Author: Psychotherapy.net Team

Ethics of Treating Two Psychotherapy Clients who Know Each Other

Posted on by Psychotherapy.net Team

A question was recently posed to us about what to do when you discover in an early session with a new client that they are the former partner of another well-established client. Well, for those of you who actually stopped to think, “Oh, this may be a problem,” then you are certainly one step further away from sliding down the slippery slope of unethical behavior than those who did not recognize that this situation may pose a potential ethical dilemma. Professional codes of ethics (e.g. APA 3.06, NASW 1.06) ask us to be mindful of conflicts of interest that arise and to take steps to resolve them. The best resolution is to refer the new client to another therapist (if possible).

For those of you who can refer this new client to another therapist, then the question arises as to how to do so in an ethical manner. First, remember that you cannot ask permission to disclose your relationship with the other client because this will breach patient confidentiality. You can, however, simply express that in reviewing this new client’s case you believe he/she would be better served by a different therapist who is more closely matched or specialized with his/her needs. Remember, you are not mandated to treat every client who seeks treatment from you. Second, provide the names of two or three therapists who currently have openings for new clients in their practice. It is important that these referral therapists have the capability to accept new clients at the time so that continuity of treatment is maintained and the client’s (potential) feelings of abandonment are diminished. Third, if you terminate in a responsible clinical manner then you will likely be terminating in a responsible ethical manner. Thus, if you terminate in accord with the standard of care for your theoretical orientation, using good clinical skills to transition the new client and allowing them to feel heard about your decision, then you again decrease the probability of the client feeling abandoned which often leads to board complaints. Last, provide a written termination letter confirming the termination of treatment and the referral therapists contact information. Keep a letter in your file as part of the clinical record.

Earlier I mentioned that this situation “may” pose a dilemma because if you practice in a small or rural town then you may encounter this situation frequently since you are one of the few practitioners available. In those situations, if you cannot refer out then it is best to have a clear plan as to how you will keep from falling down that slippery slope of potentially unprofessional conduct. For example, how will you handle information you learn from your well established client from seeping into your sessions with your new client, and vice versa? How will you identify and handle information learned from one client inadvertently influencing how you think about the other client? Consultation, and of course subsequent documentation of decisions and rationale, is a good way to keep your own personal biases and such influences in check.

As a general rule of thumb remember that our professional codes of ethics require us to be mindful of conflicts of interest that arise and to take steps to resolve them. While the best resolution (especially in this scenario) is to refer the new client to another therapist, if this course of action is not possible, and refusing service to a client is clearly detrimental to the client’s welfare, then chart and note the steps taken to minimize potential conflicts and difficulties that arise in the course of treatment. Such documentation is part of good (and mandated) record keeping procedures but also demonstrates your contemporaneous judgment, which is always your best proactive defense.
 

First Impressions in Psychotherapy

Posted on by Psychotherapy.net Team

A woman wrote to me, having heard me on a radio programme. She had picked up my concern that not enough attention was being paid to the quality of the therapeutic relationship (as opposed to techniques) and wondered how her 25 year-old son, who was seeking a psychotherapist, could assess that in advance of therapy when neither of them knew any therapists where they lived. The obvious answer is that he should wait until he and the therapist meet. Therapy is after all a personal relationship and only by knowing the person could there be a real alliance. If on meeting the therapist for the first time, he felt uneasy or badgered or misunderstood or puzzled or demotivated, then perhaps the therapist was not the right person and he should find someone else. But is that right?

First impressions are important. Think of meeting someone for the first time and how even after the end of a brief exchange, you have already formed an opinion of them. I met a neighbour at a party my wife and I gave, someone I was prepared to like having already met his charming wife. To my surprise, I disliked him. What was it about him that provoked this strong reaction? Thinking back, I realised it was that he had shown not the slightest interest in me and my attempts to engage him in conversation had been met with distracted inattention. I even resented the fact that, when I moved past him to get someone a glass of wine, he made no effort move aside! (This says as much about me as him, I realise). A prospective client could do something like this, evaluating the therapist by how he or she responded and how the client felt in the session.

But therapy is not the same as a conversation. Most therapists are good at putting clients at ease, asking questions sensitively, listening attentively and making the client feel safe and understood. For most clients the experience of the initial session is likely to be positive, allaying anxiety, reinforcing the hopeful expectation that at last help is at hand. Unless the therapist is distracted or disturbed, the first session will generally pass well. That does not mean the therapy will always be bathed in this arm glow of positivity and, if it were, we might wonder whether the therapy was really that helpful. As Patrick Casement points out in his autobiographical memoir, Learning from Life, good therapists must learn they should not always be nice to their clients.

In the first session unconscious processes in both therapist and client will be at play. I recall reading about a client who knew from the therapist’s name alone that he would be the right one for her. Once I heard a client’s hesitant and garbled message on my answering machine and that made me reverse my just made policy of not taking on any new clients. And on another occasion, opening the door to a new client I took fervently against her and, to my shame, manoeuvred the session so that I could refuse her help. For all these factors, conscious and unconscious, the first session may not be the best place to judge the therapeutic relationship, although of course a judgment will inevitably be made. The truth is that the success of the relationship can be judged only in the experience of it.

Perhaps I should be a bit more psychological in my response to this woman’s question. Why was she contacting me, not her son? Was she just an over-protective mum, simply anxious that her son should find the ‘right’ therapist? Or was she anxious that he would find such a therapist who would replace her? Was she seeking help for herself? I don’t know and, no longer being in practice, means I will never know. My first impressions therapeutically occur now only in the virtual world and that is altogether different.
 

The Spinoza Problem: An Excerpt

Posted on by Psychotherapy.net Team

Prologue

Spinoza has long intrigued me, and for years I’ve wanted to write about this valiant seventeenth-century thinker, so alone in the world—without a family, without a community—who authored books that truly changed the world. He anticipated secularization, the liberal democratic political state, and the rise of natural science, and he paved the way for the Enlightenment. The fact that he was excommunicated by the Jews at the age of twenty-four and censored for the rest of his life by the Christians had always fascinated me, perhaps because of my own iconoclastic proclivities. And this strange sense of kinship with Spinoza was strengthened by the knowledge that Einstein, one of my first heroes, was a Spinozist. When Einstein spoke of God, he spoke of Spinoza’s God—a God entirely equivalent to nature, a God that includes all substance, and a God “that doesn’t play dice with the universe”—by which he means that everything that happens, without exception, follows the orderly laws of nature.

