistance

I don’t often hear people in therapy say, “I don’t think I’m ready to continue with this issue.” Sometimes other reasons come up, which is known as resistance. Therapy can provide wonderful possibilities, benefits, and outcomes, but occasionally we still resist the experience. This may be because of fear of success, failure, feeling overwhelmed by truth, fear of the unknown, or simply overwhelming emotions.

Therapeutic Breach

Misunderstandings, miscommunications, and impasses can often happen between therapists and people in therapy during the treatment duration. In the study mentioned earlier, the top reason people dropped out of therapy after the initial session was dissatisfaction with the therapist, or the feeling that the therapist didn’t really “get” them. There can be both competent and unprofessional behaviors found in all professions, and this is holds true in the therapy world. Further, even with the best training and the heart to serve people, the best therapists are not omnipotent, nor will they be perfect in their approach.

Many interventions are chosen according to what the person in therapy presents. Some will make unintentional mistakes or misunderstand what people meant. Therapy is not like getting a medical exam. There is no therapeutic equivalent to getting blood drawn, waiting for it to be studied, then receiving a detailed evaluation and report. The journey of healing through therapy must be a collaborative effort to be effective. If or when a therapeutic breach happens, a person may choose to drop out prematurely, or avoid the elephant in the room—the elephant being that there’s something hindering your therapeutic growth; you can feel it’s there but you are not able to talk about it. Alternatively, the person in treatment and therapist could have a dialogue, which can offer the most constructive growth for both parties. Often, however, it’s difficult to initiate that dialogue.

Giving Feedback

Healing in therapy is not just about getting results and meeting goals; it is also about the process of the therapeutic relationship. It is about how things unfold as you are exploring issues with your therapist. Therefore, sometimes constructive feedback is needed from people in therapy to minimize impasses and misunderstandings. This proactive approach can itself be a reflection of significant growth. For example, let’s say this person has relational difficulties, such as discussing vulnerable feelings. This is a wonderful opportunity to practice giving constructive feedback, which the person can then apply to other relationships. A competent therapist will often be very receptive to constructive feedback at any time during the sessions.

Readiness for therapy often comes at a point where people experience greater pain and discomfort by remaining personally stagnant than by initiating small adjustments in life to feel better in the long run. While there is no exact time frame for those lasting changes to occur, that readiness provides that platform for real growth to occur. The key is consistency. Premature termination sometimes cuts that opportunity short, despite improvements thus far in therapy sessions. Therapy, no matter the duration, is not a pass-or-fail experience, but rather an opportunity for positive growth with the right therapist.

References:

1. Lambert, M., J. & Barley, D., E. (2001). Research Summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy, 38, 4, 357-361.
2. Schwartz, Bernard, PhD and Flowers, John, PhD. (2010). How therapists fail: Why too many clients drop out of therapy prematurely. Impact Publishers.

Chances are most of what you think you know about therapy is misrepresented in the media. Why? Because pop culture’s idea of what goes on in the therapy room is largely based on fictional therapists. In short, good TV and movies depict bad therapy. The dramas—made famous by fictional therapists—that interest viewers portray the qualities that would be harmful to real-life people in therapy (and most likely would get those therapists in legal trouble).

Below are the top five lies that you may have learned about therapists on television and in movies, followed by a more realistic view of therapy:

Lie No. 1: Therapists can’t be trusted to keep your secrets or respect your privacy. Television and movie therapists are often portrayed as devious or self-serving. On Mad Men, Don Draper’s wife was seeing psychiatrist Dr. Arnold Wayne, who then reported the details of their sessions to Draper (this one tops the list).

The reality: Therapists are ethically bound to maintain confidentiality. What is said in a therapy session will never be shared with anyone else without your permission. The exception to this rule is when someone is in danger, as in the case of child abuse, for example. Legitimate therapists will explain the limitations of confidentiality at your first session.

