Therapy is a special place. A relationship is created in order to help you feel better, or at least that's the hope. When you start therapy you have all these feelings swirling around that control your life and you want the therapist to fix it. That is understandable. However, it is a false expectation. First of all, a therapist has no magic wand to make all the pain go away in an instant. We would if we could. It is a process of small changes and insights that build to create a better, calmer, more fulfilling life. 

As you build the relationship with the therapist and start trusting (oooh bad word) them, you start revealing deeper more painful things. These things often seem scary, embarrassing, and they can hurt. The irony is the more you hold onto these feelings and negative thoughts (that are hurting you) the more you are scared to face them. When you start revealing those tender, inner parts to a trusted professional, it does seem to hurt a little more for a while. However, you find out you are strong and courageous by facing those inner struggles and the emotions start to decrease. You win. You become more confident and able to make choices that benefit you and help you reach your full potential. 

Therapy is a place to be vulnerable and take risks. Speak up. Say what you need to say. Trust yourself. You will be better off in the end for finding your voice. What a precious gift to have a place to share the depths of who you are with someone you know cares for you no matter what.

Shelley Quinones is a Licensed Therapist in San Dimas, California. She has been in the field in various roles for over 20 years. She is trained in EMDR which helps process minor daily traumas that accumulate, or major traumas that influence daily choices, or even allows for performance enhancement. She is a Christian and believes faith plays an important part in healing. Her website is www.shelleyqmft.com.

Neuropsychological evaluations are used to gain a better understanding of a range of problems that involve the brain. For instance, people who have had a head injury, a stroke, or brain tumor may be referred for a neuropsychological evaluation to assess the impact of the injury on cognition, memory, language, and motor coordination. Neuropsychological evaluations are also performed with children or adults to gain more information about problems such as learning issues, attentional problems, autism, and even emotional conditions such as anxiety or mood disorders. Referrals for neuropsychological evaluations come from primary care doctors as well as neurologists; primary care physicians; mental health providers such as psychiatrists, psychologists, and social workers; speech/language therapists; and educational tutors. 

Neuropsychologists use indirect methods to study brain functions and their relationship to behavior. The "tools" of the neuropsychological evalauation look like puzzles, drawings, language activities, checklists and computer games. However, these tasks have been carefully designed to measure some function that is important in learning and problem solving, and then administered to a large number of people. The results are transformed into standardized scores that allow for the direct comparison of people of different ages and backgrounds. Using the pattern of strengths and weaknesses revealed by these scores, the neuropsychologist can then identify problems, make recommendations for needed services and even design interventions to improve functioning in key areas of a person's life, such as school, work, and interpersonal relationships. 

A neuropsychologist is a licensed psychologist who has completed two years of additional training in the administration and interpretation of neuropsychological measures and the development of treatment regimes to address areas of concern. Neuropsychologists may work in a hospital setting as part of an interdisciplinary team of medical doctors, physical therapists, speech and language therapists and other specialists. They may also work independently in private practices. Some neuropsychologists work in research settings where they use technology such as brain imaging to learn more about brain structure and functioning. 

Neuropsychological evaluations can vary in length and complexity, depnding on the setting and the referral questions. The actual testing time can range from less than an hour in an inpatient unit for someone who has suffered a stroke, to five hours or more in an outpatient unit if the question involves learning issues. The cost of evaluation can also vary widely depending on the amount of testing, scoring, provision of feedback and extensiveness of the written report. Insurance coverage for neuropsychological evaluations varies between insurance companies and plans, and it is important to check with your company to ascertain benefits for different conditions. 

Stephanie Monaghan-Blout, Psy.D. Formerly an adolescent and family therapist, Dr. Monaghan-Blout specializes in the assessment of children and adolescents with complex learning and emotional issues. She has a particular interest in working with adoptive children and their families as well as those contending with the impact of traumatic experiences. She is a member of the Trauma and Learning Policy Initiative (TLPI) associated with the Harvard Law Project, and is working with that group on an interdisciplinary guide to trauma sensitive evaluations. 