I also believe that Spinoza, like Nietzsche and Schopenhauer, on whose lives and philosophy I have based two earlier novels, wrote much that is highly relevant to my field of psychiatry and psychotherapy—for example, that ideas, thoughts, and feelings are caused by previous experiences, that passions may be studied dispassionately, that understanding leads to transcendence—and I wished to celebrate his contributions through a novel of ideas.

But how to write about a man who lived such a contemplative life marked by so few striking external events? He was extraordinarily private, and he kept his own person invisible in his writing. I had none of the material that ordinarily lends itself to narrative—no family dramas, no love affairs, jealousies, curious anecdotes, feuds, spats, or reunions. He had a large correspondence, but after his death his colleagues followed his instructions and removed almost all personal comments from his letters. No, not much external drama in his life: most scholars regard Spinoza as a placid and gentle soul—some compare his life to that of Christian saints, some even to Jesus.

So I resolved to write a novel about his inner life. That was where my personal expertise might help in telling Spinoza’s story. After all, he was a human being and therefore must have struggled with the same basic human conflicts that troubled me and the many patients I’ve worked with over the decades. He must have had a strong emotional response to being excommunicated, at the age of twenty-four, by the Jewish community in Amsterdam—an irreversible edict that ordered every Jew, including his own family, to shun him forever. No Jew would ever again speak to him, have commerce with him, read his words, or come within fifteen feet of his physical presence. And of course no one lives without an inner life of fantasies, dreams, passions, and a yearning for love. About a fourth of Spinoza’s major work, Ethics, is devoted to “overcoming the bondage of the passions.” As a psychiatrist, I felt convinced that he could not have written this section unless he had experienced a conscious struggle with his own passions.

Yet I was stumped for years because I could not find the story that a novel requires—until a visit to Holland five years ago changed everything. I had come to lecture and, as part of my compensation, requested and was granted a “Spinoza day.” The secretary of the Dutch Spinoza Association and a leading Spinoza philosopher agreed to spend a day with me visiting all the important Spinoza sites—his dwellings, his burial place, and, the main attraction, the Spinoza Museum in Rijnsburg. It was there I had an epiphany.

I entered the Spinoza Museum in Rijnsburg, about a forty-five-minute drive from Amsterdam, with keen anticipation, looking for—what? Perhaps an encounter with the spirit of Spinoza. Perhaps a story. But entering the museum, I was immediately disappointed. I doubted that this small, sparse museum could bring me closer to Spinoza. The only remotely personal items were the 151 volumes of Spinoza’s own library, and I turned immediately to them. My hosts permitted me free access, and I picked up one seventeenth-century book after another, smelling and holding them, thrilled to touch objects that had once been touched by Spinoza’s hands.

But my reverie was soon interrupted by my host: “Of course, Dr. Yalom, his possessions—bed, clothes, shoes, pens and books—were auctioned off after his death to pay funeral expenses. The books were sold and scattered far and wide, but fortunately, the notary made a complete list of those books prior to the auction, and over two hundred years later a Jewish philanthropist reassembled most of the same titles, the same editions from the same years and cities of publication. So we call it Spinoza’s library, but it’s really a replica. His fingers never touched these books.”

I turned away from the library and gazed at the portrait of Spinoza hanging on the wall and soon felt myself melting into those huge, sad, oval, heavy-lidded eyes, almost a mystical experience—a rare thing for me. But then my host said, “You may not know this, but that’s not really Spinoza’s likeness. It’s merely an image from some artist’s imagination, derived from a few lines of written description. If there were drawings of Spinoza made during his lifetime, none have survived.”

Maybe a story about sheer elusiveness, I wondered.

While I was examining the lens-grinding apparatus in the second room—also not his own equipment, the museum placard stated, but equipment similar to it—I heard one of my hosts in the library room mention the Nazis.

I stepped back into the library. “What? The Nazis were here? In this museum?”

“Yes—several months after the blitzkrieg of Holland, the ERR troops drove up in their big limousines and stole everything—the books, a bust, and a portrait of Spinoza—everything. They carted it all away, then sealed and expropriated the
museum.”

“ERR? What do the letters stand for?”

“Einsatzstab Reichsleiter Rosenberg. The taskforce of Reich leader Rosenberg—that’s Alfred Rosenberg, the major Nazi anti-Semitic ideologue. He was in charge of looting for the Third Reich, and under Rosenberg’s orders, the ERR plundered all of Europe—first, just the Jewish things and then, later in the war, anything of value.”

“So then these books are twice removed from Spinoza?” I asked. “You mean that books had to be purchased again and the library reassembled a second time?”

“No—miraculously these books survived and were returned here after the war with just a few missing copies.”

“Amazing!” There’s a story here, I thought. “But why did Rosenberg even bother with these books in the first place? I know they have some modest value—being seventeenth-century and older—but why didn’t they just march into the Amsterdam Rijksmuseum and pluck a single Rembrandt worth fifty times this whole collection?”

“No, that’s not the point. The money had nothing to do with it. The ERR had some mysterious interest in Spinoza. In his official report, Rosenberg’s officer, the Nazi who did the hands-on looting of the library, added a significant sentence: ‘They contain valuable early works of great importance for the exploration of the Spinoza problem.’ You can see the report on the web, if you like—it’s in the official Nuremberg documents.”

I felt stunned. “‘Exploration of the Nazis’ Spinoza problem’? I don’t understand. What did he mean? What was the Nazi Spinoza problem?”

Like a mime duo, my hosts hunched their shoulders and turned up their palms.

I pressed on. “You’re saying that because of this Spinoza problem, they protected these books rather than burn them, as they burned so much of Europe?”

They nodded.

“And where was the library kept during the war?”

“No one knows. The books just vanished for five years and turned up again in 1946 in a German salt mine.”

“A salt mine? Amazing!” I picked up one of the books—a sixteenth-century copy of the Iliad—and said, as I caressed it, “So this old storybook has its own story to tell.”

My hosts took me to look at the rest of the house. I had come at a fortunate time—few visitors had ever seen the other half of the building, for it had been occupied for centuries by a working-class family. But the last family member had recently died, and the Spinoza Society had promptly purchased the property and was just now beginning reconstruction to incorporate it into the museum. I wandered amid the construction debris through the modest kitchen and living room and then climbed the narrow, steep stairway to the small, unremarkable bedroom. I scanned the simple room quickly and began to descend, when my eye caught sight of a thin, two-by-two-foot crease in a corner of the ceiling.

