Being considered a “perfect child” by one’s parents feels fantastic. Basking in the glow from parents’ approval and love can feel safe and special, like one is living in a magical world where everyone is happy and satisfied. These feelings are very seductive. The child is usually not aware that they pay a price in order to maintain the parents’ continued extraordinary approval. That price is the giving up of one’s unique sense of self in order to comply and be the child and then the adult that the parents adore. Being kept on a pedestal distracts from being aware that one has wants and needs that are not defined by one’s loving parents. This interference with developing an individual self can result in difficult and/or empty relationships as one becomes an adult.

Here is Grace’s story. After Grace and I said our goodbyes during our last session, after 5 years of working together in therapy, I began to think about her journey from the pedestal to the development of a unique self. Grace had become a person with her own separate, individual needs, thoughts, and feelings.

Grace came to see me for therapy when she was 28 years old. She was a pretty young woman who described herself as feeling depressed and confused. She told me she was unhappy with herself and her life. She expressed puzzlement about her feelings, as she described herself as having a successful job, good friends, and a wonderful family. She wished she had a steady boyfriend, but she dated and had been in two almost-year-long relationships. Those relationships “just sort of petered out” and she wasn’t sure why. She shrugged and said, “Something seems off about my life. Nothing feels satisfying; I don’t know what I want. I don’t know what’s wrong.”

As Grace and I worked together in therapy, Grace began to describe how she always felt her life was wonderful. She was an only child and was especially close with her mother, who always referred to her as the perfect child. She told me that she felt special to both her mother and father. They idolized her and believed she could do no wrong. In fact, she told me she did no wrong. She was happy to do whatever they asked: set the table, be home on time, practice piano, not hang out with friends they felt were not a good influence. Grace felt her parents knew what was best for her and she complied.

In therapy, Grace began to talk about how it felt to be seen as so perfect by her parents. She told me she really liked it. She felt safe and loved when they would tell their friends what a good daughter she was. They were so proud of her good grades and her outstanding abilities on the piano and flute. When I asked Grace if she had ever felt like skipping piano practice or coming home later than expected, she looked surprised by the questions as if such behavior was unimaginable. Then she responded that she never behaved that way.

One day, Grace came to our session wondering about why she didn’t have any differences with her parents. She noted, for example, that most of her friends went away to college. She went to a local school and lived at home. She had no memory of wanting to go away to school but realized that now she regretted staying home for college. Grace’s sense of regret about her life began to pervade our work. Over time, Grace posed a number of questions to herself and to me.

Grace wondered if she didn’t consider the possibility of going away to school because she knew her parents wanted her to stay home. She wondered if she majored in music because her parents were so thrilled with her music making. She wondered why she went with her parents on vacations rather than taking vacations with her friends in college. One day Grace began to cry in our session. She was remembering her middle school friend Fran, who her parents didn’t like. They told her she should stop seeing Fran when they overheard her use a curse word. In our session, Grace became angry at herself and her parents. “How could I have agreed to such a thing? Fran was my best friend!” I asked Grace why she thought she should go along with her parents. What did she think would happen if she asserted what she wanted? Sobbing, Grace said she didn’t know. Her parents were good people; they loved her, why couldn’t she say what she wanted to them? Then, Grace stopped crying and gasped: “Oh! I would disappoint them.” I asked “What would be so terrible about disappointing them?” Grace looked very sad and was silent for a long time. Then she looked at me, tears returning to her eyes: “I wouldn’t be the perfect child!”

As Grace and I explored what it would mean to give up being the perfect child, it became clear that such an idea was frightening to her. She loved the feeling of making her parents glow when they saw her. She believed she kept them happy as long as she continued to be their good and perfect child. If she stopped being compliant and who they needed her to be, she worried they would become sad and hurt, and she believed this would harm them. She also would feel guilty. Talking about Grace’s concern and need to keep her parents happy led Grace to the realization that she not only wanted to make them happy, but she was worried that if she didn’t keep them happy, they wouldn’t continue to think of her as so amazingly special. Grace began to understand that to give this up felt like she would be losing their love. She was willing to consider, however, that in fact, she probably wouldn’t lose their love, but that maybe it wouldn’t continue to feel that she was quite so amazing.

Feeling less anxious about the idea that her parents would be hurt and that she would not be loved, Grace began to notice that the way she related to the people in her life was similar to the way she related to her parents. She didn’t like to disappoint or make anyone in her life unhappy. She considered whether the people in her life seemed to like her so much because she always went along. She realized that she didn’t express what she wanted if she knew it would conflict with others. One day she excitedly came into our session and said “I think the reason my relationships with men don’t work out for me is that they never really get to know who I am because I never know what I want and I am always avoiding conflict.” She said with a smile, “I am never satisfied because nothing that happens in the relationship is about me!”

Grace’s smile told me a lot. I congratulated her on the discovery she made and our work turned to focus on Grace’s wishes, desires, and needs for herself in the world. While Grace was eager to embark on a journey of discovery to learn more about herself, she was understandably anxious about how this would affect the relationships she was in. Would the people she was close to, her parents, friends, and new boyfriend, still want her in their lives? Would they love her? Would she hurt and disappoint them? Would it feel like love to her if she didn’t feel she was the most special person to the other in the relationship? These were all important and real issues that Grace would have to contend with.

Over the next 2 years, Grace gradually began to learn what she wanted and liked, what she hated, and what thrilled her. She discovered a passion for cooking and went to school to train as a chef. She weathered her parents’ disappointment that she gave up a career as a musician. And she came to believe she had the right to recognize and follow her own dreams. Her parents didn’t glow as much as they did when Grace first came to therapy, but they didn’t stop loving her.

Grace’s friendships changed. Over time and in spite of her anxiety, Grace pushed herself to reveal more of her wants and feelings as she tested the waters and developed more of a voice with her friends. Some welcomed this new Grace and were excited to learn more about her and make room for another voice. Others were not so welcoming to this new assertive Grace, and some friendships didn’t last. Grace’s dating life changed too. She felt more engaged with her boyfriend. She said “Now the relationship is about us because I am more of a whole person.”