Dr. Monaghan-Blout obtained her doctoral degree at Antioch New England Graduate School. She completed an internship in pediatric neuropsychology and child psychology at North Shore University Hospital in New York and a postdoctoral fellowship at HealthSouth/Braintree Rehabilitation Hospital. She joined Children's Evaluation Center in 2003, and NESCA at its inception in 2007. Dr. Monaghan-Blout is currently a member of the Board of Directors of the Massachusetts Neuropsychological Society. 

Dr. Monaghan-Blout is the mother and stepmother of four children, and the grandmother of four (and counting). She is also an avid ice hockey player. 

I had been working with Annie for 3 months. Her symptoms of anxiety, insomnia, and frequent bouts of crying had improved, but not to the extent either of us would have liked. Annie began to wonder whether difficulties in her marriage were implicated in her symptoms, and she decided to invite her husband Matt to join her in therapy. Matt agreed, but reluctantly. After the introduction he said, "I'm here, but I don't believe in psychotherapy". 

As I said to Matt that evening, I don't believe in psychotherapy either. Psychotherapy involves a knowledge base, a skill set, and a relationship, and hence is not something to "believe in". It requires knowledge of human behavior, interpersonal and family dynamics, emotional wellness and illness, and an awareness of the impact of culture and economic systems on people. It requires communication skills, along with a capacity for insight, intuitive understanding, the ability to suspend judgment, and a knack for making connections between seemingly unrelated events, behaviors, and feelings. The knowledge and the skills needed for the practice of psychotherapy qualify it as a science. 

As a relationship, psychotherapy is also an art. While certain principles underlie therapy as a particular kind of professional relationship, like boundaries, ethics, and non-reciprocity, it can't be learned from a book or even by imitating other therapists. Relationships must be experienced and felt, and too many rules or road maps diminish them. 

When I sit down with Annie and Matt, I can't forget what I've learned or the skills I've developed. Paradoxically, however, I have to bracket them time and again to e receptive to these unique human beings, and to open myself to a brand new relationship. Empathy, which is the ability to walk a bit in someone else's shoes, so that they might possibly walk farther or more easily, involves both a  commitment and an aptitude. 

I suggested Annie and Matt think of therapy like a house, a house being important, even essential, but not something to believe in. The foundation, the framing, the siding, and the roof make up the science of psychotherapy. Everything else is art. 

Susan Donnelly has been a practicing psychotherapist for over 30 years, and presently maintains a private practice in Ridgewood, NJ. she has held clinical and administrative positions in public and private agencies and has recently completed a term as Chair of the Bergen Country Mental Health Board. You can visit her website and blog at www.ridgewoodtherapy.com. 

Question: My general practitioner can prescribe anti-depressants...why bother also seeing a psychiatrist? 

Most psychiatric medication in the United States is prescribed by General Practitioners. This is probably the result of at least two factors: 1) most visits to General Practitioners are motivated by physical symptoms which at least in part are caused by emotional problems; and 2) most people feel less likely to be stigmatized if they tell their General Practitioner that they are depressed, or anxious, or overwhelmed, because expressing these concerns in the primary care setting doesn't suggest you are mentally ill. In our society, even going to see a psychiatrist for help with emotional symptoms is often seen as 'proof' that a person is mentally ill. 

Unfortunately, this often leads to people not getting the specialized help they need.  It has been shown that more than half of anti-depressants given in a primary care setting are not given at the right dosage, are not monitored carefully, and do not result in ongoing treatment or resolution of patients' emotional symptoms.  Patients have side effects to anti-depressants given at incorrectly high starting dosages, and stop their medicine prematurely.  Alternately, if the starting dose is too low, patients won't feel like the medicine is helpful, and will simply stop taking it, rather than taking higher doses of the medicine until their symptoms resolve.  Without close monitoring, people don't know what to expect and how to cope with side effects.  This leads to a situation where more than 75% of the prescriptions written by General Practitioners for anti-depressants and anti-anxiety medications are never filled at a pharmacy.  People have reached out for help, but most often they do not receive the kind of help that will end their emotional problems, and related loss of normal functioning.