“What’s that?”

The old caretaker climbed up a few stairs to look and told me it was a trap door that led to a tiny attic space where two Jews, an elderly mother and her daughter, were hidden from the Nazis for the entire duration of the war. “We fed them and took good care of them.”

A firestorm outside! Four out of five Dutch Jews murdered by the Nazis! Yet upstairs in the Spinoza house, hidden in the attic, two Jewish women were tenderly cared for throughout the war. And downstairs, the tiny Spinoza Museum was looted, sealed, and expropriated by an officer of the Rosenberg task force, who believed that its library could help the Nazis solve their “Spinoza problem.” And what was their Spinoza problem? I wondered if this Nazi, Alfred Rosenberg, had also, in his own way, for his own reasons, been looking for Spinoza. I had entered the museum with one mystery and now left it with two.

Shortly thereafter, I began writing.

Chapter One

AMSTERDAM—APRIL 1656
As the final rays of light glance off the water of the Zwanenburgwal, Amsterdam closes down. The dyers gather up their magenta and crimson fabrics drying on the stone banks of the canal. Merchants roll up their awnings and shutter their outdoor market stalls. A few workers plodding home stop for a snack with Dutch gin at the herring stands on the canal and then continue on their way. Amsterdam moves slowly: the city mourns, still recovering from the plague that, only a few months earlier, killed one person in nine.

A few meters from the canal, at Breestraat No. 4, the bankrupt and slightly tipsy Rembrandt van Rijn applies a last brushstroke to his painting Jacob Blessing the Sons of Joseph, signs his name in the lower right corner, tosses his palette to the floor, and turns to descend his narrow winding staircase. The house, destined three centuries later to become his museum and memorial, is on this day witness to his shame. It swarms with bidders anticipating the auction of all of the artist’s possessions. Gruffly pushing aside the gawkers on the staircase, he steps outside the front door, inhales the salty air, and stumbles toward the corner tavern.

In Delft, seventy kilometers south, another artist begins his ascent. The twenty-five-year-old Johannes Vermeer takes a final look at his new painting, The Procuress. He scans from right to left. First, the prostitute in a gloriously yellow jacket. Good. Good. The yellow gleams like polished sunlight. And the group of men surrounding her. Excellent—each could easily stroll off the canvas and begin a conversation. He bends closer to catch the tiny but piercing gaze of the leering young man with the foppish hat. Vermeer nods to his miniature self. Greatly pleased, he signs his name with a flourish in the lower right corner.

Back in Amsterdam at Breestraat No. 57, only two blocks from the auction preparations at Rembrandt’s home, a twenty-three-year-old merchant (born only a few days earlier than Vermeer, whom he would admire but never meet) prepares to close his import-export shop. He appears too delicate and beautiful to be a shopkeeper. His features are perfect, his olive skin unblemished, his dark eyes large, and soulful.

He takes a last look around: many shelves are as empty as his pockets. Pirates intercepted his last shipment from Bahia, and there is no coffee, sugar, or cocoa. For a generation, the Spinoza family operated a prosperous import-export wholesale business, but now the brothers Spinoza—Gabriel and Bento—are reduced to running a small retail shop. Inhaling the dusty air, Bento Spinoza identifies, with resignation, the fetid rat droppings accompanying the odor of dried figs, raisins, candied ginger, almonds, and chickpeas and the fumes of acrid Spanish wine. He walks outside and commences his daily duel with the rusted padlock on the shop door. An unfamiliar voice speaking in stilted Portuguese startles him.

“Are you Bento Spinoza?”

Spinoza turns to face two strangers, young weary men who seem to have traveled far. One is tall, with a massive, burly head that hangs forward as though it were too heavy to be held erect. His clothes are of good quality but soiled and wrinkled. The other, dressed in tattered peasant’s clothes, stands behind his companion. He has long, matted hair, dark eyes, a strong chin and forceful nose. He holds himself stiffly. Only his eyes move, darting like frightened tadpoles.

Spinoza offers a wary nod.

“I am Jacob Mendoza,” says the taller of the two. “We must see you. We must talk to you. This is my cousin, Franco Benitez, whom I’ve just brought from Portugal. My cousin,” Jacob clasps Franco’s shoulder, “is in crisis.”

“Yes,” Spinoza answers. “And?”

“In severe crisis.”

“Yes. And why seek me?”

“We’ve been told that you’re the one to render help. Perhaps the only one.”

“Help?”

“Franco has lost his faith. He doubts everything. All religious ritual. Prayer. Even the presence of God. He is frightened all the time. He doesn’t sleep. He talks of killing himself.”

“And who has misled you by sending you here? I am only a merchant who operates a small business. And not very profitably, as you see.” Spinoza points at the dusty window through which the half-empty shelves are visible. “Rabbi Mortera is our spiritual leader. You must go to him.”

“We arrived yesterday, and this morning we set out to do exactly that. But our landlord, a distant cousin, advised against it. ‘Franco needs a helper, not a judge,’ he said. He told us that Rabbi Mortera is severe with doubters, that he believes all Jews in Portugal who converted to Christianity face eternal damnation, even if they were forced to choose between conversion and death. ‘Rabbi Mortera,’ he said, ‘will only make Franco feel worse. Go see Bento Spinoza. He is wise in such matters.’”

“What talk is this? I am but a merchant—”

“He claims that if you had not been forced into business because of the death of your older brother and your father, you would have been the next great rabbi of Amsterdam.”

“I must go. I have a meeting I must attend.”

“You’re going to the Sabbath service at the synagogue? Yes? We too. I am taking Franco, for he must return to his faith. Can we walk with you?”

“No, I go to another kind of meeting.”

“What other kind?” says Jacob, but then immediately reverses himself. “Sorry. It’s not my affair. Can we meet tomorrow? Would you be willing to help us on the Sabbath? It is permitted, since it is a mitzvah. We need you. My cousin is in danger.”

“Strange.” Spinoza shakes his head. “Never have I heard such a request. I’m sorry, but you are mistaken. I can offer nothing.”