[fat_widget_right] Lie No. 2: Therapists’ foibles, oddities, and mistakes are the norm. The media often portray therapists as incompetent, either because they are pompous or because they just aren’t effective in therapy. Sometimes they’re depicted simply as being off-the-wall. The most obvious example of an incompetent therapist is the delusional Tobias Fünke on Arrested Development—a failed psychiatrist with multiple phobias and a total blindness to the problems in his marriage and family. Mind you, Tobias is a hilarious character (and that is the point)—but there’s nothing therapist-like about him.

The reality: Therapists are highly educated, normal people. In general, therapists hold either a doctorate or a master’s degree in psychology or a subspecialty (such as marriage and family therapy), and they are required to take continuing education courses on a regular basis to keep their skills and licenses current—a license is required in most states. Therapists are bound by the ethical standards of their profession as well as by local and federal laws. While perfection might be desired by a person in therapy, therapists are human just like everyone else.

Lie No. 3: Your therapist will fix your problems. Fictional therapists on TV and in movies tell people in therapy what to do, taking for granted they “have the answer.” Even Dr. Phil (who is not fictional) primarily lectures and offers advice on his show.

The reality: A good therapist will assist you in finding your own answers. Your therapist might occasionally offer a suggestion about changing a behavior, or give you “homework” to try out between sessions (this isn’t advice, but a directive). It is much more likely that if you ask your therapist for advice, he or she will help you explore your own inner knowledge about what is best for you in a given situation. Each therapist has his or her own style. And there are different therapies that prescribe a more direct vs. indirect approach.

Lie No. 4: Your therapist will become very involved in your life as your on-call crisis manager. Many TV therapists are portrayed as being intimately involved in the day-to-day dramas of people’s lives, taking endless phone calls to help the client resolve a sticky situation. In the comedies Analyze This and What About Bob? this concept is taken to an extreme, as the therapists become overly involved and react defensively to people’s needy behaviors.

The reality: Therapists maintain therapeutic boundaries in order for therapy to be effective. The therapist will explain his/her policies at your first visit. Most likely, your interaction with your therapist will be limited to scheduled visits, which are typically just once a week, but short five- or 10-minute calls between sessions are usually not prohibited (this is an individual therapist courtesy). Therapists often do respond to crisis calls when deemed appropriate to do so. It is good practice to ask your therapist how he or she handles these issues if you are uncertain.

Lie No. 5: Your therapist might become romantically or sexually involved with you. It’s easy to think, from the examples we see on TV and in the movies, that most therapists end up in romantic entanglements with people in treatment. As an example, in the blockbuster romance The Prince of Tides, the psychiatrist played by Barbra Streisand begins therapy with her client’s brother and eventually has a sexual fling with him.

The reality: Therapists are ethically bound to avoid dual relationships or sexual contact with people in therapy. A dual relationship refers to a situation in which the therapist interacts with a person in therapy in a way that may be harmful to the person. In general, this is highly frowned upon by therapeutic ethics. No therapist should engage in a romantic or sexual relationship with you while you are in treatment with him/her.

“My therapist told me the way to achieve true inner peace is to finish what I start. So far today, I have finished two bags of M&M’s and a chocolate cake. I feel better already.”
—Dave Barry

So, how are you supposed to feel safe and keep pace with all these potential issues? First of all, it’s your therapist’s responsibility to handle sticky situations correctly and within the laws that govern them. Mental health professionals are required, ethically and legally, to explain these issues to you before the process of therapy begins. Typically, you will be asked to read and sign a detailed document (usually called an “informed consent” or “disclosure”) that describes the therapist’s way of practicing and his/her ethical and legal obligations. If you have questions, you can also contact your state licensing board, as it is set up to protect your rights.

Reference:

Squiddo (2013), Retrieved May 5, 2013, http://www.squidoo.com/psyquotes by Jaktraks.

Many people associate a sandbox with children’s play. However, there is a special type of expressive therapy in which a tray of sand is used to create and explore imaginary worlds. This modality, called sand tray therapy, can be appropriate for people of any age. Many adult clients enjoy sand tray therapy as a way to bypass the logical and intellectual parts of themselves in order to access a deeper, creative aspect.