For this reason, seeking help from a Psychiatrist for depression (or any other emotional problems that are interfering with normal functioning) is much more likely to lead to these problems being properly treated so that patients will regain normal functioning. Psychiatrists are able to understand both the biologic, psychological, and social/family components of emotional illness. They can order diagnostic laboratory tests and prescribe medications at the proper dose and monitor closely for side-effects, increasing the chances that you will be able to continue taking the medication. They can also assess whether the emotional symptoms might be caused by an underlying physical or hormonal problem, such as thyroid disease, diabetes, or anemia. They can provide a wide range of different kinds of psychotherapies to help change feelings and behavior.

Unlike General Practitioners, Psychiatrists are specially trained in understanding the causes and treatment of emotional problems, and are more knowledgeable about the use of anti-depressants and other medications used to treat these emotional problems.  They are also trained more extensively than other therapists to take primary responsibility for their patients' total care, which can include providing both medication and therapy, making sure that underlying medical problems are adequately treated, and they can provide long-term follow-up.  They can more completely distinguish the different kinds of emotional problems and how to treat them:  is the problem only depression? is there both depression and anxiety?  is the depression part of a manic-depression cycle?  is the depression or anxiety a normal reaction to stress or grief?  In clarifying the nature of the problem, Psychiatrists are more able to choose the correct treatment,  in terms of medications and also with psychotherapy.  They can carefully monitor the patient's response to treatment and therefore minimize side-effects, allowing patients to remain on medicine that could lead to the resumption of normal functioning.

For all these reasons, getting help from a Psychiatrist rather than a General Practitioner is the best way to be sure that emotional problems don't continue to interfere with normal functioning and having normal relationships, at work as well as with family and friends.

About the author: Irene Kitzman MD has been practicing general adult Psychiatry since 1984. She graduated from the Yale University Department of Psychiatry, where she was a Chief Resident at the West Haven Veterans' Administration Hospital. Most recently, she was appointed Clinicial Associate Professor at the University of AZ and was Director of the Outpatient Clinic at Kino-UPH hospital, where she taught doctors in training to be Psychiatrists. She evaluates and treats adults, couples, and families for a number of issues including depression, anxiety, post-traumatic stress disorder, and psychiatric symptoms of Lyme disease. Dr. Kitzman received the honor of being named one of "America's Top Psychiatrists 2006" by the Consumer Research Council of America. For more information, visit her website. 

*Top photo credit: Amada Hatfield 

More than one colleague or client has asked me how I came to work with children. I used to work mostly with adults and when time, after time, these adults turned to me in session and said, "Steve, I wish someone had recognized the amount of emotional pain I was in when I was a child--then maybe I wouldn't be 40 years old and sitting in your office now!" When I reflected upon what those adults were saying to me, then I decided to do something about the emotional pain of children. 

I like to think of my work with children as preventive medicine--i.e. treat the child before their emotional difficulties become a chronic condition. Some people are concerned about the meta-message being sent to children who are brought to counseling. I've been asked, "What does this do to their self-esteem--especially if siblings or peers find out?" In my experience is rarely a problem. I think the much bigger problem is what it does to a child's self-esteem to leave depression or anxiety or other disorders untreated. When a child has had difficulties for months or years and is brought to me, one of my first interventions is to counter their sense of worthlessness and guilt for having problems. The earlier the child is treated, the less their self-esteem is eroded. 

Some researchers think that a large number of children with childhood disorders have a genetic predisposition to the disorder, then this predisposition is activated by environmental problems or other stressors. The following case illustrates this paradigm: A six year old was brought to me with feelings of sadness, isolation and withdrawal following the death of a loved one, continued for four months, and was accompanied by school and social problems. Both parents had a history of multiple losses and depression. After a month of psychotherapy the client's depression was greatly reduced and the client's grief was on track to being resolved. It appears that the stress of losing a loved one had triggered in the client a depression stemming from a biological predisposition toward depression that was inherited. 

Children come to counseling with a need to be listened to and respond positively to attention, encouragement, empowerment, and assistance with their emotional and practical difficulties. Research shows that children have a high need for sharing personal experiences and feelings, which they do with relatively few reservations. I create a safe, friendly environment so the child feels free to express her/his stress and concerns. I find the child responds openly to suggestions for change when presented in a caring manner. 