Franco, who had been staring at the ground as Jacob spoke, now lifts his eyes and utters his first words: “I ask for little, for only a few words with you. Do you refuse a fellow Jew? It is your duty to a traveler. I had to flee Portugal just as your father and your family had to flee, to escape the Inquisition.”

“But what can I—”

“My father was burned at the stake just a year ago. His crime? They found pages of the Torah buried in the soil behind our home. My father’s brother, Jacob’s father, was murdered soon after. I have a question. Consider this world where a son smells the odor of his father’s burning flesh. Where is the God that created this kind of world? Why does He permit such things? Do you blame me for asking that?” Franco looks deeply into Spinoza’s eyes for several moments and then continues. “Surely a man named ‘blessed’—Bento in Portuguese and Baruch in Hebrew—will not refuse to speak to me?”

Spinoza nods solemnly. “I will speak to you, Franco. Tomorrow midday?”

“At the synagogue?” Franco asks.

“No, here. Meet me here at the shop. It will be open.”

“The shop? Open?” Jacob interjects. “But the Sabbath?”

“My younger brother, Gabriel, represents the Spinoza family at the synagogue.”

“But the holy Torah,” Jacob insists, ignoring Franco’s tugging at his sleeve, “states God’s wish that we not work on the Sabbath, that we must spend that holy day offering prayers to Him and performing mitzvahs.”

Spinoza turns and speaks gently, as a teacher to a young student, “Tell me, Jacob, do you believe that God is all powerful?”

Jacob nods.

“That God is perfect? Complete unto Himself.”

Again Jacob agrees.

“Then surely you would agree that, by definition, a perfect and complete being has no needs, no insufficiencies, no wants, no wishes. Is that not so?”

Jacob thinks, hesitates, and then nods warily. Spinoza notes the beginnings of a smile on Franco’s lips.

“Then,” Spinoza continues, “I submit that God has no wishes about how, or even if, we glorify Him. Allow me, then, Jacob, to love God in my own fashion.”

Franco’s eyes widen. He turns toward Jacob as though to say, “You see, you see? This is the man I seek.”

Two Therapy Poems

Posted on by Psychotherapy.net Team

“On the Way Out”

Whether it is a the end of a session or at the end of our work
Information is sometimes disclosed that leaves me wondering
“Seriously, you are telling me this now?”
Other questions follow, “How should I respond to this … the disclosure and your timing?”
Extend the session beyond the therapy hour to make sure it is okay to end?
Or say, “It sounds like something that would be helpful to address in future therapy or sessions?”
A decision has to be made in seconds while maintaining an appropriate facial expression
(What is an appropriate facial expression at this time, anyway?)
Sigh
Hopefully, I will make the best therapeutic decision or one that will pass “the pillow test”
But there are times when I want to ask, “Please, stop dropping these bombs on your way out.”

“Therapy Soundtrack”

My stomach gurgles
I respond by tightening my stomach muscles while wondering, “Did ­__ hear that?”
Previous experience has taught me that stomach gurgles are not like the Lone Ranger, travelling with only one companion
They are more like rabbits, born in a litter
So, as a safeguard, I cross one hand across my stomach
Hoping that, although it has not worked before, this time the gesture will soothe the sounds to a whimper
I draw some comfort from the fact that at least I am not hiccupping or having a sneezing fit
One that triggers a concerned, “Are you okay?” from my client
Biological processes creating an unwanted therapy soundtrack
Perhaps they come in sessions to remind both my client and I that I am a normal human, not one endowed with super powers

Videotaping Therapy

Posted on by Psychotherapy.net Team

Therapists have been using videotape to enhance psychotherapy training and supervision for decades. Recent technological advances have allowed for a range of creative new affordable ways to record “picture-in-picture”, so the video shows both the client and therapist. These setups do not require any video editing. Below is a list of instructions for picture-in-picture video setups, with links for more information. If you know of another recording setup, please email me, and I’ll add you to the list.  

(Updates to this list are available here:  http://istdpinstitute.com/resources/)

1. I use Wirecast software to combine two digital webcams, connected to my computer, into one picture-in-picture therapy video. Psychotherapy videos are stored on the computer and can be burned onto DVDs. No editing is required.

2. Nat Kuhn developed a system to video therapy sessions that uses two digital cameras, two DVD recorders and a Picture-in-picture (PIP) video mixer. Therapy videos are stored on DVDs and no computer editing is required. He provides very detailed equipment and setup instructions here: http://natkuhn.com/equipment/equipment.pdf.

3. Arno Goudsmit in the Netherlands has developed a psychotherapy recording tool for a 2-camera and computer setup (also adaptable for 1 camera), which gives a picture-in-picture effect on an mpg-file. He uses memory sticks which the patient can take home; and they keep a copy of the psychotherapy video for study purposes. (You could also burn the therapy video onto a DVD.) You can find his software at: http://www.edtmaastricht.nl/2cameras. His software is free and no video editing afterwards required.

4. Rick Savage is a producer in New York City who has experience helping setup therapy videotaping systems using Apple computers and digital cameras. He can be reached at 917-364-1866 and
www.savagetunes.com.

Also:  Jon Frederickson and I have been experimenting with the use of Skype for one-way-mirror supervision. Jon provided live, one-way-mirror supervision for me from Washington, DC, while I was working with clients in San Francisco. We have had very positive clinical and training outcomes with this new technology. If you would like setup instructions, email me.

Clinicians and supervisors may also find the following articles of interest:

1. Allan Abbass, a psychiatrist in Halifax, published “Small-Group Videotape Training for Psychotherapy Skills Development”, as well as “Web-Conference Supervision for Advanced Psychotherapy Training: A Practical Guide”

2. Peter Costello, a media ecologist and clinical psychologist at Adelphi University, wrote “The Influence of Videotaping on Theory and Technique in Psychotherapy: A Chapter in the Epistemology of Media”
 

Is Self-Regulation or Co-Regulation Better for Couples?

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Should couples in distress attempt to change their partner or themselves? Recent research discusses concerns about both of these strategies, and raises an interesting third option. Shreena Hira and Nickola Overall examined 160 couples attempting to change their partner or themselves. As they expected, attempts to change their partner didn’t make either their partner or themselves feel better. Surprisingly, however, a focus on self-change did not consistently help the relationship either. Instead, the researchers discovered that the most beneficial change occurred when one or both partners in the relationship perceived the other as changing themselves (self-regulating.)

