Psychotherapy and Counseling Defined

Psychotherapy and counseling are synonymous terms to describe a professional relationship between a trained clinician and client (the “client” may be an individual, couple, family, or group). The initial task of the therapist and client is to jointly decide how best to address the client’s presenting problem(s), what avenues of exploration to take, interventions to be used, and to prioritize the urgency of issues. Most therapies, in some form or another, foster increased awareness or insight of the hidden and not so hidden parts of ourselves, including symptoms and defenses (the mechanisms that protect us from further pain). As we become more aware of our thoughts, feelings, actions, perceptions, and experiences, we tend to have greater acceptance, choice, and freedom in life – all of which contribute to a potent sense of well-being. An analogy of how this works: Ideally, we want a varied menu at a restaurant because it gives us more choices. Similarly, if we have a longer internal menu of perceptions, experiences, and the like, we end up with greater choices in life.

Contrary to popular opinion, psychotherapy is not advice giving or teaching, nor is it preaching. You can easily get advice from well-meaning friends, family, acquaintances and even from strangers and the media. You don’t need one more person telling you what to do or giving you a prescription for life. Rather, the goal of therapy is to re-discover your own voice to help guide you in the directions you need to go, and to cultivate trusting your own self more fully in order to make your own decisions. It is becoming more common for clients to inquire about “brief therapy”, mainly because HMO insurance companies prefer short-term therapy because it costs them less. Although consultation and Employee Assistance Program brief therapy (ranging from one to eight sessions) can be very effective for managing a crisis, it is usually not helpful for meaningful personality change or substantive solutions. Realistically, it makes sense that long standing, complex issues require longer-term therapy. “Longer-term” is relative in that you should see definite positive results in 15-30 sessions, and, by all means, if you see no change week after week, broach this with your therapist. He/she should be eager and willing to discuss problems with the therapy, explore alternative treatments, refer you to a more appropriate clinician, etc.

Several factors may have contributed to your last therapy experience:

The fit and dynamics between you and the therapist may not have been a good one; the quality of the therapeutic relationship is key to the change in therapy.
The specific interventions used may not have been appropriate, e.g. research has shown that for chronic anger and for certain personality disorders, cathartic methods (expressive techniques such a banging pillows) are contraindicated and often make the problem worse.
The therapist may not have had the experience, expertise, interest, etc. in working with your particular issues.
Perhaps you felt more afraid in the past, and found it safer to leave therapy rather than confront the pain. If so, it is understandable that you needed to protect yourself, and it’s especially courageous of you to think about trying it again now.

Books, lectures, workshops, etc. are valuable as general information and as resources to get you started on thinking about yourself in new ways. But they do not acknowledge who you are as an individual. Therapy accommodates for and responds to your unique personality, style, and needs so that a healing relationship can take place. No amount of seminar attendance and book reading can give you a custom made therapy tailored specifically for you. Because psychology as a discipline needs to legitimize itself as a science, it waxes on about “human nature”, as if the nature of humans is unified, and as though there are many similarities for us all as a species, the fact remains: there is no one in the world quite like you. You are like no other. The beauty of therapy is its unwavering commitment to help you discover your true self and be your personal best.

The process of psychotherapy should be coherent and lucid to you as your therapist clarifies the reasons for the steps you are taking and explains the rationale for exploring specific themes. If something does not make sense to you, feel free to ask your therapist to explain it. Therapy is not classroom learning, nor is it listening to advice or lecturing. The basic therapy process involves you talking as honestly and openly as possible (presenting internal and external data, so to speak) and the therapist gives his/her guidance and reflections about your content/context. You would again respond, verbally and/or non-verbally – this is the back and forth interpersonal exchange. Your conversations may explore everything from the meanings and dynamics between you and others, you and the therapist, you and the world, and of course, your relationship with yourself. You make the final decisions about what you want to broach in sessions, how far you want to go with it, and what you need to do in your life. You are the ultimate and final judge of your own truth.

