Category Archives: About Psychotherapy

Thoughts on Psychotherapy for Therapists

Thoughts on Psychotherapy for Therapists

As a psychotherapist, you already know that “you are the tool.” And like any tool, it is important to stay in the best working order. I like to think about therapy for therapists in the same way I think about knives in the kitchen: a sharp one makes the work easier and safer, while a dull one makes the work harder and more dangerous.

Therapy for therapists falls into several categories. First, if you are a therapist who has not yet been in your own therapy (yes, a surprising number of graduate programs do not require their students to be in therapy), there is no time like the present to start. As well-trained as you may be, as good as you may be at your work, as much as your clients may love you, having had the experience of being a client is necessary and important. We are asking people to be courageous and vulnerable and we need to know for ourselves what that feels like. And unless you have done your own work, the work you will be able to do will always be limited.

Second, maybe you are a therapist who has had therapy but it has been a while. Or maybe your last therapist had an approach that was just fine back then, but your interests have changed or you feel like you just didn’t get as far or as deeply into the work as you would have liked. I have had the privilege of working with many therapists whose own approach is very different from mine, but who sought therapy with someone offering a different perspective. Therapists who have done this report that it has been helpful not only personally with respect to knowing themselves better, but also professionally in broadening their thinking about their own clients and approach to therapy.

Third, you don’t need another therapist to tell you how difficult and isolating this work can sometimes feel–you already know this. Our clients tell us many difficult things, things that we are not at liberty to share with others. Being in our own therapy offers a safe and confidential place to talk about the many stressors we encounter in our work. It can help us to look at how our own experiences, belief systems, blocks, and unresolved issues might get in the way of our work. It gives us an important and protected space to not have to try to get it right, to be able to let down our guard. We are not always our own best observer. As Thomas Ogden says when discussing the ideas of psychoanalyst Wilfred Bion, “It requires two minds to think one’s most disturbing thoughts.” (Ogden, T. Bion’s Four Principles of Mental Functioning. 2008. Fort Da 148: 11-35)

Finally, seeing a therapist yourself is a terrific way to observe–up close and very personal–another therapist at work. Sure, you are likely in a consultation group or two and you have had plenty of supervision, but talking with colleagues and supervisors is a very different from the direct experience of sitting across from another therapist as a client. It offers a unique opportunity to simultaneously be able to be inside the mind of the client (you!) and hear how a therapist responds.

Even if you have been in therapy before, returning to therapy from time to time over the course of your career can offer new insights, as each therapist is different and you will learn different things from the experience. With so many therapists now working online, this is a great time to find someone you might want to work with without the limitation of having to choose based on distance from your home or office. It also offers the opportunity to minimize the chance of conflicts by working with a therapist outside of your professional circles. Based in the San Francisco Bay Area, I am licensed in California, Colorado, and Illinois; and I am a Florida Registered Telehealth Provider. I welcome inquiries from therapists in any of these states.

Questions about psychotherapy or about my approach to psychotherapy? Please see my website at www.marlacass.com and contact me at: 415-218-2442 (phone link works from smartphones only) or at info@marlacass.com.

Why Therapy Needs to be Weekly

Why Therapy Needs to be Weekly (or more frequently)

Psychotherapy represents a significant investment of both time and money. It is because I respect the importance of this that my practice is limited to  people who are willing and able to meet weekly or more frequently.

You are probably thinking that this is a contradiction: if I recognize that therapy is time-consuming and expensive, why would I not be willing to meet with people less frequently so that more people can afford it? I hope this blog post will help you understand why meeting with your therapist at least weekly is so important.

For most of us, when we spend money or give up our valuable time, we usually expect something in return. When it comes to spending time and money on therapy, we are naturally expecting something from the experience: maybe you want to feel better, find new ways to understand yourself, reduce your anxiety, have a safe place to talk about your life, or receive some other benefit. Therapy is costly and it can be uncomfortable. Looking at ourselves and our problems is not easy! You choose to do it because you want to see results for your time and effort.