When Grace described her new feelings and new ways of relating, she realized that she is much less compliant as a way of being in the world. She no longer felt perfect in her relationships. She knew she had to continue fighting her resistance to keep her needs quiet. Now Grace feels much more authentic with her family and friends.

Grace often smiles at me ruefully and sighs: “I do sometimes miss the feeling of being so special. Now I struggle to express what I want and it’s hard to accept that sometimes my needs aren’t met. But it is worth it. What I didn’t have, that I do have now, is I feel like a person. I usually know what I want and how to get it. I am not so scared that people won’t like me or that I will disappoint someone. In my relationships, I try to talk about what I want and feel. Sometimes it’s hard, like when I have a fight with my boyfriend or when I feel my parents disapprove of my decisions. But now I make decisions. I don’t go along automatically. I like me. How wonderful is that!”

Grace terminated therapy with the ability to continue the process of discovering and growing her unique self. While she was not yet able to assert herself as much as she wished, she was committed to the struggle to tolerate her uncomfortable feelings and risk that others might not always have the feelings she wished they would have.

That is very wonderful!

Related articles:
The Undeveloped Self and the Difficulty of Relationship
The Pink Elephant of Perception
The Fear of Hurting the Other and the Inhibition of Self

Traumatic experiences and the trauma healing process can expose the shrapnel from what feels like perpetually open wounds. Time lost to history and recovery, missed opportunities, broken relationships, and a delay in building life’s foundation can be negative side effects of traumatic experiences.

Therapists and people who have experienced trauma are able to identify, with ease, what may seem like irreversible damage or pain. However, it is simple to overlook the pieces of people’s trauma stories that are peppered with traces of hope and with a certain innocence that runs counter to what many of them have survived. This article will reflect on what people in therapy have shared with me. Through their eyes, these are the gifts of trauma:

Gratitude

We can begin with the basics. Survivors regularly express gratitude, disbelief even, for the fact that they are still living. Operating from this premise provides a great deal of delight in each day received. While it may sound cliché, perhaps this is so because of the ordinariness of what is being conveyed; it seems natural that life would be lived with greater enthusiasm in the face of its uncertainty. However, near-death experiences do not appear to be a necessary condition for people to begin to appreciate each new day; rather, being confronted with suffering, fear, or an assault on one’s humanity appear to be more relevant to our ability to appreciate existence.

Enjoying Simple Pleasures

Despite the real struggle associated with trauma recovery, there is often a simultaneous increase in a person’s capacity to enjoy the mundane. A blue sky, a delicate fragrance, a small act of compassion, the subtleties of nature, and the innocence of children and animals are often noted as having significance. Perhaps the sweetness of normalcy is illuminated when confronted with certain kinds of darkness.

Enhanced Awareness and Intuition

Survivors of trauma regularly inform me of what they experience as something akin to having superpowers. The capacity to feel things other people can’t, to identify either the goodness or inherent evil in someone just by looking at them, or to “predict” interpersonal outcomes are some of the new-found abilities people have described. People who have experienced trauma often indicate that they are able to pick up on covert human behaviors, and there is a great deal of trust in their capacity to intuit. Oftentimes, these powers really do exist; survivors have developed a discriminating aptitude for picking up on environmental cues that may have significance to them. A clinical explanation could be hypervigilence; however, people do not necessarily experience this skill negatively and are often quite opposed to this capacity diminishing.

Sense of Surprise and Enchantment

Finally, survivors often work from the assumption that, at some point, things will go awry. There is a sense of something lurking, and they conclude that something will happen that will take them out emotionally (or physically). The consequence of being right is the devastation of experiencing their truth (i.e., the world is not safe, I will never be happy) as real. However, when things go well, even smoothly, a genuine sense of surprise and enchantment is rendered.

[fat_widget_left]Feelings of defeat, pain, and innocence lost can be simple to identify following trauma’s destructive trail, while the search for a trailhead to peace can feel insurmountable. Throughout the witnessing of people’s narratives, I have discovered that there are nuggets of their remaining truth that may linger under the surface. During the process of unfolding and unpacking their stories, honoring each component of truth can facilitate a sense of hope for those who have none. In addition, some people are fully aware of what their trauma has provided them and do not want to lose these new strengths; they may have concerns about admitting this to themselves or the therapist.

Identification of trauma gifts throughout one’s story provides a platform for discussing this in a nonpathologizing way. It may also allow therapists to assist people in letting go of vigilance while embracing intuition, releasing pain while maintaining gratitude, and experiencing safety while holding on to joy.

Many people, but primarily young, educated, Western women, struggle to sustain a positive body image—for a multitude of reasons that have been discussed in previous posts. Often a negative body image leads to a poor relationship with the body and other aspects of self. It is associated with impoverished self-care and unhealthy eating and lifestyle habits.

Having a negative body image is related to general low self-esteem and depression or anxiety. Women with poor body image often struggle with boundaries in relationship to self and others. In this post, I will attempt to shed some light on the issue of boundaries related to poor body image, a concept often discussed and infrequently understood.

Women with poor body image tend to have a compartmentalized approach to well-being. For example, they may be overly focused on certain parts of the body or particular goals, such as weight loss, while devaluing other important aspects of overall health and fitness. People who have poor body image demonstrate an all-or-nothing approach to wellness, swinging from one extreme to the other, sometimes within the same day. They tend to have an exceptional level of acquired knowledge about what is healthy and set idealistic goals based on this knowledge and also are frequently disappointed and blame themselves when they are unable to attain these goals.

The lack of a holistic perspective is evidenced in an inability to balance fitness with relaxation, healthy food choices with enjoyment of food, and so on. Not surprisingly, it is common to hear that they have dissatisfying relationships with others. The all-or-nothing tendency is implicated in their sense of being overwhelmed in relationships. They sometimes become preoccupied with the other person, swinging from feeling too close to feeling uncomfortably vulnerable even feeling lost in a relationship and wanting to cut it off.

The biggest and most obvious issue I see in working with women with poor body image is that most of the information used to make decisions about relationships and well-being comes from external sources. A total and complete lack of trust in the body and the self’s ability to regulate is obvious in their decision making. There is usually a clear history in the development of this lack of trust with regard to personal, familial, and cultural messages that have been internalized. (A full discussion of these factors is beyond the scope of this article). A lack of trust in the body and in the self leads to poor listening and misinterpretation of the cues that emerge from within. After a prolonged period of not paying attention to these signals, one’s ability to understand and act in accordance to one’s own needs becomes weakened. The needs of others become the focus of too much energy and attention, often referred to as a boundary issue.