Sand tray therapy has been in use since the 1940s. It emerged in the form of Jungian sandplay, a type of psychoanalytic expressive therapy in which clients were asked to “create a world” in the sand. In current times, sand tray therapy has evolved to be used by therapists from a variety of backgrounds, including humanistic or transpersonal.

How It Works
The sand tray that is used in therapy with adults and adolescents is a rectangular, wooden tray, several inches deep and painted blue on the inside. Typically, the tray is placed on a wheeled table that is about regular table height. The tray is filled about two-thirds full with clean, white sand.

In the same room, there is an open shelf containing a broad variety of small toys or figurines. These usually include human figures of different types, as well as animals, plants, buildings, vehicles, and other types of things that are commonly seen in everyday experience. Any of these figurines can be placed within the sand tray to create a small, imaginary world. In addition, the sand in the tray can be shifted to make an evocative landscape. Sand can be piled up to show a hill or mountain, or it can be scraped away from the bottom of the tray to show the blue interior in order to represent water.

How It Helps
Sand tray therapy can be used with adults when success with verbal therapies is stifled, or when a therapeutic modality that allows more access to innate creativity is desired. An excellent use for the sand tray can be with grief or trauma, when words are difficult to utter or fully process. When clients touch the sand, it can be very soothing to the psyche, offering a healing beyond what we can visibly understand.

“When the beginnings of self-destruction enter the heart, it seems no bigger than a grain of sand.” —John Cheever

There are several components of sand tray therapy that make it effective for many people, including:

• The design of the sand tray environment is a safe, contained world that is fully controlled by the client, and can be manipulated or changed by adding, subtracting, or moving figurines within the scene.
• It does not require any artistic skill to have a satisfying sand tray experience—only selecting and placing objects.
• Physically moving representational objects within the sand tray container has a beneficial effect on the body, especially in people who have undergone traumatic experiences—more so than simply talking about memories or ideas.

What to Expect
In a session using sand tray therapy, the therapist will typically begin by encouraging the client to explore the sensory experience of the sand tray itself. Many clients may spend a few minutes just experiencing the cool, smooth sand on their fingers.

The client can leave the sand smooth and flat or create a landscape by shifting the sand in the tray. Then the therapist will explain how to choose figurines in order to create a world or scene in the sand tray. The therapist will instruct the client to choose several figurines that elicit a strong reaction, either positive or negative, and reassure the client that it’s OK not to “know” what each figure represents. Then the client will decide where to place each object in the sand landscape. The scene may be static, or it may evolve over the course of the session. The therapist will encourage the client to observe what has happened in the world of the sand tray and discuss the meaning that the client sees in this experience. A photograph of the scene may be taken in order to keep a record of the session.

My Experience
Having sand trays in therapy rooms can provoke a client’s curiosity. I recall a non-sand tray client in the sand tray room stroking the sand as he was talking to me. I called his attention to this and he remarked, “It’s soothing.” Just having the sand tray nearby to touch supported his ability to relax in the room. Another example is when I was working with a couple. After a turbulent session with his wife, the man took the opportunity before he left the therapy room to put a shark head down in the sand—a visual and nonverbal communication about his feelings.

As I allow each and every client to have his or her own experience, I find the benefits of sand tray therapy useful. It allows clients to have experiences they may not if they were to use only language.

Reference:

The Columbia World of Quotations (1996), Columbia University Press. Retrieved April 11, 2013, from http://quotes.dictionary.com/search/sand_?page=3

One of the aspects of existential psychotherapy that I most value is the idea of personal responsibility. On one hand, we humans are free to live our lives the way we choose (within reason), while on the other, we are responsible for the choices we make. Freedom and responsibility go hand in hand, whether we like it or not.

Often, clients who enter psychotherapy have complaints about their lives, including their marriages, children, work environments, and many other interpersonal situations. Just as often, the clients are steadily looking outward at other people they deem responsible for the trouble. It is the spouse who is selfish, the children who just won’t listen, the unreasonable boss and the inconsiderate friends who drove the person to seek therapy. It is less often that a client comes in with a strong sense of personal responsibility and willingness to change in the beginning stages of therapy.

