While most people traditionally think of therapy as involving two comfortable chairs in a fairly cozy office, psychotherapy has been offered many different ways for decades (e.g. phone therapy and even therapy by email). Over the last few years, we have seen an increased interest in video based therapy. Using software similar to Facetime or Skype, online therapy or internet based counselling is an alternative method of traditional therapy that enables one the opportunity to meet with a mental health care provider even if you are far away or when your time is limited and you want to sneak in a session during a break from your daily demands.
While video based therapies also open up the opportunity to see professionals from a larger geographic region, it is important to recognize that much of the work provided over this medium must be provided by an individual registered provincially to work in Ontario. This means that you are generally restricted to Ontario-based psychotherapists and psychologists. This can also mean that moving out of the province may make it difficult for your local therapist to service you from afar. This restriction is not in place in all regions, so you should certainly discuss with your treatment provider whether this is an option for you.
I am often asked if I think the same level of connection can be cultivated in an online session versus an in person one. I would say that video based sessions are essentially 90% the same. Whenever possible, I prefer to have at least one in person session with a client before offering to switch to online support. This allows us some time to get to know each other and build a strong rapport with all of the context of in person. Perhaps there is something special about sharing the space with your therapist or having increased presence to allow the conversation to deepen. However, for many people the alternative of online support is more feasible and therefore more helpful than getting no support at all. Differences between online and in-person care may vary from person to person, and some might even find that they are more easily able to open when discussing concerns from the comfort of their own space. For individuals that struggle to get out of the house due to mobility issues, phobias, transportation barriers, or child/elederly care responsibilities this alternative avenue for support may be essential.
Because this form of support is becoming more commonly available at clinics across the world, it is now easier to continue therapeutic relationships despite life changes instead of having to start over with someone new. This online opportunity also opens up many avenues for individuals in rural communities to access qualified support that may not be available close by or may be limited by a local clinician’s areas of expertise. Furthermore, clinics are starting to offer online structured module based psychotherapy where clients complete educational pre-recorded videos and readings, complete homework and are monitored by a therapist. These might be more suited towards individuals who are not as comfortable opening up, looking for something structured and have limited financial funds to pursue long term options.
While video therapy may not be for everyone, it has become an increasingly available and research-supported method of intervention. If you find getting to session a challenge, why not consider talking to your support team about including some video based work.
For many things in life, the timing of an event can be critical. When to text your date from Tuesday, but are trying to play hard to get with, now that is critical timing. But when it comes to seeking help for mental health concerns, timing tends to align more with the saying “better late than never”. For many of us, making that first appointment takes a lot of courage, and we still are not certain what we expect will come out of it. For those individuals, therapy is usually about planting the seeds for readiness for change. One might worry what the consequences of attending therapy will be, but generally, other than the financial cost of receiving private mental health support, getting support from a registered and qualified professional usually does not hold any notable risks. Therefore, the earlier you seek support the easier it is to learn ways to help prevent things from getting worse, support yourself better, cope better, or see yourself and your problems in a new light.
As long as you have a goal in mind and are open to making changes, therapy can be extremely helpful not just for those who have severe mental illness, but also those who desire to grow emotionally.
Positive psychology is a branch of psychology that focuses on the application of psychology for self improvement, rather than the resolution of illness. Therefore, its emphasis is on health promotion and focussing on what is going well rather than on pathology. As the stigma associated with therapy continues to shrink, seeking counselling/therapy services for the purpose of goal attainment and wellness rather than treatment of clinical psychopathology is growing. Seeking a regulated therapist is more like finding a “coach” who is trained to help guide you toward your goals.
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We are now at our final installment of our Exploring Therapy series at Wellness Wednesday, during which we are exploring different treatment modalities to assist readers in recognizing the variety of options available to them to support their needs and move forward towards wellness. We are also featuring the return of our first guest author, Michael Decaire, clinical psychologist, registered psychotherapist, and the founder of FLEX Psychology.
When people imagine what therapy looks like they probably picture a leather chaise lounge and a bearded man with a pocket watch. The chaise lounge or “therapists couch” image is a hold-over from the classic Freud-inspired psychoanalysis days of a half century ago, the majority of therapists I work with are women, which tends to impact the beard ratio at the office, and you are going to legitimately struggle to find a therapist who has been trained in hypnosis these days. I, however, love to be a contrarian and a stereotype at the same time, so I do have one of those couches, I definitely have a beard, and clinical hypnosis is part of my treatment toolkit. With the exception of the hypnosis, the rest of these therapy tropes are a bit of a facade. The chaise was purchased for wellness naps when my son was born, and the beard is mainly because I’m from the north and like to look like a lumberjack.