But when people go to therapy less frequently than weekly, there are things that happen or, perhaps more importantly, don’t happen, that can get in the way of seeing results and from truly seeing a return for the time and money they are spending. Here are some of the things I have observed:

  • It is much harder to build a solid therapeutic relationship when you see your therapist less frequently. Almost every approach to therapy recognizes the importance of this relationship as foundational;
  • Your therapist never gets to know you well enough to offer the kind of insight that can only come from knowing a person deeply–or it takes so long to get to know you that valuable time is lost before the work can deepen. You might even become frustrated and decide it isn’t worth continuing with your therapist;
  • The continuity of the conversation that takes place in therapy gets lost, e.g., it is hard to hold onto the thread of what is being worked on or to keep track of important topics have come up but have not yet been discussed. Or something big came up since your last session and you never get back to what you last talked about because there isn’t enough time;
  • When people come to therapy less frequently, considerable time is spent updating your therapist on the events that have taken place since the last meeting. There is a lot less time available for the deeper work of therapy;
  • Some of what happens in therapy, while it can’t always be described, happens as a result of continuity–the knowledge that you have set this time aside to focus on yourself and your life. Knowing this, people can “hang on” when they are having a hard time because they know they will soon have a chance to talk about whatever is going on for them;
  • You may decide–consciously or unconsciously–to avoid difficult topics because there isn’t time to talk about them and work through them;
  • Or you may decide–consciously or unconsciously–to avoid difficult topics because once you open up a topic, you won’t see your therapist for two whole weeks and this is a long time to wait before you can talk about it again;
  • You might find yourself frustrated with therapy because you don’t feel a connection to your therapist or because nothing seems to be happening;
  • You may be thinking that every other week is just fine, but you may not be fully aware of your unconscious motivations. For example, you might be thinking that it is about finances, but maybe it is about something else. Some things to consider: are you comfortable with close relationships? What happens when someone tries to really get to know you? Does the thought of being close to someone or allowing someone to really know you feel energizing or like you want to run screaming from the room? If you see yourself in this paragraph, going to therapy less frequently may simply replicate issues in your life that do not serve you. Therapy is about looking at things in as safe a way as possible, even when they are scary;
  • You may have other reasons for not wanting to meet weekly such as discomfort with spending money on yourself, prioritizing the needs of others over your own needs when it isn’t necessary, not making time for yourself, or there may be fear about what you might find out if you saw a therapist weekly;
  • You might be worried that you won’t have enough to talk about every week. In fact, some of the most important therapy sessions will occur when you don’t know what to talk about. If you are working with a good therapist, these sessions are great opportunities to look “under the hood,” so to speak, to see what is happening for you when the problems and distractions of daily life are not the topic of conversation.

Many people feel that opting for every other week therapy is a way to spend less money but, in fact, it is likely that they will spend more money in the end and get less out of the experience.

Consider your own reasons for wanting to meet less frequently. Is something other than time and money standing in the way of getting the help and support you need? Are you afraid of what you might discover about yourself? Are you experiencing shame or other uncomfortable feelings when you think about the things you want to talk about in therapy? One thing worth mentioning is that enthusiastically embracing the idea of weekly therapy is not a requirement for going to therapy! When you contact a therapist to see about starting therapy, express your concerns about this and listen to the response.

Although I have given many reasons why you should consider weekly therapy, finances are real and important and cannot be ignored. Therapy is expensive. What do you do if you want to see a  therapist but money is an obstacle? Rather than settle for every other week, consider the following:

  • If you have insurance, find a therapist who accepts your insurance. Be cautious and make sure you understand what your plan covers so that you don’t end up with unpleasant surprises. Some of the risks of going this route are:
    • Your plan may only cover a certain number of sessions, which may be less than what you need or want. This could get in the way of digging deeply into the issues you are bringing to therapy;
    • Your therapist may decide to stop taking your insurance (insurance typically involves considerable paperwork for the therapist, along with significantly reduced payment from insurance companies, which is why many therapists choose not to accept insurance) or you may change jobs and end up with a different insurance plan that your therapist doesn’t accept;
    • When you use insurance, your therapist has to give you a diagnosis. It is possible that this could cause problems down the line if an insurance company decides to call your diagnosis a “preexisting condition”;
    • While therapists are legally and ethically obligated to maintain your confidentiality (with certain very specific exception such as if you are danger to yourself or someone else), insurance companies are under no such obligation;
    • Because accepting insurance requires considerable additional paperwork and pays therapists a very low rate, many experienced therapists do not accept insurance. This may mean that it will be difficult for you to find someone with openings, the therapists who accept your insurance may be less experienced, or the therapists who have openings may not feel like the best fit for you. Unfortunately, when you use your insurance, you may have fewer choices.