This poses an interesting challenge for couples therapists, as partners don’t always perceive the change (or effort) made by their partners, and rarely does either partner want to “go first”.  One idea to address this dilemma, proposed by Victor Yalom, is for the therapist to help clients  tune into the changes and effort made by their partner, even if the change or effort is very small.  This can help build trust, morale and set the stage for greater changes later.  Likewise, therapists could use recognition of small-item effort or change as an assessment tool for determining when the couple is ready to work on more challenging change goals.

There is currently a hot debate in the field between therapists who promote self-regulation (differentiation) and therapists who promote co-regulation (attachment). This research suggests that couples may in fact improve co-regulation capacity by witnessing self-regulation efforts by their partner. 

From: Shreena N. Hira & Nickola C. Overall. (2010). Improving intimate relationships: Targeting the partner versus changing the self. Journal of Social and Personal Relationships 28, 610-633.

Techniques, Therapeutic Relationship and the Importance of the Body

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Throughout my career as a psychotherapist I struggled to find the right balance between using specific techniques and the importance of establishing a safe therapeutic relationship. Toward the end I veered more to the latter as I realised, rather belatedly I admit, that people sought therapy not necessarily to get better but often just to be heard. A safe haven and a sensitive, empathic and caring individual can be enough; specific techniques can get in the way. Of course this is hard to square with the demand for evidence-based psychotherapy where therapy is defined as applying identifiable techniques and improvement seen in terms of symptom reduction. This quasi-medical model is rightly seen as simplistic, ignoring both individual meaning and the influence of socio-economic factors on mental health. Nevertheless, it has certain virtues. It enables those who know very little about psychotherapy to grasp what is supposed to be happening, something that both clients and commissioners of psychotherapy legitimately wish to know. Seeing a CBT therapist, for example, means that the approach is likely be collaborative, problem-focussed and address the client’s thoughts, feelings and behaviour in an open, adult and rational way. Seeing a psychodynamic therapist, on the other hand, means the therapist is likely to be passive, say relatively little, attend to underlying meanings and dynamics and use the therapeutic relationship as the main vehicle of gaining understanding from which change may or may not happen. Neither of these descriptions captures the subtlety and complexity of psychotherapy, nor the uncertainty that is part of all therapies. But they are not unimportant especially when it comes to making useful distinctions to those who know very little about what goes on behind the therapist’s closed doors.

In researching a book about peoples’ response to major traumas, I discovered some interesting and new (to me) therapies, ones that worked primarily through the body. I watched a DVD in which therapists trained in Emotional Freedom Techniques worked with highly disturbed combat veterans with strikingly positive results. I read up on the many and varied somatic therapies and began to understand how therapists who attend to the physical body gained much from not having to work verbally or at least not as the primary means of intervention.

Peter Levine is one of the best known exponents of “somato-sensory psychotherapy,” an approach that sees traumatic reactions as largely due to undischarged energy. Therapy is geared to enabling the person to discharge energy through more sensitive and balanced physical actions. Levine is adept at seeing the embodied person in a way that most psychotherapists are not. It is easy to equate the somatic therapies with their striking physical techniques. Tapping pre-defined meridian points in a particular sequence and in relation to a particular phrase or thought is clearly one such technique. But it also reflects a general therapeutic approach, one that conceptualises the psychological impact of trauma not in terms of trauma narratives or past history but in terms of physical experience. If, as seems to be the case, people can recover remarkably quickly, sometimes in a single session, then this different approach deserves to be taken seriously.

EMDR, essentially the precursor of the somatic therapies, was very critically received precisely because it seemed too good to be true. But it has proved its worth since. Similarly, it is easy to dismiss therapies as ‘wacky’ if they draw on traditional Chinese Medicine, focus on acupressor points, use an uncertain and vague term like “energy,” and involve rather simple physical actions like tapping. Beware of not seeing the wood for the trees. Energy psychology and somatic therapies offer something radical and different. Traditional (verbal) therapists would be well advised to keep an open mind. Seduced by our Freudian heritage, we plunged into the complexities of the mind and, with some notable exceptions, forgot the body. Isn’t it about time we brought the body back?

Nordstrom: Psychotherapy Lessons From The Cathedral Of Commerce

Posted on by Psychotherapy.net Team

Let's get something straight right from the get-go. I don't work for Nordstrom, nor am I am affiliated with them in any way, shape, or form. I've never spent a dime there. Truth be told, the only time I ever set foot in a Nordstrom was to walk from the mall to the parking lot. (Elapsed time: one minute and forty-five seconds.)

But I do know this. Nordstrom has become the darling of the customer service movement. If you are searching for the prime example of the customer-is-always-right philosophy, trust me when I say, you just found it. The stories are legendary, such as the time during the mid-1970's when a customer returned a set of snows tire to Nordstrom. Yes, the customer received a cheerful refund. The only wrinkle was that Nordstrom didn't sell snow tires. Then there's the saga in which an unhappy customer returned a set of ice skates. Here again, Nordstrom took them back. Never mind that Nordstrom didn't carry ice skates.

Historians and business scholars who have investigated these transactions are still debating how much is myth and how much is fact. I don't pretend to have the answer and indeed will let the MBA's battle it out on their own turf. Nevertheless, there is no doubt that Nordstrom is the poster child for the customer is always right, even when the customer is wrong philosophy.

But do we, as helpers, always abide by this stance or do we hide behind our favorite technique, what helped us when we were wounded warriors, or what the latest evidence based practice literature tells us?
A well-known dyed-in-the-wool behaviorist once gave me an excellent clue. The therapist noted that he was seeing a client whom he was treating with behavior therapy and behavior modification techniques. But there were two problems with this approach. First, was simply that the behavioristic modalities did not seem to be working. Second, was that the client kept insisting he wanted classical psychoanalysis. This went on for a significant period of time until one day when the therapist was so frustrated he threw in towel and agreed to provide classical analysis.

The situation became a tad more bizarre when the therapist explained to the client that he was sure psychoanalysis would not work. He thus created a behavioral contract stating if the analysis didn't work in six weeks, the client (excuse me, I mean the analysand), would agree to give behavior therapy another whirl. Since a course of analysis usually runs approximately three to five years this contract was about as paradoxical, if not downright silly, as it gets! Moreover, the use of a behavioral contract in psychoanalysis is little like trying to mix purified water and used motor oil!