You may be right, you could feel better without professional help; in fact, it’s likely that you will get some relief simply as a function of time – we all have ups and downs over the course of days to months. Feeling temporarily better is not a substantive solution because you might be prey to the same problem(s) in the future. In therapy, you would proactively initiate strategies to not only effectively manage the present, but also to prevent the same issues from returning in the future. Just as a medical symptom responds better to prompt treatment, the same is true for a psychological symptom. Problems are often more easily dealt with if addressed earlier, before they build steam and gain momentum. It is natural to feel apprehensive about starting therapy; if you feel this, please do not think you need to handle it on your own or get over it before coming in. I encourage you to call me to talk about your apprehensions, fears, doubts, etc. so we can make this process as comfortable as possible for you.

Remember, you are the final judge of what you need to do. Given this, you can stop whenever you want to, e.g. as in when you are not being helped despite your therapist’s and your best efforts. You have the right to ask your therapist to refer you to someone else.You SHOULD immediately stop if the therapist is behaving inappropriately and unethically, e.g. want to socialize with you, confiding in you about his/her own problems, wanting to have sex with you, borrowing or lending money to you, etc. These are all boundary violations and ought to be reported to the therapist’s regulatory board.There may be times when you want to leave therapy because it is too painful to talk about difficult things. This is normal and it’s best to talk to your therapist about your feelings without leaving (acting out). You and your therapist can then collaborate on ways to help the process feel safer while still making progress.If you are inclined to leave therapy for other reasons, e.g. fee concerns, disliking the therapist’s style, not liking the therapist, or liking him/her romantically, etc. all of this and much more is grist for the therapy mill, so to speak. Your therapist should be happy to discuss your concerns at length. No topic is off limits for you to bring up in your therapy.And finally, you are likely to want to stop therapy either when you feel you have reached your goals and wish to make no further changes or when you come to a point where you no longer want therapy for inner exploration or personal growth.

A 2008 study published in Journal of Cognitive/Behavioral Science vol 15 (2) 194-202, suggests that psychotherapy outcome (follow-up at 2 years) is dependent on whether clients continue using skills learned in therapy. Just as clients often do “homework” while in therapy, doing “afterwork” is crucial upon leaving therapy. If clients integrate their experience into their lives post therapy and practice what they’ve learned, they’re far more likely to keep improving and building on the already laid foundation. This is one of innumerable studies where clients are shown to maintain their progress after leaving therapy, e.g. a U.K. 2008 follow-up study from Counseling and Psychotherapy Research vol 8 (2), 80-84, reports clients as “significantly less distressed” 30 months after counseling. Regardless of type of therapy or orientation or any other variable, if the original therapeutic experience is a positive one, the client is likely to use it as a springboard. The mechanisms are debatable but the results are not.

Stages and Sub-Stages of Therapy

Regardless of type, all effective therapy moves through the same general six stages:

• The issue(s) are defined with respect to
• History,
• Present context, and
• Further direction, from which
• The goals naturally arise, and all the while
• Therapeutic alliance is simultaneously being formed.

If change is the chief goal of therapy, then this process of change is further divided into six sub-stages:

• Relinquishing an old pattern – internal, e.g. thought process, and/or external, e.g. behavior
• Initiating a new pattern
• Maintaining the new pattern
• Applying current understanding to the past, changing one’s personal narrative/memory-set (subjective biography)
• Incorporating the new pattern into current life
• After leaving therapy, continuing to use the skills/patterns.

The nature of outpatient therapy, by definition, usually means that the client spends 167 hours a week away from the therapist, making it crucial to supplement the 50 minute session with interventions for the client outside of the office. These include an infinite number and type of “homework” assignments, e.g. readings, journaling, self-help groups and/or therapy groups, practicing behaviors, self-observations, implementing communication strategies, dreamwork, relaxation techniques, etc.