Boundaries can be physical, mental, or emotional. Clear boundary violations are easy to identify and are well known as something that is usually morally or legally wrong and/or clearly harmful to another person’s safety, integrity, or well-being. However, there is a huge gray area between what is ideal and what is harmful, and sometimes subtle violations can lead to hurt, shame, self-doubt, and low self-esteem. Violations usually happen by the person who is in a perceived position of power, as in the obvious case of an adult taking advantage of or imposing his or her personal needs on a child, or a doctor over a patient. But there are other relationships in which people can feel vulnerable and open to influence, harmful or positive. In these more subtle cases of power and vulnerability, the delivery of emotional (or more direct) messages about the self can also lead to unhealthy attitudes, self-doubt, and low self-worth. For example, people in positions of perceived or felt power who regularly directly or indirectly impose their opinions and choices can influence others to have doubts about their own choices.

A healthy boundary between people is a perceived buffering zone, whereby a felt sense of acceptable difference exists. Respectful support of differences by people in positions of perceived power and influence can help a person grow a strong sense of self and hence the ability to re-enact these perceived boundaries in other relationships. Good boundaries lead to healthy awareness of needs of the self and also positive choices that enhance the sense of self and relationships. Supporting an individual’s development involves a strong sense of self and honoring differences in others, an open attitude of acceptance and humility. A supportive stance involves allowing another person to feel, think, struggle, learn, and identify what is right for him or her without unwelcome advice or control tactics or too much distance or silence.

Recognizing and accepting differences, a supportive stance, involves sharing personal views and opinions with a sense of humility and recognizing that they are indeed personal and individual and should not be imposed on others. Offering help when it is asked for and refraining from taking over, micromanaging, or rescuing another person is important. Healthy boundaries lead to healthy relationships, and healthy relationships lead to healthy development of individuals.

Where the development of healthy boundaries has been challenged, an individual will often be overly dependent on external information and feedback to feel safe in their decision making and hence may have a poorly developed or negative sense of their own worth. In the case of the person with poor body image, this person becomes adept at information gathering, using perceived feedback to set expectations for the self that are often unrealistic. Perception itself is flawed and is often skewed towards negative, self-fulfilling ideas of self-worth. By engaging in a selection bias, people with low self-esteem will seek out and attend to cues that confirm what they think they know about themselves that is usually negative. In addition, they may believe it is possible to please others all of the time, which is clearly faulty.

Emphasis on interpretation and internalization of other people’s expectations is a recipe for impoverished self-worth. Living according to perceived notions of other people’s expectations often leads to repressed resentment, disempowerment, and disappointment. In some cases, the only way to assert the self is in a passive-aggressive manner, which is usually not received well by others. While indeed it is healthy to have a sense of social expectation and be kind and thoughtful towards others, these behaviors need to be enacted based on a clear and healthy sense of self, which requires an awareness of personal thoughts, beliefs, feelings, and needs and the differences between self and other. Healthy self and healthy relationships interrelate and influence the development of both. The development of clear boundaries has a positive impact on individuals and on others with whom they have relationships.

However, the responsibility for nurturing clear boundaries falls on individuals in a position of power of any kind. Most people in some domain of their lives are in a position to help or hinder the development of another person. It is important that we always be aware of the difference between our own needs and feelings and those of others and to refrain from overstepping and imposing or, conversely, mistakenly taking on responsibility for other people in a way that invalidates or challenges their own development.

Where boundaries were violated, or not properly developed, psychotherapy can help to personalize new ways of being that include more emotional self-awareness and self-regulation, as well as assertiveness and effective communication skills. Healthy boundaries and self-esteem are achievable goals.

Related articles:
Our Bodies/Ourselves
The Vanity Myth: Eating Disorders and Beauty
Self-Esteem and Standards

Expressive arts therapy bridges the gap between the conscious and the unconscious mind. It can bring light to areas of therapy that are blocked, inhibited, and stuck, as well as bringing greater focus to those areas of concern. The primary focus is on the process, which allows a person to discover new insight and meaning that might not be achieved with traditional talk therapy. Appropriate for all ages, it can enhance a person’s emotional, spiritual, cognitive, and physical well-being. While no talent in the use of expressive arts is required, several modalities available within expressive arts therapy magnify and deepen the process.

This article will explore five common benefits associated with the use of expressive arts therapy:

1. Expressive arts therapy encourages the unfolding unconscious. When working with expressive media, people often benefit from the unconscious bubbling to the surface of their awareness. Various media like painting, psychodrama, dance, and sculpting draw forth unearthed material that may not have been seen, felt, observed, or accessed in some way via talk therapy. Through letting go and getting into the creative flow, a portal is created to the process, enabling listening, watching, and observing what might not be explained through words. An example of this would be a person viewing an image and recalling a buried memory shaping their current experience. Another example would be a therapist suggesting to a person that mask-making might deepen the process of a new sub-personality. Whether the choice is a specific media (i.e. paint or sculpture) or the person’s own media (i.e. voice and movement), the process of unfolding to the unconscious material is supported as the person allows the new material to emerge.
2. It informs communication between a person and their therapist. Another benefit that makes expressive arts therapy inviting is the increased depth of spoken and unspoken communication which results from the expression process and the product itself. [fat_widget_left]The process makes way for additional communication to be made known, which may inform the person and his/her therapist of new insights. An example of this might be when the process of creating an authentic movement piece stirs additional emotion within a person’s experience, resulting in a dialogue about the new feelings that have emerged. The product can also increase or enhance the meaning, infuse additional unseen material, and provide an externalized venue for further discussion. An example of this would be a therapist supporting a person in expressing his or her grief by tapping into his or her talent as a watercolor artist and creating an abstract of his or her grief. The therapist could inquire about the use of color, line, and symbols present in the art.
3. Expressive arts therapy externalizes and gives form to unfolding material. Giving process a physical form allows a person to feel in control of their process. It can bring depth and life to feelings and images. It shines light on ambivalent feelings by externalizing them and giving them shape and color. One example is having a person draw an image of how they are currently feeling. Doing this might elicit additional information that wasn’t available to the person cognitively. Additionally, one of the benefits is externalizing the process so that a person can witness and be an observer of their own process. This is especially helpful for painful and difficult images and memories by allowing the a person to observe things from a distance. An example of this would be to have the person talk and explain their experience as if they are watching a movie. This allows them to psychically remove him or herself from the painful somatic response that might be risky in the moment.
4. It awakens and sparks process. Probably the most obvious benefit of expressive arts therapy is the spark created in the imagination. This awakening process allows the person to experience something new. It’s like an a-ha moment, a new discovery. It can lead to new things, bring light to something stuck, open a new doorway to unarticulated feelings, and shed light on the past. It can provide a new language and foster existing language when current circumstances and words cannot describe the unfolding process.
5. Expressive arts therapy supports integrative learning. It encourages the undiscovered places of knowledge within each person. The opportunity for a person to experience a different way of knowing is enhanced by different sensory experiences. Each experience is enhanced by the other and forms new experiences, thoughts, sensations, and images not normally experienced in the person’s normal one-dimensional experience. As a result, a rich tapestry takes form. An example of this might be asking a person to explore sounds representative of their current experience, which then deepens into the depth of pain that had gone unnoticed.