Here are some other  options for paying for therapy:

  • Check with your insurance for out of network benefits and ask your therapist to provide you with a “superbill.” A superbill is a type of receipt for services. In most cases, you would pay your therapist directly and then receive the superbill and submit it to your insurance company for reimbursement. Most therapists are willing to provide a superbill upon request. Or use the money in your flexible spending account, if your company offers this. Some downsides to these options include:
      • You will have to pay your therapist directly and then submit the superbill to your insurance company. This means you might have to wait for the reimbursement;
      • You will likely be reimbursed for a percentage of the actual cost of your sessions, which means that you will have to pay for more of the actual cost of the therapy;
      • Your plan may have a high deductible that needs to be met before you will see any money from your insurance company;
      • Your therapist will have to give you a diagnosis which could be seen as a preexisting condition;
      • Your insurance company may not reimburse for out of network providers;
      • If you use your flexible spending account, this will help offset some of the cost of your therapy, but the rules will not allow you to set aside enough money to cover everything.
  • Look for a training center. There are many training centers in the Bay Area that provide excellent services. Some of the places I routinely suggest include Access Institute and the Marina Counseling Center, both in SF; and The Psychotherapy Institute in Berkeley. Your therapist will likely be someone who is gaining experience towards licensure and is working under an experienced, licensed therapist. Some downsides to this approach are:
    • Your therapist will eventually leave the training center when they have completed the program and you will be assigned to someone new;
    • The fees vary and are based on your income. The fee can often be surprisingly similar to seeing a therapist in private practice;
    • You will likely be assigned to a therapist, although most places will ask if you have any preferences, e.g., a male or female therapist, a therapist of color, etc., and try to match you IF there is someone on staff who meets your requirements AND has openings. Again, you will have less choice.
    • Be sure that the training center you choose offers individual supervision for each of their therapists in training. This way, you can be sure that your therapist is getting appropriate guidance so that he or she can be helpful to you. There are a surprising number of training centers that do not offer this.
    • If you request a sliding scale fee, you may have to provide documentation regarding income before your fee can be determined.

Ultimately, only you can decide what you can afford to pay for therapy and what will work for your budget. Before you decide to meet with a therapist who is willing to work with you every other week, please consider whether this is really what you want and whether it will help you get to wherever you might want to go. For most people, a much better option is to try to find a therapist with fees you can afford so that you can attend weekly.

Questions about psychotherapy or about my approach to psychotherapy? Please see my website at www.marlacass.com and contact me at: 415-218-2442 (phone link works from smartphones only) or at info@marlacass.com.

Reviewing Therapy

Reviewing TherapyRelational Psychotherapy for Therapists

One of the values of the internet is that it not only provides opportunities to easily find the services we are looking for, it also gives us a chance to see what others are thinking about those services. While we probably don’t know the people who have written these reviews, we trust that they are mostly honest and fair, and, at a minimum, are offering some useful information on which to base our decision as to whether or not to use a given service.

To the extent this might work for some services, many services do not fit this model at all or, at least, only fit with some major caveats. Psychotherapy is an example of a service that fits awkwardly, at best.

Therapists are ethically prohibited from soliciting reviews

Something most people do not know, including many therapists, is that therapists are ethically prohibited from asking someone they have worked with to write a review for them. Some therapists who are aware of this ethical requirement try to get around it by having signatures on their email that include language such as “Like me on Yelp,” which delivers a strong hint that the therapist would appreciate an online review. Arguably, this is not keeping with the spirit of the ethics of the profession.