When providing counseling to children, I use imaginative play, games, books, puppets, various toys and art therapy to facilitate self-expressiveness and empathy to connect them to their inner feelings and to develop insight. After a therapeutic alliance is formed, even young children are quite capable of clearly talking about their thoughts and feelings. I find an easy give and take between play therapy and talk therapy facilitates the healing process. 

The goals of counseling are to improve the child's immediate adaptation to her or his life situation, build ego strength and teach problem-solving skills. Sometimes what a child needs is more structure, discipline and attention from parents and that involves family therapy, but that is a topic for another article.

*Photo "India Whistling" by apdk

ABOUT THE AUTHOR: Mr. Knezek is a clinical social worker in private practice in New Haven, CT. His practice consists of 50% children/adolescents and 50% adults. In addition to his clinical work, Mr Knezek is a Practice Building Consultant who helps clinicians realize their dream of a thriving private practice, and a clinical supervisor. www.stephenknezek.com

After receiving a diagnosis of schizophrenia, bipolar disorder, or a personality disorder, one can become overwhelmed with the seemingly disastrous news. Fear and anxiety may creep in and take over, but it is important to gain knowledge and learn how best to cope with the news. By learning about these disorders, one can come to terms with the diagnosis and move toward seeking appropriate treatment. 

Schizophrenia, bipolar disorder (previously known as Manic-Depressive Illness), and the personality disorders are all treatable conditions. While they each have distinct characteristics, they can also have overlapping symptoms, making proper diagnosis challenging. 

Schizophrenia and bipolar disorder are two major mental illnesses. Schizophrenia is primarily a thinking disorder. Bipolar disorder is primarily a modd disorder. Both conditions can cause the person to lose touch with reality. 

Personality disorders refer to enduring patterns of being, which are maladaptive, and interfere with an individual's attainment of contentment, stability, safety, and integration into society. A personality disorder often supports symptoms that trouble the individual such as anxiety, depression, eating disorders, and substance abuse. 

The most talked about personality disorder is borderline personality disorder, distinguished as the personality disorder that may require specialized treatment for its behavioral aspects. One one personality disorder, antisocial personality disorder, is not considered to be treatable with medication or psychotherapy techniques currently available. 

Schizophrenia

Schizophrenia commonly starts in late adolescence. The young person with an emerging schizophrenia may suffer from unrealistic, compelling ideas (called "delusions"), perceptual disturbances such as hearing voices, social withdrawal, and difficulty putting thoughts together. 

Early intervention with psychotropic medications is always indicated in stabilizing the individual before symptoms become flagrant and disruptive to the person's life. Sometimes hospitalization is needed to accomplish this goal. Psychotherapy and group therapy centers are important adjuncts of the treatment for this illness in many cases. 

Social workers play an important role in providing psycho-education for patients and families, and making appropriate referrals for services specially designed for helping people with this illness. Clinical social workers directly deliver psychotherapy for the conditions of mental illnesses. People with schizophrenia often lack the consistency of judgment to cope alone in the world, can show deterioration over time, and may need lifelong help in sustaining themselves in the world.

Bipolar Disorder

Bipolar disorder is expressed in people who have episodes of serious depression (characterized by symptoms such as lack of appetite, withdrawal, pessimism, lack of energy and disinterest in normal activities), coupled with episodes of mania or elation (characterized by such symptoms as sleeplessness, high energy, distractibility, irritability and excessiveness of sexuality, spending, talking, and self-importance. 

As with schizophrenia, medication is essential to stabilize mood. In the case of bipolar disorder, psychotherapy is also essential for the person's overall understanding of, and coping with, their condition over their lifetime. Sometimes people resist believing they have a mental problem. Disbelief can lead to repeated involuntary hospitalizations for the safety of the person and others. Therapists who are social workers can be especially well equipped to look for and be sensitive to cultural attitudes which may impede the acquiring of appropriate mental health services.

Personality Disorders 

Personality disorders provide fertile soil for the maintenance of uncomfortable and sometimes behavioral symptoms. While medications may temporarily help with symptoms that are supported by the particular disorder (depression, anxiety, insomnia), the ultimate help comes with the psychotherapy that treats the underlying personality disorder. 