As you can see, there are many deepening and enriching experiences that expressive arts therapy supports to create a richer, more vibrant therapeutic experience. Each modality is unique, as is each therapist’s use of the modality and the client’s comfort with the material. The beauty is in the process and not the product, which is at the heart of all therapy.

“Immediacy is the act of discussing in the here-and-now how the therapist is feeling about the patient, about himself/herself in relation to the patient, or about the patient-therapist relationship,” said A. Jill Clemence of the Department of Psychiatry at Albany Medical College. Immediacy has been shown to be a critical component of the therapeutic alliance and can have a significant impact on the client’s ability to process emotions. “Immediacy is also conceptualized as a potent technique for managing an alliance rupture, for moving beyond a patient’s defenses, and for providing emotional support,” said Clemence, lead author of a recent study highlighting the effects of in-session immediacy.

Previous research has shown that clients respond better when a therapist readily identifies a disturbance in the therapeutic relationship and addresses it in a positive way. However, few studies have looked at immediacy as it occurs. “Because the act of disclosing alone is insufficient for facilitating change, the ways that timing, tact, and competent delivery of immediacy interventions impact the patient’s ability to process affective material and deepen personal exploration requires further investigation,” Clemence said, explaining the motivation for her study. Using the Therapeutic Environment Scale (TES) and the Therapist-Patient Interaction Rating Scale (TPIRS), Clemence examined the effects of immediacy in a session between a therapist (Dr. V) and client (Alice) as it occurred.

“Immediacy, when used in an active and acknowledging way by Dr. V, was found to deepen Alice’s exploration of affective and interpersonal material,” Clemence said. The alliance was ruptured from the onset, and when Alice’s attempts at immediacy were ignored, it worsened. “However, when Dr. V actively engaged Alice using immediacy during a later segment of the interview, this appeared to move the pair out of rupture and into a more effective working alliance.” Clemence added, “The ability and willingness of the interviewer to engage the patient on an affective level in active discussion of the here and-now relationship may create the opportunity for building a positive alliance and furthering exploration of relationship themes in the moment.”

Reference:
Clemence, A. J., Fowler, J. C., Gottdiener, W. H., Krikorian, S., Charles, M., Damsky, L., & Johnson, B. (2011, December 19). Microprocess Examination of Therapeutic Immediacy During a Dynamic Research Interview. Psychotherapy: Theory, Research, Practice, Training. Advance online publication. doi: 10.1037/a0026090

As a companion piece to the 50 Warning Signs of Questionable Therapy article, it’s important to understand there are many signs of good therapy as well. After all, good therapy has been proven to help people from all walks of life, in thousands of different situations, and in countless ways.

Good therapy is all about helping the person seeking help to feel better, to make healthy decisions and set healthy boundaries, to move from a place of poor emotional health to good emotional health, to make connections with others, and to replace sadness, anxiety, anger, and frustration with happiness, peace, and hopefulness for the future.

Because the “Warning Signs” article is so focused on the therapist and the behaviors they engage in—or don’t engage in—we wanted the “50 Signs of Good Therapy” to put the focus on the person in therapy, which is exactly where it belongs.

While the “50 Warning Signs of Questionable Therapy” is structured in a list format, these 50 signs of good therapy are structured along thematic lines.

Themes include:

• Training/credentials, experience, and professionalism
• Informed consent and other legal issues
• Communication and client focus
• Empathy and the therapeutic relationship
• Progress

Below is a listing of the 50 signs of good therapy, placed in order by theme:

Training/Credentials, Experience, and Professionalism

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Most states and other municipalities require that therapists or counselors meet specific education and training requirements. Though these vary from location to location, all therapists must be educated, trained, and must follow basic professional codes of ethics and guidelines. The foundation for good therapy exists when:

1. Your therapist is trained appropriately and meets all local and/or state guidelines for providing therapy.

2. Your counselor seems competent and experienced enough to help you with your issues and does not appear overwhelmed by them. While it is possible you may see a counselor who does not have the training or experience to help you with your problems, they should always let you know if that is the case.

3. Your therapist explains the therapeutic process and how you can benefit from it, without guaranteeing your success or promising that “everything will be okay.” The bottom line is that no one can make such guarantees—neither the therapist, nor you.

4. Your counselor always maintains professional business practices by keeping the focus on you. They prepare ahead of time for your sessions by reviewing notes or action items from previous sessions. They keep your appointments; are generally on time; and demonstrate they are paying attention by not answering their phone, checking their email, or otherwise becoming distracted during your sessions.

5. Your therapist provides a diagnosis if necessary but remains steadfastly focused on helping you to manage any such diagnosis and get better. The diagnosis remains the backdrop for therapy, not the focus of it.

6. Your counselor understands and communicates to you that there are many effective approaches to therapy, and no one approach can meet the needs of every client. They model open-mindedness about other approaches to therapy.