For the next six weeks the client made the couch his new psychotherapeutic home as he babbled on about his childhood and his dreams, while the his behavior therapist, turned Freudian analyst, sat out of his sight and took copious notes.

In less than six weeks the client reported that he had overcome his symptoms and was feeling well enough to terminate treatment. No doubt somebody had to pinch the therapist to make sure he wasn't dreaming.
So, the next time your client makes a treatment suggestion, my advice is to listen very carefully. You might just catch a rare glimpse of the path less traveled from the annals of Nordstrom.

Eda Gorbis on Body Dysmorphic Disorder

Posted on by Psychotherapy.net Team

Characteristics of Body Dysmorphic Disorder (BDD)

David Bullard: To begin, could you give us a little background on BDD for our readers who may not be familiar with it?
Eda Gorbis: I began learning about treatment for obsessive-compulsive disorder (OCD) when I was helping to create day treatment protocols at UCLA Neuropsychiatric Institute in 1992, and then I furthered my knowledge by studying with Dr. Edna Foa in 1994. In 1996, I began work with a patient who had both OCD and BDD and was addicted to plastic surgery procedures. After successful treatment that was specifically designed to ameliorate the stress associated with her BDD, we were able to work with her on her remaining OCD, and my interest grew in this patient population.

Body dysmorphic disorder is self-perceived ugliness. It is when a person feels ugly inside about a minute anomaly—usually invisible to the naked eye of another—or has a markedly excessive preoccupation with even a slight defect, together with the feeling of being unable to make it right.

DB: So it’s a feeling and self-perception. I’ve noticed that, for some people with BDD, there is a vivid visual picture in their minds. One study highlighted the intrusive visual imagery these people have in addition to negative self-cognitions and feelings.
EG: When they look into the mirror, they see themselves as ugly.
They do not perceive themselves in the mirror as we perceive ourselves. They see a distortion that is invisible to others.
They do not perceive themselves in the mirror as we perceive ourselves. There is something wrong in their visual fields, from the eyes into the brain, that gives them inaccurate feedback. They see a distortion that is invisible to others.

What people with BDD perceive is actually similar to the reflection we have all seen in carnival funhouse mirrors. This differs from the common feelings of insecurity or self-consciousness about one's appearance that most people experience from time to time. Many people who have had cosmetic surgery are happy with the results and can move on with their lives without continuing to obsess about the original defect. With BDD, however, any surgical "correction" will itself be seen as imperfect, or an obsessive fixation with another body part will take over.

There are some theories, but the specific causes of BDD are not known. Many experts agree that sociological and biological factors play a role in the development of BDD.

DB: And it can be extremely debilitating.
EG: Yes, one of the most disabling conditions I know of. People experience extreme self-consciousness, and often avoid social situations, feeling others are judging and criticizing their self-perceived imperfections. The more the fixations intensify, the more it seems rational that others are also focusing on the “defect.” It can be a kind of paranoid ideation.

Then a person’s relationships suffer, along with many aspects of daily life. They can repeatedly request reassurances from others, but with no relief from their certainty about the ugliness. These compulsive requests for reassurance actually reinforce the false belief system and fixations; this leads to further compulsive questioning in a continuing cycle. They get so focused on their appearance that much time is spent hiding or trying to perfect the “flaw” cosmetically. These people are often unable to leave the house to make appointments, or to hold a job.

DB: Can you tell us about co-morbidity?
EG: BDD has a high co-morbidity with other anxiety disorders. The research is not perfect, but it seems that more men are treated for BDD than women. Perhaps female BDD symptoms are more likely to be interpreted as "normal" female behavior in our culture and are likely to be overlooked and remain untreated. The onset of BDD is not exclusive to a particular age, though symptoms often emerge during the teen-age years.

Treatment Considerations

DB: Could you give our readers an idea of how you work with someone with this particular disorder?
EG: More often than not, BDD is intertwined and co-morbid with OCD. Both disorders must be targeted at the same time—the perfectionistic concerns or fear of being criticized on a performance level that are characteristic of OCD, and also elements of social phobia that are associated with BDD.

BDD has certain expected features: for example, an exaggerated physical anomaly would be chin, eyelids, cheekbones—oftentimes in males, it would be penile size—with symmetry and exactness issues. I have found that women compare and contrast their breasts or their arms—any body part can be compared with the corresponding part on the other side of the body. The self-perceived anomaly also has a tendency to move from one body part into another: it can shift from the nose into the ear, for example.

DB: You mentioned that the first patient you worked with had had multiple surgeries. That’s a good example of how it shifts from one body part to another, and they get the surgery based on that.
EG: Right. That patient had more than a hundred cosmetic surgery interventions.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician, because you do not find this so much in strictly obsessive-compulsive disorder. Some of the patients with BDD have also met diagnostic criteria for sexual addiction and gambling. It is the exact opposite for people with OCD. Patients with OCD are not impulsive. They would be like Rodin's "Thinker."

With patients with body dysmorphic disorder, you have an overlap between impulsivity and compulsivity. Whereas people with OCD are extremely moral and truthful, people with this overlap of impulsivity and compulsivity would show no guilt or remorse. This overlap makes treatment extremely challenging. Some patients with BDD have also met diagnostic criteria for sexual addiction and gambling, which was a little bit surprising to me. Well, not really surprising, but interesting how impulsivity and the pleasure is associated with the alleviation of tension or excitation. For example, in gambling, it's not the reduction of anxiety that is the aim of the behavior. The aim is the attainment of tension release, like hair pulling or when they squeeze pimples, and excitation—the adrenaline rush in gambling or sexual addition. So you have very different aims of the behaviors that are intertwined in very complex ways.

DB: Some of the people who have written in the field make a distinction between delusional versus nondelusional BDD—for instance, someone who looks in the mirror and sees that his ears are too big, and he really thinks that they are too big, versus someone who looks in the mirror and knows he feels bad about it but accepts reassurance. He knows that his ears are really okay, and he recognizes that he has a problem in his perception. Do you see that distinction? Is it helpful to you in your work?
EG: Let's call it poor insight. That is a better term than "delusional." And it is classified along with other OC-spectrum disorders, such as Tourette's syndrome, eating disorders, trichotillimania, and compulsive skin picking. BDD is also often seen as part of the impulse control disorders—where impulsivity can be thought of as seeking a small, short-term gain at the expense of a large, long-term loss. People with BDD get completely dysfunctional, as I described earlier-becoming addicted to surgical procedures, getting stuck in front of mirrors, needing to ask constantly for reassurance, etc.