That is one of the challenges therapists face: how to help the client assume responsibility for his or her life without shaming or blaming. Without the clients taking on personal responsibility, no change can ever really happen because, as we all know, we can change and improve only ourselves. When faced with this challenge, I like to ask my client, “In all of the bad relationships, failed communications, and frustrating encounters in your life, what is the one common denominator?” That question allows the client to begin focusing on his or her role in whatever situation he or she is facing. Even if his or her role is as little as 1% of the issue, that 1% is where we start working. That 1% is where the change begins, and generally, the acceptance of responsibility of that small amount is what leads the client to being able to recognize other ways of being that may cause problems in his or her life.

The ability to take responsibility for one’s life is one of the greatest gifts we can offer ourselves and our clients. Although the weight of responsibility may seem heavy at times, it carries within in the seeds of freedom. When a person assumes responsibility for himself or herself, the person becomes empowered to be the person he or she chooses to be. Holocaust survivor and psychiatrist Viktor Frankl reminded us that the “last of the great human freedoms is to choose how to behave in any given circumstance.” Indeed, we have complete authorship over our attitudes, interactions, and responses.

Philosopher Jean-Paul Sartre states that to be responsible is to be the “uncontested author of an event or thing” and means that each individual, alone, is responsible for the creation of his or her life, including “self, destiny, life predicaments, feelings, and if such be the case, one’s own suffering” (Yalom, 1980). Becoming the author of one’s own life may start with something as simple as taking ownership for the 1% that is you, but will likely lead to a much deeper sense of ownership and freedom in one’s entire life. Therapy, done well, will assist participants in grasping a greater sense of self by way of freedom and responsibility.

Marriage counseling can save your marriage, prepare you for the stress of a baby, help you communicate more effectively, and get you on track for a lifetime of love. But when marriage counseling doesn’t work, it’s like throwing away money. This can make marriage problems even worse; studies show that many couples tend to fight often about money, and the false hope given by bad marital therapy can lead to despair and increased conflict.

If you need help in your relationship, it’s usually not enough to pick the first therapist you find online or on your insurance plan. Not every marriage counselor works well for every couple, and couples seeking help need to find someone who works for their specific situation.

Reputation and Recommendations
Recommendations from friends and other people you trust can be a great starting point for finding a therapist. If you’ve noticed meaningful change in someone else’s relationship, the odds are good that his or her therapist is doing something right.

If you can’t rely on recommendations from friends, read online reviews and check out discipline records with licensing boards. A therapist with a stellar reputation—particularly one who has been in practice for several years—is likely one who has a long history of helping couples wade through difficulties.

Shared Values
Marriage counselors each have their own approach to marriage. Some draw on biblical principles, while others are influenced by feminism and humanism. You don’t need to agree with your therapist about everything, but you do need a therapist who shares your core values.

If you and your spouse are struggling to build an egalitarian relationship in which you share chores, you need a therapist who recognizes this goal as important and who has helped similar couples. If you’re deeply religious, you need someone who understands the important role faith plays in your marriage. If you start therapy and your counselor makes a recommendation that runs counter to your core values, find someone else.

Strategy
A therapist isn’t a paid friend. And while marriage counselors can serve as referees and mediators, this should not be their only role. Your therapist should have a specific strategy for helping you move past marital issues.

Ask your therapist how he or she wants to proceed with treatment, and if there’s a specific therapeutic modality he or she uses. After you’re in therapy, if you don’t feel like the therapist takes control and directs the session, it may not be a good fit.

In therapy, many people want results without having to make lifestyle changes. If your therapist doesn’t call you on problematic behaviors or make suggestions about what you can do at home in between therapy sessions, he or she might not be proactive enough to help you navigate the storms of marriage.

Results
After you’re in counseling, the key measure of success is results. Your marriage won’t be changed after one session or even five, but if you’re slogging out your differences in therapy week after week with no change, it’s time to move on.

Some people get stuck with an ineffective therapist because they like the therapist or because they’re not carefully monitoring results. But good counseling works, and if you don’t notice changes within a few months, find someone else.