The use of hypnosis in treatment is also not all that consistent with the common stereotypes. The idea of using hypnosis to tackles life’s challenges is extremely attractive to some clients and terrifying to others. Those who are attracted to hypnosis often see it as a quick fix for longstanding problems, an idea that is commonly promoted by smoking cessation and weight loss programs (these people also suggest using lasers to treat these things, so I would be suspect of their claims). Those who are fearful of hypnosis worry about mind control and the idea that the hypnosis-informed therapist can make you do something against your will. Fortunately, both of these are extremely unrealistic perceptions of hypnosis and how it is used in treatment.
Hypnosis or hypnotherapy are treatment tools that can be integrated into a variety of other treatment methods. While it can be the main component of treatment, this is relatively rare and applies to only very narrow problems (e.g. a phobia) where a client, for whatever reason, is unable to engage in a more standard course of treatment. In most cases, hypnosis is used as a tool that augments or supports talk therapy. The aim of the approach is to assist an individual to enter a deep state of focus and relaxation that permits one to work on goals without being countered by their negative emotions or worries. Sometimes your internal thoughts can seem deafening. Hypnosis quiets the mind and allows you to do the meaningful work you have been struggling to get to. It allows any place and time to be the “right” place and time to resolve difficulties and move forward in a positive manner.
Aside from quieting the mind, hypnosis also uses “suggestions” that can be thought of as a signpost that directs you to a state or experience that you have decided you want to obtain. These “suggestions” are pre-determined between the client and their therapist, as attempts to suggest something an individual does not actually want will undoubtedly result in someone coming out of the focused hypnotic state.
The first time a client undergoes hypnosis they rarely report feeling that they are in a “trance” like you see in the movies. While a deeper state of focus and relaxation is possible and that state can look like a “trance”, getting to that level of focus generally requires multiple hypnosis sessions because the client needs to practice getting themselves to that state. The key here is that it requires the client’s efforts and work, as their therapist is really never controlling the situation or the deepness of the hypnotic state. That control always remains with the client. The hypnosis-informed therapist simply provides an opportunity to enter that state if the client chooses.
Hypnosis is not the right approach for every client or every problem. I generally incorporate hypnosis into treatment only a few times a year and always assess the benefit it may provide to my clients before I introduce the idea of using this approach to treatment. It is an approach with a efficacy in treating fears and phobias, the management of difficult but rare situations (e.g. anxiety around medical procedures or upcoming events), or providing momentary relief from high levels of stress.
If you think hypnosis might be the right tool for you, there is a good list of Ontario-based certified hypnotherapists available at the Canadian Society of Clinical Hypnosis.
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For the next few weeks Wellness Wednesday will explore different treatment modalities to assist readers in recognizing the variety of options available to them to support their needs and move forward towards wellness. We will also feature a few guest authors who specialize in different modalities, while #WellnessWednesday's Jessica enjoys a little vacation-based self-care. This weeks guest author is Dr. Jennifer Marcus, Clinical Psychologist and co-director of FLEX Psychology.
A couple weeks ago, we spoke about Cognitive Behavioural Therapy and how therapy can target thoughts and behaviours in order to make changes in our emotional experience. In Emotion Focused Therapy (EFT), the emotions themselves are used to change the experience of emotions. Though this sounds like a more “direct” route if you want to feel less anxious or more happy, in practice it can be a little harder to work directly with emotions.
The premise behind EFT is that our emotional experience can tell us what is important in our lives, direct us to meaningful experiences, and foster growth. However, our past experiences, such as our childhood, relationships, or traumatic events, can influence our ability to attend to and regulate our emotions. When we have had challenging experiences in the past, we can become caught up in emotional states that can cause us harm, such as when we feel guilt, shame, and depression. Often, we push out these primary emotions in favour of emotions that are easier to express, like anger. However, reacting with anger when we actually feel hurt or sadness does not help us to manage these emotions and move past them.