If you think about this, it is easy to see how being asked to write a review for your therapist can be a conflict. If my therapist asks me to write a review, I might do it to please her or because I want her to like me (or not dislike me!). It might cause me stress when I start to worry about whether I wrote the “right” thing. If I refuse, will my therapist be angry? How honest can I be? What if I say something negative? Will it get in the way of the work we are doing? You can see how this can quickly turn into a conflict and potentially take the therapy off course. This is a big reason why almost all of the therapist codes of ethics prohibit the solicitation of reviews.

In addition, therapy is supposed to be about you, not about your therapist. When a therapist asks (or even hints) that you should write a review, the needs of your therapist are getting in the way of your needs. This is not what therapy is supposed to be about and, in fact, is a violation of ethical standards.

So why do some therapists have so many reviews on social media?

Despite this, some therapists have dozens and dozens of reviews on sites such as Yelp. How does this happen? In some cases, the therapist may not be aware that asking clients to post to social media on their behalf is ethically prohibited and s/he may be unwittingly asking clients to do this. Or the therapist may know that what they are asking is inappropriate but might be assuming that the client doesn’t know the ethical standards of the psychotherapy world so it isn’t a problem. Many businesses routinely ask their customers to review them, so they assume clients will not think anything of the request. In other cases, the therapist may offer classes and workshops and groups and the reviews may be a result of many enthusiastic attendees who have not actually been in therapy with the therapist.

The theoretical orientation of the therapist may play a role, as well. A therapist who primarily works with people for short periods of time on specific issues will have many more people passing through his or her door than someone who primarily works with people who are looking for a longer and more depth-oriented experience in therapy.

Often, the population with which the therapist works may be a factor. For example, a therapist who works with young children may have few reviews because young children are (usually!) not writing reviews and busy parents (usually!) don’t have the time. A therapist who works with older adults may not have any reviews because the people he or she works with are not active on social media.

On the opposite end of the spectrum, a therapist who focuses on services for people in the tech industry may have many reviews because tech people are usually more comfortable with social media. But for most people, psychotherapy is a uniquely private matter, which means that they are not likely to be writing online reviews about their therapist.

In the end, however, the number of social media reviews for a given psychotherapist is dependent on many factors and may or may not be a reliable source of information.

Some ideas on how to find a therapist

If you can’t rely solely on reviews, what should you do? Read the online profile(s) for therapists and see who resonates with you. Try to be specific when you search on Google or look at sites that have profiles set up by therapists in your area, such as Psychology Today or Good Therapy. Consider whether you are you looking for help with a specific issue or whether you want to focus on looking at yourself at a deeper level. Is there a particular approach to therapy that interests you? Has a trusted friend worked with someone who might be a good fit for you? (This can present additional complications, especially if your friend is still working with the therapist, so make sure to check with your friend and with the therapist to make sure everyone is ok with this.) Gather information, contact the therapists who sound like they are interesting and could be helpful, and then talk with them and meet with them in person.

Consider the bigger picture when choosing a therapist

Online reviews can be helpful, but they are just one data point to consider. Don’t let a lack of social media visibility deter you from contacting a therapist who might be just the person you are looking for.

Questions about psychotherapy or about my approach to psychotherapy? Please see my website at www.marlacass.com and contact me at: 415-218-2442 (phone link works from smartphones only) or at info@marlacass.com.

The Experience of Therapy

The Experience of Therapy

It can be helpful to keep in mind that, regardless of how stuck you may feel, there are many opportunities to view the world through a different lens. Many years ago, I read a poem about washing dishes.[1] The poet, Al Zolynas, made this ordinary task sound like a fascinating exploration. His poem offered an opportunity to look at something we have seen and done countless times, yet experience it in an entirely new way.

Thoughts and Feelings

I think that psychotherapy is a lot like this poem. In therapy, we take the events of our lives and their accompanying feelings and embark on an exploration in the hope that we will find a new way to see. We consider the content—the moments that have caused us grief or sadness or disappointment—and allow these buried thoughts and feelings to come to the surface. Some of what might emerge may be painful feelings that seem almost unbearable, but in the safety of working with a trusted person, we can stop keeping them in the darkness and allow them to be seen.