7. Your counselor explains what psychotherapeutic technique they plan to use, welcomes and answers any questions you may have about a specific technique, and requests your comments for any technique that may be new or different for you.

8. Your counselor is active in the therapy community and regularly interacts with other professionals. It is this regular collaboration with other professionals that keeps your therapist current and able to provide the best therapy for you.

9. Your counselor provides insight and knowledge that you otherwise might not have seen. This insight clearly comes from experience and training.

10. Your therapist maintains a good balance between your thoughts and your feelings without neglecting or diminishing either one.

11. Your counselor always demonstrates a balanced and appropriate level of emotion during sessions. Because good counselors are empathic and genuinely care for their clients, sometimes they express emotion when learning about a client’s experience. For example, if the client has experienced the loss of a loved one, the counselor may show sadness. While some emotion is appropriate, an abundance of emotion is generally not okay. Good therapists maintain their focus on you and not their own emotions.

12. Your therapist helps you to work through highly vulnerable feelings or memories in a safe and therapeutic way that does not re-traumatize you. Because of your work together, they know when it is safe to deal with these feelings or memories and when it is not. They neither push you to “go there” nor do they prevent you from “going there.”

13. Your counselor has also experienced being in therapy. Many counselors choose this field because they’ve had positive therapy experiences themselves, and they want to do the same for others. For those who have not experienced therapy prior to entering a counselor education program, most curricula require counseling students to participate in therapy, even if briefly so. This allows therapists to understand therapy from the client’s perspective.

Informed Consent and Other Legal Issues

The term informed consent is common among therapists. It simply means that the client should be made aware of any and all benefits and risks of therapy or a particular treatment or technique so that he or she may make the best decision about proceeding with the therapy. Informed consent is often a legal requirement as well, and these next few signs of good therapy are specifically about informed consent and other legal issues. The foundation for good therapy exists when:

14. You receive a packet, commonly called intake forms or informed consent, to complete before or with your first appointment. This packet should explain how therapy with your counselor works, what your rights are as a client, the fee schedule, insurance information, privacy information, and more. Your therapist should also answer any questions about this packet to your full satisfaction.

15. Your counselor explains to you that therapy is always your choice. They should make you feel comfortable with the choice to discontinue therapy or to choose another therapist. Some people decide to leave therapy before the counselor thinks it is healthy to do so, and your therapist is obligated to express any concern if you opt to discontinue therapy before the therapy has been “completed.” However, this concern should not make you feel as if you don’t have the choice to leave.

16. Your counselor maintains your confidentiality at all times. While there are some occasions when it’s necessary for a counselor to break confidentiality, these are typically outlined very carefully in the state’s or other municipality’s legal and ethical guidelines for counselors. Though the guidelines vary depending on where you live, generally speaking, a counselor can divulge the contents of a therapy session or sessions if the client or another person appears to be in imminent danger, or if the court requires information for a legal proceeding. You may want to check your own local and state guidelines.

17. Your counselor maintains the confidentiality of other clients as well. While your counselor may tell you anecdotal stories of other people’s experiences with counseling if there is a therapeutic value to you, they should never reveal the identities of other clients or give you any information that would allow you to identify them.

18. Your therapist responds openly and honestly to any questions you may have about complaints filed with the licensing board. We recommend that you always check with the licensing board to make sure your therapist’s license is current and that there are no unresolved issues.

Communication and Client Focus

Effective communication and the relationship between you and your counselor are probably the most important and indicative factors in whether or not your therapy will be successful. While everyone has different communication styles, it is the counselor’s role to be clear throughout the counseling process. A key part of effective communication is the focus of the counselor—which should always be on you. The foundation for good therapy exists when:

19. Your counselor explains right up front how they can help you. They give you concrete examples of what they will do, what you will need to do, and how you will know the therapy is progressing.

20. Your counselor regularly checks your progress against your goals and helps you to understand where you are and where you may still need to go.

21. You feel a connection with your counselor that shows they really believe in you and in the goals you have set for your life.

22. Conversations with your counselor seem natural and balanced. They neither talk too much nor too little. They use terms and language you understand and explain any concepts that may be difficult or confusing.

23. Your counselor helps you to see your own role in your level of happiness and recognizes that, while some people in your life may influence you negatively, blame is a destructive force and cannot be part of healthy choices.

24. Your therapist balances the day-to-day needs of managing your symptoms using effective coping skills with the need to work through and resolve the underlying root causes of those symptoms. By focusing on both, they are better able to help you progress and move forward than by putting all therapeutic attention on one or the other.

25. Your counselor models the behavior they are trying to help you with. They are thoughtful with comments and responses. They remain calm and speak at a moderate volume and are not antagonistic or aggressive with you.

26. It is clear that your therapist’s sole purpose is to help you—without focusing on meeting their own needs, talking excessively about themselves, disclosing personal information that does not hold some therapeutic value for you, or enlisting your assistance with anything that is outside the purpose of helping you.

27. Your counselor recognizes they may not have all of the answers or be able to help you in some circumstances. They freely acknowledge any mistakes, welcome your honest feedback, and use these as learning experiences in order to better help you and understand your needs in the future.

Empathy and the Therapeutic Relationship

Empathy, or being able to “put yourself in somebody else’s shoes,” is a hallmark of good therapy. And therapists are often naturally empathic, as this is one of the common reasons they choose to be therapists in the first place. Demonstrating empathy within the therapeutic setting helps the client to feel safe, to feel understood, and ultimately to feel like they can make progress.

Empathy is what helps build a relationship with your therapist. And your relationship with the therapist is key to the success of therapy itself. Without a strong relationship, the therapist has little chance of genuinely helping the client work through difficulties, and the client has an equally low chance of progressing.

A number of the warning signs refer to a “dual relationship,” which is quite simply one where the client knows the counselor in another context or setting besides the counseling environment. This secondary relationship can cause confusion for the client, which is why it’s typically an ethical issue. Good therapists maintain a productive and professional relationship with you at all times. While the relationship with your therapist can seem quite close—after all, you are sharing your most private thoughts, sometimes over long periods of time—therapists are trained to manage this closeness and not cross the ethical line of becoming friends or romantic partners. The foundation for good therapy exists when:

28. Your counselor maintains a professional relationship with you at all times.Their demeanor could be friendly, but they never depict your relationship as a friendship.