The goal of EFT is to clarify adaptive emotional experiences in a safe space so that we can move forward in a healthier way. This includes bringing attention to the mix of emotions that people experience and increasing connection to emotions on a regular basis. The meaning of different emotions can also be shifted as these are explored more deeply in therapy. Part of EFT also includes counteracting repeated invalidation of emotions that many people experience throughout their lives. To support this, the relationship or alliance that you build with your EFT therapist is very important. It should be a place where you feel comfortable to explore the most uncomfortable feelings associated with key events now and in the past.
Practically, EFT can feel very different from CBT or ACT. Whereas the approaches we have discussed so far have a lot of practical strategies, this is not necessarily the case with EFT. Though some concrete exercises are performed in therapy and individuals usually show an increase in awareness of their own emotions, very little homework is usually given. Instead, sessions can focus on uncovering and reworking emotions and relational patterns that have arisen throughout an individual’s life. Through this change process, they can then act differently in their day to day lives and not be stuck in the patterns that they have experienced in the past.
Though EFT can sometimes feel challenging when you are not used to attending to emotions and giving them space, it is a very helpful approach that can highlight the strengths and resilience that are present in us. By validating our own negative emotions, understanding where they are coming from, and building our ability to experience positive emotions as well we can move forward in our lives in a more genuine way.
For the next few weeks Wellness Wednesday will explore different treatment modalities to assist readers in recognizing the variety of options available to them to support their needs and move forward towards wellness. We will also feature a few guest authors who specialize in different modalities, while #WellnessWednesday's Jessica enjoys a little vacation-based self-care. This weeks guest author is Michael Decaire, clinical psychologist, registered psychotherapist, and the founder of FLEX Psychology.
Acceptance and Commitment Therapy (ACT) is a more recently developed approach to therapy that integrates and expands on the key elements of many popular treatments that preceded it (e.g. Cognitive Behavioural Therapy [CBT]; Mindfulness Therapies). ACT starts by having the individual identify their values and goals, which will ultimately act as a guidepost to where they hope to end up at the end of the day. Once a direction is chosen, an ACT therapist will help you identify thoughts that emerge and tend to push you down a path that moves you away from your identified values and goals. These thoughts might be distortions similar to those that are identified in CBT, or they just may simply be unhelpful.
While breaking down and reconsidering distorted and unhelpful thoughts can be fruitful, ACT is more of an action oriented treatment. It is anchored on the idea that we can choose a path that moves us towards our values and goals in the face of unhelpful thoughts. More often than not, in the moment, we act in a manner that may respond to or resolve an uncomfortable thought, but that act ultimately moves us away from our goals. For instance, while writing this post I found myself struggling to find the words I was looking for. This was mildly frustrating. I have the option to choose to put off writing this post and go read something on my phone. This would resolve my momentary frustrations, but it would also move me away from my goals of submitting this on time and supporting Jessica while she is on her wellness vacation. Alternatively, I could choose to read over what I have already read and see if that triggers the words I was looking for to finish my thought. Since my goal was to support Jessica (and not to avoid frustration) it makes it fairly easy to decide what choice to make.
ACT therapists will often integrate mindfulness meditation into treatment. Mindfulness approaches focus on increasing one’s moment-to-moment awareness. In ACT, this assists in noticing unhelpful thoughts when they emerge and that facilitates an increased ability to make an informed choice in how you want to respond to those thoughts. Sometimes you will still miss a thought and my notice once you are already down the wrong path. Returning to my original example, consider a scenario where I began with the intention of writing this post and suddenly found myself on my phone reading the news. This means I may have missed a thought that pulled me off my initial goal, but, most importantly, I am noticing now that I am heading in the wrong direction. That awareness allows another path to emerge to my initial goal, causing me to put down my phone and reengaging with my writing.
Often ACT-informed therapists will integrate these principals into their work, but may also include other approaches that fit your needs. So do not be surprised if you see some of these concepts emerge in the course of another treatment. In essence, this was the therapist’s choice to create an alternative path to meeting your agreed upon goals. At the end of the day, it’s all about noticing and then choosing wisely.
Image used under Creative Common license. CLICK HERE for the source.
For the next few weeks Wellness Wednesday will explore different treatment modalities to assist readers in recognizing the variety of options available to them to support their needs and move forward towards wellness. We will also feature a few guest authors who specialize in different modalities, while #WellnessWednesday's Jessica enjoys a little vacation-based self-care.