Cognitive-behavioral therapy

DB: Although each case is individualized, can you give us an overview of how a cognitive-behavioral approach can be utilized in treating OCD?
EG: With cognitive-behavior therapy (CBT) a person learns to change the way he or she thinks and acts. We know different people can have different attitudes about the same specific conditions: A large facial birthmark can certainly be noticeable to others, but may have no negative impact on someone who has accepted it, while being debilitating to someone with BDD. And, of course, even a nonexistent or minor flaw can be devastating to a person with BDD. It is important to help people change their thinking habits. Exposure and response prevention are taught to people with BDD to help them face their anxiety and any co-morbid BDD concerns. This means repeatedly learning to tolerate discomfort. Anxiety gradually subsides as they continue to confront situations without the avoidance response.

We also use the 4-step model of our colleague Jeffrey M. Schwartz, MD, as
outlined in his books Brain Lock and You Are Not Your Brain: The 4-step solution for changing bad habits, ending unhealthy thinking, and taking control of your life.

The steps we teach our patients to help them get freed from obsessional thinking are:
Step 1: Relabel (recognize that the intrusive obsessive thoughts and urges are the result of OCD).
Step 2: Reattribute (Realize that the intensity and intrusiveness of the thought or urge is caused by OCD).
Step 3: Refocus (Work around the OCD thoughts by focusing your attention on something else, at least for a few minutes: do another behavior).
Step 4: Revalue (Do not take the OCD thought at face value. It is not significant in itself).

The Role of Psychoeducation

DB: Yes, I've found that simple process very useful for some OCD clients, and it goes along with my favorite bumper sticker: "Don't Believe Everything You Think!"
How helpful do you find psychoeducational materials?
EG: I think psychoeducational materials are always very helpful and important, because then patients know they are not alone. In fact, we now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
We now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
DB: Isn’t it a characteristic of BDD that it feels so shameful that the majority have hidden it from the people who are closest to them?
EG: Well, the dysfunction is most often extreme, and usually afflicts young people by the time they are 18 and ready to get out of the house and into college. Then, because of the self-perceived ugliness, they are unable to get into social situations or attend lectures. They can't date. They camouflage themselves with glasses and excessive makeup. It is similar to an anorexic who is quite underweight and having cardiac problems and broken bones, and losing consciousness and so forth, but still worries that she's too fat. These people, in a very similar way, feel ugly, and there is a delusional component to this feeling ugly, as in anorexia. A distinction from anorexia, however, is that an individual with BDD would be preoccupied with the appearance of his or her face, while the anorexic will be more preoccupied with self-control strategies regarding weight and shape.
DB: Can you recommend some books for therapists who want to learn more about this disorder?
EG: The classic in the field of BDD is Dr. Katharine Phillips' The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (2005). She also has a newer one: Understanding Body Dysmorphic Disorder (2009). I have already mentioned the books of Dr. Schwartz. Other good ones are Feeling Good About the Way You Look (2006), The BDD Workbook (2002), and The Adonis Complex (2000).

We also have information on our website: hope4ocd.com. There are some other good ones such as Dr. Phillips' at www.butler.org; and the Massachusetts General Hospital BDD clinic; and www.bddcentral.com.

Mirror Externalization

DB: On the treatment end of it, would you say something about the mirror approach to your work?
EG: Because the physical anomaly is so exaggerated in the minds of these patients, I was thinking one day, "How do we externalize this self-perceived ugliness?" And I thought of the carnival funhouse mirrors, because they really exaggerate everything. It's a form of exposure. So we have a laboratory at the Westwood Institute in which a certain part is exaggerated when they're looking into a mirror. The room also has lighting controls, because different lighting and angles change our perception of the reflection. At this time the patients are just writing their anxiety levels.

We then cover all the mirrors for three days in a row, and all violations are recorded to track the compulsion. Compare-and-contrast behaviors—with those around them or with photos in magazines—are also counted as compulsive because they're done out of the anxiety. Or asking for reassurance: "Do I look good?"

The process of "externalization" works by causing the breakdown of maladaptive associations and repetitive manipulation of their external, material icons. In exposure therapy, BDD patients are provided with a symptoms list and must then induce the debilitating condition and self-monitor/rate objective signs, such as pulse rate, extent of nausea, dizziness, and cognitive distortions—for example, "My nose and forehead are too big." Cognitive restructuring through writing exercises and observational records are emphasized.

Our patients stay in the program from six to eight hours a day, and there are three clinicians working with them in shifts on a daily basis. After they work with the clinicians, I expose them in a controlled way to a regular mirror where they have to write a self-description, like someone in the police department is looking for them—a profile with no emotion associated with it.

We use cognitive-behavior therapy (CBT) with exposure and response prevention, and add mindful awareness training, cognitive restructuring, and Socratic questioning. We also use videotaping. Very often, I will use makeup artists to do an exaggerated prosthetic part. We have an interdisciplinary team. Treatment is tailored to each case. We also have six psychiatrists associated with us, who are OCD and anxiety disorder specialists.

DB: You have mentioned in the past that the model most clinicians have in private practice of the 50-minute session once or twice a week is inadequate for extreme cases of powerful dysfunctions such as BDD. It is wonderful that you are able to do such intensive work with those who are suffering with the most severe cases.
EG: We are able to do this work because we specialize only in OCD and BDD and other anxiety disorders. We don't treat anything else. And because of this narrow specialization, it is possible for one patient to work with three or four clinicians in a day. However, insurance companies just rejected one BDD case because they still don't accept the necessity for this intense treatment—they think it can be treated once a week, although this particular patient had been treated unsuccessfully once a week for years. It is a very debilitating illness—far more severe, I think, than OCD.

Medication

DB: That brings us to the issue of medications. SSRIs have been often prescribed to people with BDD. Would you say the majority of these people you work with are already on SSRIs, or do they end up on SSRIs?
EG: Based on my work with the six psychiatrists at the Institute, SSRIs alone do not seem to be helpful. There is no scientific evidence at this point for what really works with body dysmorphic disorder because of the delusional component and extremely poor insight. For people with high baseline anxiety, medication may be targeted to reduce anxiety. Depression and panic attacks can also be addressed with some medications, and atypical psychotic medications have also been used. But I have to emphasize that some kind of effective therapy is required, such as cognitive-behavioral therapy tailored to the individual case.