29. Your therapist treats you as a “whole person,” an equal who is not defined by your issues, and does not make negative judgments about you. You feel genuine care and concern from your therapist. One of the hallmarks of good therapy is known as unconditional positive regard. This is an idea that is taught in counseling programs across the country; it maintains that the therapist should see clients in a positive light regardless of any behavior, lifestyle, or other issues.

30. Your therapist is respectful of your values and belief systems and does not exhibit an agenda founded on personal values or belief systems. They are sensitive to your culture and religion and use aspects of these as part of your therapy, when appropriate. If they lack knowledge about your beliefs, they ask questions in a respectful way to gain better insight.

31. Your therapist knows you well enough to understand any physical boundary issues you may have and does not “move into your space” or touch you without asking if it’s okay with you.

32. Your counselor empathizes with you at an appropriate level, such as a natural or fitting response or level of emotion to your life’s experiences, and not one that is either overdone or exaggerated, or flat and almost nonexistent.

Progress

Finally, your progress in therapy is the ultimate indicator of whether or not you are receiving good therapy. After all, regardless of how competent or skilled your therapist may be, you getting better is what really counts. Before we get into the final list, it is important to note that just because someone is not making progress doesn’t mean the therapist is bad or incompetent. Therapy by its very nature is highly subjective and influenced by the varying needs, readiness, and styles of both the client and the therapist. Sometimes a client may not be ready for therapy and sometimes the therapist and the client are not a good fit.

With regard to the changes listed below, it should be mentioned that they don’t usually happen all at once; instead, they often happen gradually and in different sequences. The foundation for good therapy exists when:

33. You feel better! You notice that you are happier, calmer, at ease more often, and more hopeful about the future.

34. You are resolving your own issues and not looking to your therapist or anyone else to fix things for you. A good therapist guides you to your own best solutions. They are not “rescuers” who are there to save you from the issues you are facing. Instead they help you achieve insight into your own thoughts, feelings, and experiences so that you can make the right choices for yourself and move toward a healthier emotional state.

35. You handle life’s ups and downs more easily and with more control over your emotions. You see the difficult times as part of life and are less likely to become overwhelmed by them.

36. You are more forgiving and accepting. You are seeing those around you, including those who may have hurt you, as humans who may have simply made mistakes just as you have.

37. You are more connected to yourself and your own emotions, to those around you, and to life in general. You look forward to living your life and not just moving through it.

38. You are beginning to see things differently. Your perspective on life and everything around you is changing, and you see solutions where you may have seen problems in the past.

39. You are making different choices and looking at your own needs more often. You recognize that you have choices you didn’t used to think you had.

40. You smile or laugh more; your whole demeanor is more positive and future-focused.

41. Other people are noticing differences in you, and they are beginning to react to you in different and more positive ways.

42. You are getting along better with the other people in your life—from your friends and family members, to your coworkers, to strangers you come across on a day-to-day basis.

43. You have more hope for a brighter future for yourself and for your loved ones.

44. You have some sort of plan or goal for what you want your life to be, and you’re working towards that goal.

45. You are setting healthy boundaries with the people in your life and actually building stronger relationships because of it.

46. You notice that you’re feeling better outside of the therapeutic setting and not just while you’re talking to your therapist.

47. You feel safe both emotionally and physically.

48. You feel important, competent, and significant in the lives of those around you. You know you have value to them and to yourself.

49. You feel stronger and better able to express your own needs and desires. You don’t feel victimized by the actions of others.

50. You are making your own healthier choices for your behavior, for your thoughts, and for your feelings.

Amphetamine abuse and addiction is a serious and growing public health issue throughout the United States. Addiction inevitably leads to rising health costs, lost productivity, broken families, and progressively declining quality of life for drug users. Medical science has yet to formulate a satisfactory answer to this problem. Rehabilitating users is clearly one of the primary objectives, but there are numerous stumbling blocks along the way. Typical users deny the seriousness of their addiction unless and until dire consequences arise. Withdrawal effects from amphetamine are profound, and recovering addicts experience relapse at alarmingly high rates. The current best practices for addiction treatment include supportive individual therapy, group therapy, and profound lifestyle changes. In severe cases of withdrawal, anti-anxiety medications are often prescribed to ease feelings of fear and discomfort.

Ironically, amphetamines serve a therapeutic purpose in the treatment of both attention deficit hyperactivity disorder (ADHD) and narcolepsy. Dexedrine (dextroamphetamine), Adderall (dextroamphetamine and amphetamine), and Ritalin (methylphenidate) are the three primary stimulant drugs prescribed for these purposes. Recently, a nonstimulant medication, Strattera (atomoxetine) has received attention both as an alternative treatment for ADHD and as a possible therapy for recovering amphetamine addicts. Researchers in Connecticut discovered that Strattera, when taken over the course of several days, actually suppresses the effects of Dexedrine. Participants in a study group pretreated with Strattera reported fewer positive drug feelings when given a single dose of Dexedrine. Similarly, blood plasma levels showed fewer chemical markers of the heightened mood state typically associated with Dexedrine and other amphetamines.

The mechanics of amphetamine addiction are still something of a mystery. Researchers know that several chemicals in the brain are important to building and maintaining a state of dependence. Dopamine is one of these chemicals, and it plays a major role in the so-called “reward system.” Norepinephrine is thought to be responsible for the feelings of energy and euphoria experienced by users. Effective pharmaceutical interventions will need to disrupt some of the patterns that amphetamines establish within the brain. The most recent experiments have shown that norepinephrine is at least as important as dopamine in generating the stimulating physical and psychological effects of amphetamines. By altering the levels of norepinephrine with Strattera, the positive drug feelings of Dexedrine are greatly reduced.

References

1. PubMed Health [Internet]. (n.d.). Bethesda (MD): National Library of Medicine. Atomoxetine. Retrieved April 18, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000222/
2. PubMed Health [Internet]. (n.d.). Bethesda (MD): National Library of Medicine. Dextroamphetamine. Retrieved April 18, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000310/
3. Sofuoglu, M., Hill, K., Kosten, T., Poling, J. (2009). Atomoxetine attenuates dextroamphetamine effects in humans. American Journal of Drug and Alcohol Abuse, 35(6), 412-416.