CBT stands for Cognitive Behavioural Therapy and relies on the premise that our thoughts, behaviours, and emotions are interconnected. Because of this interconnection, CBT upholds that a change in one domain will lead to a change in the other domain. Therefore, if anxiety (an emotion) is the target of desired change, a CBT clinician will help you learn to change your thoughts and your behaviours to best lead to changes in your experience of anxiety.
When it comes to changing thought processes, CBT aims to help individuals learn to identify unhelpful negative thoughts that emerge almost “automatically”. Upon identifying these thoughts, your therapist assists you in learning how to challenge those thoughts, identify cognitive errors that have emerged (i.e. when your brain is lying to you), and choose adaptive alternative thoughts to replace the negative thoughts with.
Within the behavioural domain, CBT aims to help you identify behaviours that maintain a depressive or anxious cycle while identifying behaviours that might help an individual to reverse that cycle.
CBT is structured, goal oriented, and therapist driven. If you are looking for a type of therapy that is action focussed and assigns weekly homework to help integrate teachings into your daily life then it might be a great fit for you. Be mindful that many therapists occupy a more eclectic approach to treatment, piecing together two or more types of therapy in a way that often augments CBT with other tools personalized to your needs. CBT is very present oriented, but occasional discussion of your past may be relevant to understanding the present.
Everyone reacts differently when sharing their struggles and vulnerabilities. It may momentarily feel overwhelming to share intimate information and this can feel emotionally draining. At the same time, crying can act as a release and may lift some of the emotional weight from your shoulders. Crying can be similar to yawning. Stifling that yawn can extend your fatigue and lead to distraction. Letting it go has actually been shown to perk you up and allow you to focus a little bit longer.
It is not unusual to cry in a treatment session and it does not matter how far along into treatment you are. If you don’t cry that is also completely normal. Your therapist will not judge you either way. Crying will not lead your therapist to feel uncomfortable, that is why they keep tissues in their office. It also does not mean that you are achieving more or less in a session if you do not experience the physical release of tears. Everyone is different and one’s stories and experience of reflection impacts us all differently.
I have had many clients come into my office and cry in the first session, and others never at all. Tears are not a measure of progress or success, nor are they an emotional milestone in therapy. Still, they should not be held in out of fear of making your therapist uncomfortable. What tears do tell us is that something is connecting with us on a deeper level and letting us know that we are hitting something meaningful. Connecting to our experiences in an emotional level can often be a helpful way of processing events in our lives, but tears are not the only way to connect emotionally. It’s about how you connect with your emotional experience and there is no correct or incorrect way to do that.
Last week we explored how one might find a therapist when they felt they could use a helping hand on their wellness journey. On today’s Wellness Wednesday, we will take a look at the next step and prepare for your first session.
It’s completely normal to feel unsure and nervous about the first therapy appointment. You may feel unsure of how much you should prepare, what to share, and how to appropriately respond to questions. A little insight into the process can really help alleviate some of these worries, so here’s the lay of the land.
No matter what style/orientation your therapist occupies, the first session is really a “get to know you” session. Your therapist will take the lead in the first session and start with reviewing all appropriate confidentiality and policy forms. Following the completion of these forms you will be asked about the reason /main issue that brought you to therapy, your goals, important supports/relationships in your life (e.g. friends or family) and your history with your current concerns and the specific symptoms you are experiencing as a result.
You will also likely be asked about your previous experience with therapy or other health care providers and if you have ever had thoughts or actions of self harm or suicide. It’s important to be honest on that last question. While you will have just been told about how your confidentiality will be protected unless there is a risk to yourself or others, this relates to future risk and is designed to support you moving forward. The only real exception to this is when a child or elderly individual has been harmed, as therapists have an overriding requirement to act in the interest of vulnerable populations.
There is no perfect amount of detail that you need to provide, but essentially it is a time for your therapist to gather information so that they can get a sense of who you are, start to fit together the pieces in the puzzle and collaboratively create a plan and direction that works for you. You can discuss as in depth as you would like, but try to avoid sticking to one word answers to avoid your therapist forming an inaccurate impression of your needs.
If you have ever had a psychoeducational or mental health assessment conducted you should bring it in, even if it is several years old or does not accurately portray your current needs. These assessments may help your clinician to collect more information that will best assist them in understanding your strengths, weaknesses or, at the very least, better understand your journey.