Like vampires who can’t bear the light of day, many of these old feelings will dissolve under our gaze while other feelings will find a way to tell us that they are reluctant to emerge. Even if it is not yet possible to look directly at some of our buried feelings, we might be surprised to find that they can often lose some of their energy and power in the course of our exploration. Just like light illuminates our path even though we don’t look straight into the sun, we can often change how we think and feel about things without looking directly at the source of the pain.

“Therapy is what happens when you are doing something else”

How does this happen? I like to say that “therapy is what happens while you are doing something else.” The conversation between you and your therapist looks like, well, like a conversation. I am often asked “what should I talk about in therapy” and I always respond that the answer is to talk about whatever you want, whatever matters to you. While you are talking with your therapist, the quiet and often mysterious work of therapy is happening in the background.

Helping you understand your partner

Some of this is simple and straightforward: for example, if you are having a problem with your partner or with your relationship and you talk about it with your therapist, you are thinking it through, formulating the words you would want to use, and practicing how you will say them. You might not be consciously thinking that this is what you are doing, but it is happening in the background. When you and your partner are together, you are likely to find that the words come more easily and you are able to talk rather than retreat or become angry.

…and your worklife

Some of it is more subtle: your boss keeps making you mad and when you talk about him with your therapist, you are not in the heat of the emotions and you can suddenly see how he reminds you of your alcoholic father. With this insight, you can be more compassionate with yourself when you are triggered, get grounded more quickly, and move on with your day. Underneath all of this is a sense of being deeply understood that helps you build more confidence to handle whatever life throws at you.

Seeing things in a different way

Psychotherapy is often called “the talking cure,” but, as you can see, talking is just what we are doing while something else is taking place behind the scenes. Our ever-increasing knowledge about how the brain works shows that our brains can actually “rewire” themselves: the neural pathways actually change when we start to see things in a different way. This can potentially lead to feeling less triggered and to a quicker resolution when things get bumpy. So even though it seems like you are just having a conversation, what is actually happening is far deeper and more beneficial!

[1] Addonizio, K. & Laux, D. (1997). The Poet’s Companion: A Guide to the Pleasures of Writing Poetry. New York, NY: W.W. Norton and Company, Inc.

Also available online by searching “The Zen of Housework.”

Questions about psychotherapy or about my approach to psychotherapy? Please see my website at www.marlacass.com and contact me at: 415-218-2442 (phone link works from smartphones only) or at info@marlacass.com.

Supervision of Mid-Life Supervisees

Supervision of Mid-Life Supervisees

This article first appeared on May 1, 2018 in the newsletter for the San Francisco Chapter of the California Association of Marriage and Family Therapists. Click here to read the original article on the SF CAMFT website.

Feature Article:
Supervision of Midlife Supervisees

By: Marla Cass, LMFT

One of the many interesting things about the practice of psychotherapy is that it is a profession that attracts people from a wide range of backgrounds. Unlike many career paths, becoming a psychotherapist does not require any particular background prior to graduate school, aside from a college degree and a few psychology courses. As a result, becoming a licensed psychotherapist is a career people can pursue later in life, often after being in other professions and after considerable life experience. To add to the appeal for older career changers, it is also one of the few careers in which being older is actually valued.

The transition from being in other professions to becoming a psychotherapist, however, is not an easy one. Many older Interns/Trainees/Associates are moving from careers in which they felt competent and were recognized in the form of praise and compensation. While they may have anticipated the challenges of returning to school as older students, they are often ill-prepared for the experience of working under a clinical supervisor.

Psychotherapy supervision is a hierarchical model that requires that the supervisee take direction from the supervisor. This may be an efficient and arguably necessary structure (not to mention a legal requirement), given that the supervisor has more experience in the field and the supervisee is working under the license of the supervisor. However, it often fails to recognize the unique perspective that an older supervisee brings to his or her work, as well as the psychological difficulties involved in transitioning from a person who felt competent in his or her job to being a person who now needs to take direction.