Psychotherapy for personality disorders often requires a commitment to meeting with an experienced therapist frequently and regularly over a long period of time to obtain a significant result. Those people whose condition includes seriously self-destructive behaviors do best with DBT (Dialectical Behavioral Therapy), a therapy which specifically focuses on curtailing these behaviors. As with major mental illnesses, hospitalization can be required at times. 

After Diagnosis

Post-diagnosis can be a confusing time and with a clinical social worker specializing in mental health issues can clarify the path to begin the process of obtaining help. An expert can help wade through the numerous types and modalities of therapies offered and find the best treatment available. 

Joan E. Shapiro LCSW, BCD is a Lecturer in Social Work for the North Shore University Hospital's Department of Psychiatry. She is in full time private practice on Long Island, N.Y. Ms. Shapiro earned her MSW from Smith College School for Social Work in Northampton, MA and attended the Institute for Psychoanalytic Training and Research in New York City. Ms. Shapiro has trained at New York Hospital Westchester Division, Bronx Municipal Hospital Center, and The Clifford Beers Guidance Clinic in New Haven. She was a staff social worker at North Shore University Hospital Department of Psychiatry's Out Patient Department for twenty five years.

*Photo Credit - Williamsburg Hedge Maze

The relationship which you and your therapist develop as you talk about the stresses, disappointments, frustrations of your inner life is itself a tool for life learning. 

Besides the content of your session talks, the way in which you and your therapist interact is one important way for you to see yourself handle two of the main factors of any relationship. 

The first relationship factor is trust. 

The second relationship factor is power. 

Think about how in all relationships we are in a continual shuffling, trying to find balanced ground of whether we can trust someone. 

• To what degree is the person with whom I would like a relationship trustworthy? 
• What can I safely talk about with this person? 
• How will I know within myself that I am in a place of where I can give my trust? 

Therapy is a professional service by highly trained, licensed professionals who are required to continue their education. Their job is to create a safe, uncritical, humanistic care environment just for you, the patient. 

Therapists are trained to keep their personal ways of interacting out of the relationship with you. The therapeutic relationship protects what you talk about; all sorts of laws and ethical codes exist to ensure this. 

You are safe to use the therapy space as the playground and sanctuary it is. Allow yourself new modalities and methods of recognizing and sustaining trust in a relationship. 

Similarly, in therapy you will have lots of opportunity for seeing the way you respond and utilize power, both your own and in response to the authority of the therapist. 

• Do you believe close to every word the therapist tells you? 
• Are you willing to ask questions of the therapist? 
• Are there times you feel afraid of directly stating your thoughts? 

These are a few of the key areas of a relationship in which the patient's personal power is stuck. The further you can bring yourself to releasing from what traps your power inside, the better you will be able to do your share in building healthy relationships with others. 

Remember, because the therapeutic relationship is in service to your interest, growth, healing and development, you can expect to feel safe in trying new ways of doing your part in a relationship. 

Sherry Katz, LCSW is a licensed clinical social worker who received her MSW degree in 1981. She completed her advanced clinical training in family therapy at the Ackerman Institute for the Family. She specializes in systems/relational work with individuals, couples and families. The focus of her work is supporting each client toward finding their hidden strengths and applying these newly discovered views for good growth and balance. Ms. Katz opened her Ridgewood, NJ practice in 2000. Her website is www.newviewsfamilytherapy.com.

A wave of awe comes over me as Mary describes how she’s caring for her mother with Alzheimer’s and her 6 year old granddaughter, all while dealing with her own ulcerative colitis and depression.  Do I care about her and getting her beyond the depression that’s keeping her from sleeping, eating and enjoying the sweeter moments of her life?  Yes, I do. As do most therapists. It is why we enter the profession.

Do I care about her differently than her husband, her mother or her daughter?  Of course.  The way I care about her and hear her is entirely different from the way her loved ones do.  She and I are relating for her and about her.  I am committed to seeing her through to our intended outcome – free of symptoms, contented and lighthearted again.

Your therapist will come to know you in ways your loved ones do not.  He or she will come to understand you in each of the roles you play – wife/ husband, mother/father, grandmother/grandfather, sister/brother – and as an individual. 