Just remember, its ok to feel nervous.
While one of my goals in creating Wellness Wednesday was to assist people in their self-help wellness journey, there are certainly times when a bit of guidance can help you get over bigger hurdles or provide a fresh set of experienced eyes towards your situation. Deciding to speak to a mental health professional can seem daunting, with many people struggling to know where to begin and how to find a therapist that fits their needs.
It is completely normal to want to shop around to find the right “therapist” for you. Finding the right fit is often like finding the right pair of jeans, sometimes you have to try on a few, but once you find a pair that fits right you don’t stray from that brand. Finding the right therapist can be a delicate balance between giving yourself and a therapist sufficient time to get to know each other, while also following your gut to find therapeutic relationship that feels comfortable.
It’s important to understand that the first few sessions are about developing a relationship and forming an understanding of your needs and how the therapist can assist you in reaching your goals. You cannot expect big changes to happen in these first few sessions, but you usually will be able to tell whether the therapist is the right fit for you. Be mindful that feeling nervous and awkward during the first couple sessions is completely normal. The first session itself is usually just an opportunity for the therapist to take a history of your concerns, symptoms, background and goals/areas of focus. While they may propose a way forward after that first session, even that may be deferred for session two so the therapist can truly consider all that you have brought to them.
One thing you might want to be aware of is the difference between different types of mental health care providers:
Social Workers and Psychotherapists: In Ontario, Social Workers and Psychotherapists are both approved to provide psychotherapy for a variety of complex social, behavioural, and emotional concerns. They will assess your emotional status and needs, but do not provide a formal diagnostic label (e.g. you may hear that you are reporting many symptoms of depression, but they will not label you as having a depressive disorder). In Ontario, many private extended health plans cover services by Social Workers and Psychotherapists.
Psychologists: Like their social work and psychotherapy counterparts, Ontario Psychologists (sometimes referred to as Psychological Associates) generally support a wide range of social, behavioural, and emotional concerns. In addition to their provincial approval for psychotherapy, most Psychologists are also approved to provide diagnostic services. The additional qualifications of Psychologists can provide value for complex cases where a more succinct diagnosis is warranted or when a diagnosis is required for accessing other services (e.g. academic or work accommodation; disability supports). In Ontario, nearly all private insurance plans provide some coverage for psychological services. Psychologists are not covered by OHIP.
Psychiatrists: Psychiatrists are medical doctors that completed their medical residency in the specialization of psychiatry. Like psychologists, psychiatrists can provide therapy and diagnosis, though few tend to offer regular therapeutic services. Instead, the majority of psychiatrists manage the medical side of mental health support through medication or other alternative treatments. Psychiatrists are covered by OHIP, but their wait lists and a low OHIP reimbursement rate for therapy often lead them to focus on medication management rather than the provision of psychotherapy.
It is also important to be aware of unregulated providers. People who do not list credentials after their names, or write “therapist” “counsellor” or “coach” are individuals who are not verified and policed by a regulator. This does not necessarily mean they are an unsafe choice, but it does require increased diligence on your part. New Ontario laws also prohibit unregulated professionals from providing therapy for complex or serious conditions.
How to find a therapist
Starting with asking your family doctor for a referral or looking at referral websites like Psychology Today are great places to search and compare therapists of different qualifications and refine by region. It is also acceptable to call up different clinics/professionals and ask a few questions about their population of focus, main concerns that they specialize in, their fees, and their therapeutic orientation/approach. FLEX Psychology, the clinic where I work, provides a good overview of different therapy styles. While one approach may catch your eye, it is important to seek the advice of your treatment provider for what approach will likely be more efficacious for you or how different approaches can be adapted and integrated to meet your needs.
While it certainly can seem daunting to find a mental health professional that is within your area, your budget and a good fit for you, it generally only requires a little research and taking a chance by booking that first session. Hopefully these tips help make this search a little bit less overwhelming.
Jessica is a member of the clinical wellness and learning support team at FLEX Psychology. Jessica started Wellness Wednesday out of a desire to provide further opportunities for her clients to extend their wellness journey to all avenues of their life. You can learn more about Jessica by clicking here or by learning more about her and the clinical team at FLEX Psychology by clicking here.