People often ask, “What will I get from doing this?” “How will all this help me in my daily life?” We want to know where we’re going and why. The benefits of meditating are both psychological and physical. A joint Carnegie Mellon/UCLA study (published in Brain, Behavior, Immunity, 2012) offers first evidence that mindfulness meditation is a promising intervention for reducing loneliness in older adults. Loneliness is considered a risk factor for illnesses such as cardiovascular neurodegenerative disease. Also, with a group of healthy 40 adults–age 55-85–after 30 minutes of eight weeks daily meditation and one day-long retreat (control group was used), blood samples showed reduced pre-inflammatory gene expression in the immune cells, plus a measure of C-Reactive Protein (CRP). This suggests mindfulness training may reduce inflammatory disease risk. These results are exciting because they indicate we can modulate immune cell gene expression — through psychological intervention!

Among the many psychological benefits of meditation: people are often surprised to realize this–what we’re contemplating is distinct from our mind responsible for generating such. Benefits of MeditationThe content is process. By tracking our process, we guide our content. Why is this important? It gives us a better sense of ‘control.’ We’re more focused and ‘grounded,’ more hopeful. When we witness the rhythm and chain of our mind’s events, we see our consciousness as mosaic and kaleidoscopically constant, teeming with change. Since our external Reality depends on our internal universe, we marvel at our thoughts as mirage, and as not necessarily true! “Thinking” something, does not make it fact. Understanding this deeply, we appreciate the distinction between how things appear and how things are. When we come to see this reliably, over and over again, we have sharpened awareness, feeling a huge sense of freedom in our behavior with others and the world. People often report greatest benefit from meditation when they achieve a sense of “equanimity” or abiding “still in the storm.” We feel more at ease, released from with past conditioned behaviors, and are able to live more fully in the moment. We are witness to our experience. We are observer AND participant, rather than solely the latter. Rather than feeling burdened by bad memories of the past or fearing the imagined future, we’re less anxious and despairing. Hence, we’re freer from self-judgement, more open to “happiness,” and relaxation.

Many studies confirm positive neurological changes as a result of regular meditation practice. Recently, using a type of MRI technique, diffusion tensor imaging, researchers presented a paper at the 2012 Proceedings of the National Academy of Sciences. After subjects practiced two weeks (approximately eleven hours of meditation), they looked at the following correlated brain changes:

• changes in brain structure, e.g. increase in number of axonal density (signaling connections)
• increase in myelin (protective tissue around axons) in anterior cingulate region (region responsible for self-regulation)
• enhances brain function
• increases emotional regulation
• lowers levels of fatigue, anger, anxiety, and depression (in contrast to control group)
• elevates mood and decreases hyper-vigilance/stress response (via activating left prefrontal cortex and decreasing amygdala activity, respectively)
• heightens empathy
• improves cognitive functions, e.g. increased memory

Couples seek therapy for a wide variety of issues. Some examples include the following:

The types of Therapy are:

Your right to privacy is absolute – the value underlying privacy reflects our society’s belief in individual autonomy, that we have a right to live our lives as we choose, given that our choices do not harm others in a shared society. Confidentiality is a subset of this overarching privacy principle. Confidentiality guarantees that you are free to decide for yourself with whom you share what is most personal to you. You have the legal and ethical right to expect your therapist to maintain utmost confidentiality; without your explicitly written consent your therapist cannot share your information with anyone. In keeping all communications confidential, the therapist treats clients with respect and dignity, paving the way for building trust in the therapeutic relationship. Trust is the foundation for you and your therapist to work on mutually agreed upon goals. It is crucial for you to know and trust that everything you say to your therapist is kept private, your feeling that your discussions are kept safely contained is key for effective psychotherapy.

There are some legal exceptions to confidentiality when, in the interest of society, a mental health professional has a duty to disclose what the client reveals. If, in the course of treatment, the need to disclose information arises, your therapist should be up front and honest about it, discussing with you in advance his/her intention to disclose specific content. You should not have to be unpleasantly surprised that your therapist has shared information.