Families can also be a crucial part of the treatment.

It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption.
It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption. The love, support, and understanding of the family are very important, and they also have to be educated in how not to reinforce the obsessing and compulsions. Then, it is also important where they go after the treatment program.

Post-Treatment Care

DB: What are your experiences with post-treatment care?
EG: There are few referral possibilities for BDD patients to follow through. I think that these people are extremely high risk for relapse—maybe even more so than obsessive-compulsives, who have much greater compliance levels. Because of the impulsivity characteristic of BDD, you have less compliance, so even if patients do extremely well during the program, it is necessary to continue the self-therapy and self-treatment, because this illness is not really cured. I oftentimes give my patients examples: you can go through the best weight-loss program in the world, but if you then resort to your old eating habits, everything is going to come back right away. So really, I think it depends on finding out their interests or what they're best at while they're in the program, so that these dysfunctional compulsions can be immediately replaced with other activities. I tell them, "I don't care if you study Chinese, take a cooking class, or paint your house, as long as you get up in the morning and get going." Otherwise, all of the compulsions have a tendency to come back if the patients don't do anything that is productive.

Specialty Training in BDD

DB: I can see how important it is that they really understand what you're telling them about exposure and response prevention, and not reinforcing those dysfunctional behaviors. For any of the clinicians reading this who want to get the specific training needed to work in this arena, are you doing any training at the Westwood Institute or at UCLA?
EG: I would think that it's very important for them to go through training, but it would have to be hands on. It takes me approximately six months to train a good clinician for complicated cases, but I do specialize in extreme cases—patients who have failed a few other programs. Perhaps even a month of training would be sufficient if the clinicians saw a couple of cases that they would have to really work with intensively, because of the tailoring to the individual needs. It is not a cookie-cutter training; I couldn't tell you, "Here is a cookbook for any BDD case." Each case is like a snowflake. I've never seen two that were exactly alike, so we duly tailor the treatment to the individual needs of the patient.
DB: Absolutely. Finally, could you say something about the satisfaction you’ve gotten as a clinician in being able to help people who have experienced such terrible suffering and misery?
EG: My satisfactions are now taken with a grain of salt. Ten years ago, I was far more optimistic about the outcomes. I know now how debilitating and co-morbid this is with other illnesses, and how "feeling good" is dangerous for them. People with BDD have to be alert and vigilant to not fall into their old habits of dealing with their anxieties.

It's a medical illness that is extremely serious—like tremors of the mind. You could compare it a stroke or cancer that must be attended to. It is chronic; it waxes and wanes. People can definitely get to completely functional levels provided they attend to it on a daily basis. But, like a person with extremely high blood pressure or diabetes or even cancer, that person must be mindful and aware that there's a problem. Lately I've seen a few cases that had been in remission for 10 or 12 years and then they relapsed. I cannot tell you why. I don't even know if I have a hypothesis about the relapse after years in remission. And it sometimes takes longer to get them out of the condition the second time.

DB: That’s a very sobering indication of the great suffering and difficulty of having this disorder. I really appreciate your helping these people even without necessarily always having easy answers. On the other hand, I know of some people over the past several years that have made tremendous improvement in their functioning, even if they’ve had to come back and see you periodically. It’s made a big difference in the quality of their lives.
EG: I appreciate that, but the truth is I want to warn people against being extremely optimistic. There is no cure, and even if we ourselves have some of the highest levels of successful outcomes, let’s not forget that I’m extremely careful, having been trained by Dr. Foa to assess cases for hours and hours and to administer up to 15 tests to make our understanding of the individual even more precise. We also need to reject and refer elsewhere about 50% of the cases that come to us that I think we cannot help. People who come here are self-selected. We never have more than three cases at a time in the entire Institute, and we are able to pay a lot of personal attention to each individual and tailor the treatment. If something is not working from yesterday to today, we change it. We have that luxury. If I need to, I can dedicate the entire Saturday to this patient. That said, I don’t think other therapists have that luxury, and I think it’s very important to put this element into the level of success. It was never the quantity but the quality of the work that we have been focused on.
DB: I think that's one clear understanding that your patients have about your work—the intense dedication. Without being able to promise success, you are certainly one of the most dedicated people I know working in this challenging field
EG: You are most welcome.

Conduct Therapy Sessions Like Ellis Or Rogers In 7 Days Or Your Money Back!

Posted on by Psychotherapy.net Team

Okay Rosenthal, tell me something about psychotherapy I don't know. Fine: I will! If you've read all the textbooks, analyzed the classics, and been to enough workshops to receive frequent flyer miles, I've got something new to teach you so put down the managed care forms, and pay attention.

My secret weapon for improving your psychotherapy sessions comes from the field of copywriting. That's correct, I said copywriting. Copywriting is the act of creating written documents that persuade customers to reach into their wallet or your purse, and hand over some greenbacks, a plastic card, or simply click that familiar Paypal button.

When you receive a letter trying to sell you Ginsu knives or the latest Ab blasting exerciser, that's copywriting. Ditto for those letters begging for a contribution for your Alma Mater. According to many experts, the greatest copywriter of our time was an upbeat fellow named Gary Halbert. Now according to Gary Halbert (aka "the Prince of Print"), one of the fastest ways to become a master copywriter is to take samples of the best ads ever written and simply copy them in your own handwriting. Rumor has it that Gary did this himself for hours, if not days on end, when he first entered the business. The result was that he transformed himself (and later many of his students) into consummate professionals in weeks, rather than years, using this paradigm.

Along those same lines, I would urge you to select a well-known therapist you believe in and copy their therapy dialogues in your own handwriting. Better yet, since psychotherapy is a verbal pursuit, read the helping sessions aloud. In fact read the session (or portions of the session) again and again. Notice, I said "believe in" inasmuch as Rogers would certainly conduct a therapy session with a given client in a different manner than Ellis. O'Hanlon would no doubt rely on an intervention that bears little or no resemblance to either of the aforementioned luminaries.

When you get to the point that you can guess with a high degree of certainty what the world class therapist will say next you are well on your way to becoming an accomplished practitioner in that particular psychotherapeutic modality.

Will I really give you your money back if this strategy doesn't transform you into a world-class therapist in 7 days? Hey, I'll let you know. I'm still copying a master's ad and I haven't reached the small print section yet.