Questions to Ask
A good therapist will happily answer your questions, so if you struggle to get information, this is a glaring red flag. Some questions to consider asking in your first few sessions include:

• How long have you been in practice?
• How do you define success? How will we know we’re making progress?
• How long can we expect to be in therapy?
• How much of your practice is devoted to marriage counseling?
• What is your background and training?
• Do you think divorce is ever an option? Would you ever recommend divorce?

References:

1. Harley, W. F., Jr. (n.d.). How to find a good marriage counselor. Marriage Builders. Retrieved from http://www.marriagebuilders.com/graphic/mbi7100_counselor.html
2. Meineke, S. A. (n.d.). How to choose a marriage counselor. Center for Marriage. Retrieved from http://www.centerformarriage.com/how_to_choose_marriage_counselor.html
3. Questions to ask a marriage therapist. (n.d.). The National Registry of Marriage Friendly Therapists. Retrieved from http://www.marriagefriendlytherapists.com/questionstoaskatherapist.php

Hypnosis has long been fodder for television shows and stand-up acts, and most people are familiar with hypnotists who claim to be able to make anyone do anything while under hypnosis. But hypnosis is no longer just a sideshow performance, and an increasing number of people are turning to hypnosis to quit smoking, get over depression and anxiety, lose weight, and forget about phobias.

Hypnosis is still controversial within mental health, partially because it’s often part of a comedy act and not real treatment and partially because some hypnotherapists have induced false memories under regression-based hypnotherapy.

What Is It?
Hypnosis isn’t a magic trick. It’s an altered state of consciousness that hypnotists induce via the power of suggestion. Hypnotists may use relaxation techniques, key words, guided imagery, or some combination of these to help clients slowly relax. Then, while under hypnosis, hypnotists make suggestions about changes in behavior.

The idea behind hypnosis is that, even when the conscious mind wants to do something, the unconscious mind might not fully accept this change. Hypnotists claim that, under the right conditions, they can subtly alter the effects the unconscious mind has on the conscious mind and help bring about behavioral changes. Some hypnotists use hypnosis to help gradually alter a client’s perceptions. A person struggling with pain, for example, might undergo hypnosis to help him or her see the pain as pressure. An increasing number of women are even using hypnosis to help cope with the pain of childbirth.

Does It Work?
You can’t be hypnotized to do something that is outside of your moral compass or that you don’t really want to do. People who try to quit gambling or spending through hypnosis will likely not see results if they’re quitting only because of family pressure. Hypnosis can’t change the way you think; it simply makes it easier to follow through with behavioral changes. Hypnosis can also bring about a state of relaxation, and some hypnotherapists teach their clients how to self-hypnotize under stressful conditions. For people with anxiety issues, severe stress, or depression, this can help ease the symptoms.

But hypnosis is not a panacea, and is most effective when it’s used in conjunction with therapy and lifestyle changes. Particularly for long-term, chronic problems, it may take several hypnosis sessions to see results. Some people don’t see any results at all; because hypnosis thrives on suggestibility, if you’re not particularly suggestible it probably won’t work.

Choosing a Hypnotist
If you’re thinking about trying hypnotherapy, get a recommendation from your therapist. The American Society of Clinical Hypnosis also maintains a directory of qualified hypnotists with a clinical background. Make sure you know how long your hypnotist has been practicing and what methods he or she uses. The messages you hear under hypnosis should not come as a surprise, and your hypnotist should discuss the specific tools he or she is going to use before hypnotizing you.

Regression-based hypnosis, which is used to recover repressed memories, can be dangerous. Because people are more suggestible under hypnosis, the hypnotist can inadvertently fabricate memories that didn’t actually occur. Particularly if these memories are traumatic, this can lead to additional mental health issues. People with a history of psychosis should not undergo hypnosis without first taking to their doctors, because hypnosis increases their risk of a psychotic episode.