For our 45 minute session, Mary’s needs, thoughts and feelings will have my complete attention and the benefit of my skills.  For this, Mary and her insurance company will pay me a fee. But that fee doesn’t mean I don’t genuinely care about Mary, or my other clients.

Understanding your therapist’s level of care for you is about understanding the nature of your relationship. It is not a relationship based on family or friendship.  It is centered on you and is not reciprocal.  You enter into a payment agreement with your therapist to care about you in a unique way – in a way that is responsive, useful and not particularly complicated. 

I will see Mary beyond this depression to enjoying life again.  At that time, we will wish each other well and say good-bye.  Someone else will occupy her chair and I will hear his story and his needs.  I will listen, I will care and I will help.

Michele Gustafson, LMSW, DCSW practices in Grand Blanc and Fenton, Michigan.  She has over 25 years experience doing therapy, having received undergraduate and graduate degrees from the University of Michigan where she has taught psychology and social work.  www.michelegustafson.com

Most professionals in the helping profession chose their job purposefully.  We enjoy helping, listening, and problem solving.  I found an online quiz that supposedly determines if one would make a good therapist.  It asked questions about one’s understanding, ability to help others control emotions, make decisions, give feedback and read social cues.  These are definitely telling questions, but is there more to it?  Do therapists ever think of their clients as more than a job?  Do clients feel that they are genuinely liked?  I’ve written previously about the chemistry one must have with their therapist.  That chemistry can go both ways.

Are there clients I particularly enjoy seeing?  Yes.  Is it because they are nice?  Sure, they are nice.  But it is more their motivation to work during our sessions.  As a therapist, I am easy to please:  Show up for our scheduled appointments, call if you can’t or are running late, and then use your time well.  However, that doesn’t mean I “like” you any less if you don’t do these things.  I care about my clients.  I like them too.  Some I can say I really like, especially after having known them for many years.  But let’s be honest.  It is a one-sided relationship.  They may leave a session feeling better than ever, and I am fulfilled knowing together we worked hard, but while they may ponder our work well after the session is over, I am completely focused on my next client.

Many clients come into our session with a list of topics they want to discuss and work on.  But what is he or she feeling when they leave?  Some of my clients probably feel that I am proud of them based on our talk and the progress they have made, and that feeling may transfer to feeling like they pleased me and that they did well.  They leave with a smiling “thank you so much” and will sometimes tell me they repeated some of our conversation with their loved ones.  Feeling liked is part of that along with feeling accepted and cared for.   I have never been asked the question during therapy “do you like me”, but I confidently believe my clients would all say that I genuinely do.

Sometimes a client’s issue might be insecurities and that will transfer over to our relationship as well.  A client may leave wondering if he or she pleased me and answered “correctly” instead of processing situations through their own glasses (as opposed to mine).  Once confidence is built, it is my hope that their habit of changing behaviors to please me will become pleasing to themselves.

Some therapists say it is too draining to think about work when not working.  I can’t help but brainstorm and process throughout my days.  Is it draining?  Possibly.  But again, doing a good job is fulfilling.  I think 100% of my clients would tell you that not only do I like them, but that I like them best.  And for that 45-50 minute session, I do.

Lynn R. Zakeri is a licensed Clinical Social Worker with a private practice in Northfield and Skolie, Illinois. For more information view Lynn's website at www.lynnzakeri.com.

With forecasters predicting more possible snow events, I believe that this New England winter deserves its own diagnostic category and for those of you effected by it (and please,who isn't?) we now have a new DSM IV diagnosis called "Snow Depression". This occurs, of course, when you have had just too much of the white stuff. 

Worried you might be suffering from snow depression? Below are a list of symptoms so you can tell when you have come down with snow depression*: 

So, if any of this sounds vaguely familiar you may be afflicted with "snow depression". Here, in the Boston area there is only one cure...knowing that the Red Sox are at their spring training complex in Florida, and the days are getting longer. 

Now, don't you feel better already? 

*Snow depression is not a real diagnosis. 

Rich Caplan has been a social worker since 1982. He specializes in addictive disorders and strongly believes in the healing power of laughter. His book, "Do I Really Have to Read This?" (a book for men about relationships) is available at Barnes and Noble.