My fee for a standard 50 minute session is $350.00.  Clients are responsible for payment at the time of the session, unless other arrangements have been made. I accept personal checks, PayPal, Venmo, ApplePay (iphone 6 & later–iOS 11.2, and watchOS 4.2 & later), cash, Zelle, and direct bank checks. Credit cards have a 3.5% processing fee. All transactions are kept confidential and private. If you pay with Venmo and wish your transactions with me to remain private, please default your settings to “private.” I have a 72 hour cancellation policy. Most clients come in 1x weekly, though if circumstances warrant, I see clients 2-3x weekly or bi-monthly, and also do one-time consultations. If you’re an established client, I do Skype, WhatsApp, Zoom, HIPAA compliant VSee, FaceTime, and phone sessions (telehealth is available to CA residents only). Our initial telephone consult is free of charge–this is an opportunity for us to talk at length to get a sense of each other, for you to tell me about yourself and your situation, and ask me questions. I will assess whether I can help you. If I cannot meet your needs, I will be happy to refer you to a therapist who might be a better fit for you. If my fee is a hardship, please let me know. Low income should not interfere with people getting help, and though I do not have a sliding scale, I can refer you to credible low-cost counseling centers.

If you have PPO coverage, please check with your plan for annual deductible, maximum allowed number of outpatient psychotherapy sessions, and payment per session. I will help fill out the appropriate insurance forms so you get reimbursed directly from your insurance company. I also supply you with bills for therapy – weekly or monthly – based on your preference. I am not a provider for HMOs.

The Health Insurance Portability and Accountability Act (HIPAA) is a law (in effect since April, 2003) created to protect patients who were previously ill from losing their health insurance when they change jobs and/or residences. HIPAA insures that a patient’s medical record, health information, payment history, etc. remain private and prevents them from being disclosed without the patient’s written consent. HIPAA specifically sought to standardize electronic information about not only patient’s health, but also financial and administrative data. It set security standards for protecting confidentiality of data such as: health claims, enrollment and disenrollment details, payments for care, coordination of benefits, plan eligibility, claim status, and related transactions.

Because I am not a member of HMOs nor am I a provider for PPOs, I do not use electronic transmission of billing information to obtain payment. I am exclusively a fee-for-service provider and will bill you directly. You may, however, choose to be reimbursed by your insurance company. Because my practice is not electronically mediated, I am not bound by the requirements of HIPAA. I do, however, maintain utmost strict confidentiality of client information and safe-keeping of client-records, as mandated by the law. I also preserve the integrity of client disclosure, consistent with sound ethical/clinical practice.

The content on my Facebook, Twitter, and Instagram sites are for marketing and informational purposes only. I invite you to follow me on these business pages and welcome your comments, but please understand that for your privacy and protection, I do not interact with clients on these platforms, e.g. do not take it personally when I do not reply nor ‘follow,’ or ‘like’ your posts. Such communication can be a breach of patient confidentiality and protected health information–‘friendships’ between clients and therapists on social media are unethical.

Engaging with clients on social media can be interpreted as, or lead to a ‘dual relationship,’ regardless of how superficial or benign the connection. My priority is always to preserve your confidentiality. If you have questions, comments, or concerns about my presence on the internet, e.g. my website, social media posts, blogs, articles on psychology sites, etc., please talk to me directly, and I will be happy to address your concerns in the best way befitting your therapy.

I do not search for clients on search engines nor do I attempt to access you on social media sites. I believe strongly that what I know about you–this should come directly from you. You have the right to choose what, when, how, why, and how much to reveal to me. You own your personal information and it is part of your therapeutic process for you to self-disclose in the manner most comfortable for you.

I see clients on week days and evenings; week end appointments for emergencies are also available. If you’re an established client, I offer tele-health, e.g. therapy via telephone, Skype, WhatsApp, Zoom, or HIPAA compliant VSee. If, during our work together, you’re unable to come to my office, e.g. difficulty getting childcare, if you’re ill, etc. we can do remote sessions. If you’re traveling for work, vacation, etc. I also do international and national sessions. Skype is not encrypted, and not a confidential means of communication–I ask for your informed consent before we use this medium. If you are uncomfortable with these platforms, and prefer to use a highly secure app (encrypted, does not back up in the cloud), I also use Signal or HIPAA compliant TeleHealth video/call with VSee. For privacy implications of TeleHealth and information about HIPAA compliance, please see ‘Notice of Privacy Practices’ on the “Policies” page of my document.
Frequency of sessions ranges from twice per month to three times weekly.