References:

1. About the society. (n.d.). American Society of Clinical Hypnosis. Retrieved from http://www.asch.net/
2. Beattie-Moss, M. (n.d.). Does hypnosis work? Research Penn State. Retrieved from http://www.rps.psu.edu/probing/hypnosis.html
3. Mental health and hypnosis. (n.d.). WebMD. Retrieved from http://www.webmd.com/anxiety-panic/guide/mental-health-hypnotherapy
4. Portenoy, R. (2008, August 18). How does hypnosis work, can anyone be hypnotized, and when is it used? ABC News. Retrieved from http://abcnews.go.com/Health/TreatingPain/story?id=4047906

You entered therapy feeling broken, lonely, anxious, dissatisfied with your relationships and your career. Now you feel whole and healthy; your relationships have improved, and you’ve made some professional changes that have led to a more fulfilling career. You feel good about yourself. Life isn’t perfect, but you have come to accept these imperfections, and you feel equipped to handle life’s challenges when they come your way. Congratulations! The time, effort, and willingness to openly and honestly explore the most complex and painful areas of yourself and your life have paid off. Therapy worked. Now what? You have a standing weekly appointment with your therapist, and you have probably developed a strong therapeutic alliance with him or her. But lately you have noticed that you don’t feel a need to go to therapy and you struggle to find ways to fill the hour. These are some strong indicators that you are ready to leave therapy.

For most people, therapy is not forever. Very few people have reason to be in therapy for life. In fact, many of the people who make therapy a way of life are therapists. They have a personal and professional responsibility to maintain high levels of self-awareness. They must take precautions to ensure that their issues are not getting in the way of helping their clients, and that they are not letting their clients’ issues prevent them from living their own lives. Weekly therapy sessions can create the time, space, and support for therapists to do just that.

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Certainly, there are some people who are not therapists who also come to view therapy as a way of life. These people are often deeply dedicated to self-growth, and therapy may provide the support they need as they pursue constantly evolving personal goals. However, the vast majority of people who come to therapy do so with the intent of getting help with something specific. Whether it is something as broad as wanting to feel better or something as narrow as making a decision about a career move, people usually bring a specific goal to therapy. For some, these goals can be achieved in a few short months, while for others, it can take years. But ultimately there is a resolution and they feel ready to end therapy. The question then is how to do it.

One of the things people find most useful about therapy is that there is nothing you can’t talk about in a session—including your relationship with your therapist. In fact, a growing body of research indicates that much of the positive change produced by therapy comes as a result of the therapeutic relationship. For example, if your relationships improved while you were in therapy, it is likely, in part, because you learned new ways of being in relationships by actively participating in your therapeutic relationship. So take the well-honed skill set that you developed in therapy and open a discussion with your therapist about ending the therapeutic relationship.

This will likely come as no surprise to your therapist. He or she knows what you came in to work on and knows that you have achieved your goal. Plus, this is a natural part of the process—all therapists in training learn about how to help clients work through this final stage, called termination. This is a prime opportunity to review the goals that brought you to therapy and to reflect on the growth that allowed you to accomplish them. This part of therapy is kind of like a graduation ceremony—it is an opportunity to step back, look at how far you have come, and revel in your success. And, as with graduations, it is an opportunity to ponder and plan for what comes next. Part of termination involves reinforcing the coping skills that evolve during therapy and reminding clients to continue to draw upon them in the future. Another important part of this process is to identify indicators that may signal the need to return to therapy in the future.

Finally, working through the process of termination with your therapist will allow you the opportunity to process the ending of a powerful and unique relationship. While this is a deeply genuine relationship, it is also one that exists within strictly prescribed boundaries—within the therapist’s office during appointment times. Of course, there may have been phone calls and additional meetings scheduled during times of crisis, but there isn’t a healthy way to continue the relationship you have formed with your therapist outside of therapy. Feelings of grief, loss, and anxiety about ending the therapeutic relationship often come up, and termination is designed to address these feelings. Like all aspects of therapy, this can be a difficult process, but seeing it through can be invaluable in helping you continue to develop and implement the kind of sophisticated relational skills that enable you to have deeper, more meaningful, and authentic relationships.