We all have this wall around us. It is a very defined wall that protects us from harm. At times, it prevents us from opening our eyes to something we might benefit from, but don’t necessarily want to hear. Resistance within us is very thick and it gets even thicker as we move along in our daily lives. Our routines become redundant, predictable, and too comfortable until we become unknowingly complacent. We feel there are no other alternatives, and feelings of sadness, disappointment, and annoyance creep in. These emotions seem to stick around no matter our efforts to entertain ourselves—be it with friends and outings or any extracurricular activities. Many times alcohol, gambling, and other mood-altering substances take the place of healing, as a means to self-medicate—a means to escape the vicious cycle we have created.

When we finally reach rock bottom—which varies for each person—things can go one of two ways: seeking help or staying stuck. Even when reaching out for help, we’re still separated by that wall of resistance: the old, familiar ways of thinking. In order to begin breaking old patterns, we need to learn to listen, to allow the information to penetrate even though we may feel extremely uncomfortable (especially if it challenges our beliefs and comfort zones.) It is then, when we listen and process the information and perhaps attempt to allow different alternatives to seep in, that our resistance lowers. Seeing and thinking differently is an essential tool to resume life with a new vision and attitude.

Whether advice comes by request or unsolicited from friends, relatives, or a therapist, the best suggestion is often the one that makes you feel the most uncomfortable. It’s the one that will lead you to your destination of choice. Having short- or long-term goals is important, but the time frame in which they occur is not. It’s the route you take that makes a difference.

The route consists of your behavior, meaning the steps you take; not the old familiar actions, but the new actions that stimulate you, challenge you, and lead you in directions you haven’t yet traversed. So, in essence, we still carry the protective wall, but it’s more flexible, adjustable, and creative. At all times we are in full control of our emotions, thoughts, and behaviors. All we are doing is choosing to make different choices, implement new behaviors, and allow new feelings to formulate and flow within us.

[fat_widget_left]In a nutshell, the paragraphs above describe individual therapy/counseling. Typically, therapy is something one seeks when in need, not when in want. The outcome is usually extremely rewarding, as you have done the work yourself, and you have not given up. In essence, therapy is about never giving up on your better self; thus it’s called self-growth!

In psychiatric emergency settings, the standard treatment for aggressive or agitated behavior during psychosis is an injection of Haldol (haloperidol). A dosage of 5 to 10 mg is typically effective at putting a restless patient to sleep in a relatively short period. Aggressive patients are worrisome because they can do harm to themselves or others. An agitated person in the middle of a psychotic episode is not going to respond to the ordinary line of treatments. In some emergency settings, attending physicians choose to combine Haldol with a strong antihistamine such as Phenergan (promethazine). This practice is not recommended by international guidelines; however, researchers believed that the practical experience of emergency room doctors might have revealed a better, safer treatment option for agitated patients.

A group of international researchers conducted a study at a Brazilian hospital comparing the effectiveness of certain approaches to managing aggression and restlessness in patients admitted to a psychiatric emergency room. When an admitted patient qualified for participation in the study, they were randomly administered either Haldol alone or Haldol in tandem with Phenergan. A total of 316 people participated before the trial was stopped. One-hundred and sixty received the combination treatment, while the other 156 received only Haldol. Doctors and nurses observed and recorded how much time passed between administration of drugs and sedation, as well as any adverse side effects.

The trial ended early because data monitors quickly saw the results. Haldol by itself is neither as safe nor effective as when used together with an antihistamine like Phenergan. First, full sedation took much longer with Haldol alone. The longer patients remain agitated, the greater the danger they represent. In addition, one of the more troubling side effects of Haldol is dystonia—painful spasms of large muscle groups. Antihistamines seem to counter this effect, although the exact mechanism isn’t well understood. Because of these dangers, the study was halted when only halfway complete.

Despite the fact that the Brazilian study was left unfinished, the results are still significant. The researchers strongly recommend that psychiatric emergency wards institute administration of Haldol plus Phenergan as standard procedure for aggressive patients. This combination helps increase the safety of both patients and those charged with caring for them.

References

1. PubMed Health [Internet]. (n.d.). Bethesda (MD): National Library of Medicine. Haloperidol. Retrieved February 29, 2012. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000604/
2. Huf, G., Coutinho, E., Adams, C. (2007). Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine. BMJ. 335(7625):869. Published online 2007 October 22. doi: 10.1136/bmj.39339.448819.AE

Technology has advanced by leaps and bounds over the past several decades, affording clinicians the opportunity to provide services in more unique and far reaching way ways than ever before. However, these advancements have not come without risk. “Unfortunately, professional psychologists have also identified a number of disadvantages associated with the increased use of technology in psychological practice, including difficulties in managing electronic database and communication security, unauthorized access to client data, inappropriate disclosures of identifying information, and unethical interactions in the social-media context,” said Jason Van Allen of the Clinical Child Psychology Program at the University of Kansas. “To further complicate matters, regulatory, ethical, and legal standards in psychology are not advancing at the same rate as technological advances. This technological adoption and infrastructure mismatch is associated with a variety of potential challenges and concerns (e.g., psychologists operating without guidance from the professional organizations or with a consensus of the professional community).”

In order to identify how compromised ethical and regulatory guidelines have become with cyber-psychotherapy, Van Allen surveyed 28 psychologists and assessed their responses to virtual conditions using the Critical Incident Technique (CIT). “Overall, survey responses suggest a variety of technology-related concerns among practicing psychologists,” said Van Allen. “Responses were frequently associated with inappropriate access and/or dissemination of client data, and challenges with the use of social media.”

The American Psychological Association is aware of these concerns, but has yet to issue its own guidelines for ensuring client confidentiality and ethical adherence in a virtual world. “Overall, responsibility for ethical and professional integration of technology in practice lies with individuals,” said Van Allen. “Although psychology governance can do more (and is taking initial steps at this time) to provide guidance, psychologists would benefit from assessing the security of their electronic communications, from establishing social-media policies for themselves or their organizations, and from proactively weighing the risks and benefits each time they consider incorporating new technologies in their professional activities.”

Reference:
Van Allen, Jasono, and Michael C. Roberts. “Critical Incidents in the Marriage of Psychology and Technology: A Discussion of Potential Ethical Issues in Practice, Education, and Policy.” Professional Psychology: Research and Practice 42.6 (2011): 433-39. Print.

Individuals who are “symptomatic” of post-traumatic stress disorder (PTSD) may seem sick, crazy, or irrational. They might appear dissociative, clinically depressed, anxious, highly reactive, or rageful (or all of the above). In addition, it’s common for an individual to cultivate a sense of self-loathing for displaying these characteristics. During treatment, both therapist and survivor may agree that these symptoms are a mark of disease, making it their goal to alleviate the symptoms. Alternatively, both may choose to believe that these symptoms are an expression of health versus illness. This could enable more directed treatment, internal compassion, decreasing fear of symptoms, and a relationship between survivor, therapist, and trauma.

According to the DSM IV (American Psychiatric Association, 1994) criteria for diagnosing PTSD includes intrusive memories, thoughts, or dreams of an event, a sense of reliving the event, and intense distress in response to both internal and external cues that resemble an event(s).  Individuals may thus avoid triggers or cues, increase isolation or have a sense of ‘waiting for the other shoe to drop’ (a foreshortened future), and detachment.  Sleep difficulties are common; mood liabiality, and hyper vigilance are also common (American Psychiatric Association[DSM-IV], 1994). When a survivor feels hopeless, confused, and self-loathing because of the manifestations of their trauma, the initial layer of treatment is frequently the unraveling of self-loathing for the expression of symptoms themselves.

To begin to evaluate trauma and develop a relationship with its influence on survivors, we can draw from the practice of narrative therapy and the concept of externalizing a problem, which recognizes that the person is not the problem; the problem is the problem (Playful approaches to serious problems: Narrative therapy with children and their families. Freeman, Jennifer C.; Epston, David; Lobovits, Dean New York, NY, US: W W Norton & Co. (1997). xvii, 321 pp.). PTSD, as a character in a survivor’s life, uses symptoms as tools to protect us, remind us of our core values, and ensure that what happened before won’t happen again. The trauma response could even correspond to the level of violation on self and values; from this perspective, a profoundly disturbing event calls for a profoundly disturbing response. Flashbacks, dreams, invasive thoughts, and triggers provide specific information about the violation the client’s event(s) infringed upon them. These also exemplify the concept of “stuck points” in Trauma-Focused Cognitive Behavior Therapy (Akin-Little, Angeleque (Ed); Little, Steven G. (Ed); Bray, Melissa A. (Ed); Kehle, Thomas J. (Ed), (2009). Behavioral interventions in schools: Evidence-based positive strategies, School Psychology (pp. 325-333). Washington, DC, US: American Psychological Association, xi, 350 pp.)

The aspect of a survivor’s past that is troublesome can be quite specific and idiosyncratic. Groups of people exposed to the same event often are disturbed by different parts of it. Interpersonal trauma such as child abuse, domestic violence, or sexual assault may render someone feeling responsible for what happened to them, feeling dirty or shameful, betrayed, foolish, unimportant, or completely exposed.  Trauma might be conveying to someone that they are at fault for an assault because it wants the individual to have a sense of mastery or agency.  Helplessness is too passive, so self-blame is an acceptable tone to assume. An individual might also begin to associate a traumatic feeling of betrayal with a feeling of foolishness, ensuring s/he does not trust people too easily and maintaining inner safety.

The way in which a survivor expresses their PTSD can vary widely and presentations can be very complex and oppressive.  It is common for survivors to blame themselves for their past experiences, and they often enter into treatment with a great deal of shame because they feel they should have “gotten over it” without help. A therapist can offer some relief from shame by viewing survivors’ symptoms as useful, even critical to their treatment.

Through the process of healing, a survivor can learn to establish trust in self to clearly identify his/her core values, to reflect his/her significance in the world, and to maintain personal safety. The character of trauma will refrain from presenting images (flashbacks and dreams) when the stuck point has been identified, and will cease making statements that the individual is culpable for what happened once there is a demonstration of mastery over the event. It will hold back on invasive, persistent thoughts once the survivor is able to look at the event rather than avoiding it.  PTSD symptoms reflect individual values and provide explicit guidance for healing; if therapist and client are willing to work with trauma, and absorb the information it has to offer, it will not invade with such rigor.

Turning points are life experiences that permanently change the course of one’s life. The death of a parent, a divorce, or even a geographical move are all examples of turning points that can have a positive or negative affect on an individual. “The most defining characteristic of a turning point, however, remains that the event is perceived as significant or life-changing to the individual,” said Royette Tavernier of the Department of Psychology at Brock University, St. Catharines in Canada, and author of a recent study. How individuals process those turning points is referred to as meaning-making and is theorized to affect well-being. “The purpose of this study was to examine whether meaning-making within turning point narratives, as well as the timing of these turning points, would be associated with psychological wellbeing among a sample of Grade 12 high school adolescents,” said Tavernier.

For their study, Tavernier and a team of colleagues analyzed the life stories of 418 12th grade students, half of whom had experienced a significant turning point in their lives. All of the students had been previously assessed for well-being while in the 9^th grade, as part of another ongoing study. Tavernier discovered that although the earlier assessment of well-being did not influence meaning-making in 12^th grade, those who described meaning-making as part of their turning point narrative had much higher levels of well-being than the students who did not describe using meaning-making strategies in their life stories.

“This important finding suggests that the significant positive association between meaning-making and psychological well-being was not necessarily a function of preexisting differences on this variable, prior to adolescents’ turning point experiences but instead may be related to the meaning-making process.” Tavernier added, “In conclusion, adolescents, counselors, parents, and other sources of support can benefit from the knowledge that navigating life’s unpredictable paths is not necessarily solely associated with negative affect. Although much more research in this area is needed, these findings provide some support for the possibility that when adolescents engage in a more intimate exploration of their life experiences—particularly those that cause significant change—positive consequences can emerge at the personal and relational level.”

Reference:
Tavernier, R., & Willoughby, T. (2011, November 28). Adolescent Turning Points: The Association Between Meaning-Making and Psychological Well-Being. Developmental Psychology. Advance online publication. doi: 10.1037/a0026326