Coming to this work with considerable work and life experience is certainly an asset with respect to understanding clients, but it can also be a liability when it comes to learning to become a psychotherapist. For example, it can be difficult to grasp the many ways in which the role of a psychotherapist is different from whatever role they may have had in their previous profession. And even where similarities may exist, therapists may approach seemingly similar situations very differently from people in other professions.

In addition, supervisees are expected to talk about their feelings and personal reactions to their work with clients, and to be vulnerable with their supervisors. In most professions, however, talking about feelings and being vulnerable with peers and superiors is inconceivable. It may take a supervisee time to adjust to this cultural shift and the process may be slow and difficult. This can be puzzling to supervisors, especially to supervisors who have primarily worked in the field of mental health where such openness is expected and normal.

As an older supervisee, it can help to slow down and try to understand the perspective of the supervisor. What is the underlying reason for the supervisor’s position? Ask questions about the concepts you are being taught and listen to the answers with an open mind. Recognize that learning to be a clinician is also an entry to a language and professional culture that may be very different from that of your previous profession.

For supervisors of older supervisees, it is helpful to recognize the experience the supervisee brings to his or her work and to consider how you can make use of this in supervision. Keep in mind that older supervisees may be used to dealing with their superiors in a very different way, as compared to younger supervisees. Older supervisees are more likely to challenge their supervisors when there is a difference of opinion, and it can be harder for them to take direction when there is disagreement. The emotional upheaval of being the learner rather than the teacher can be disconcerting and lead to frustration and impatience. Older supervisees may also feel the need to display a level of confidence that may not match the uncertainty they feel inside.

While supervision is not therapy, many of the same principles apply: listen closely, ask clarifying questions, try to understand the underlying feelings, and consider how the past experiences of the person in front of you may have impacted him or her and be showing up in your work together. Think about the transference and countertransference that may be occurring in the supervisory relationship.

Don’t forget about the cultural issues and recognize that psychotherapists have their own culture, too, which can present a steep learning curve for supervisees, especially those new to the field. Keeping these tools in mind will not only help clinicians get the most out of supervision and supervising, but they will also help to make them the best therapists and supervisors they can be.

Marla Cass (MFC 45402) is in private practice in downtown San Francisco. Her focus is on working with women who are successful in their careers but not in their relationships. She has been a group supervisor at The Boulder Institute for Psychotherapy and Research, Pacific Center, and The Women’s Therapy Center; and is currently an individual supervisor for Queer Life Space and Community Institute for Psychotherapy. For more information, please see her website at www.marlacass.com.

Questions about psychotherapy or about my approach to psychotherapy? Please see my website at www.marlacass.com and contact me at: 415-218-2442 (phone link works from smartphones only) or at info@marlacass.com.

Therapy is About Mental Health

Therapy is for Problems…And a Whole Lot More

One of the concerns often faced by people thinking about psychotherapy is that psychotherapy is commonly associated with mental illness, rather than with mental health. This has created a stigma that, sadly, keeps many people from seeking the help that they deserve.

Daniel J. Siegel, a psychiatrist and author of numerous books about the brain and neuropsychology (the understanding of how the brain works and how to make use of that understanding to help people) poignantly begins his presentations to therapists by asking: “who here has had a class on mental health?” In a room with one hundred or more therapists, perhaps five or so hands will go up. This is a problem for psychotherapists and for the people we serve.

Therapy is for: relationships, confidence, personal growth, and more

With members of the public associating therapy with mental illness and therapists themselves primarily receiving training in how to work with mental illness and not in how to foster and support mental health, it is no wonder that therapy is most often seen primarily as a treatment for severe mental and emotional problems–and often dismissed by people who could benefit from it. Many people who find their way to therapy often experience intense shame because of this association and we have no way of knowing how many people never see a therapist at all because of this shame.

Of course, psychotherapy can be very helpful to people who suffer from specific problems such as depression, anxiety, PTSD, etc., but the benefit of therapy are not limited to just people with particular problems. Many people turn to therapy as a way to understand themselves better—why they do what they do, what events happened in their past that have shaped them, and how they might reassemble these pieces to create a more satisfying life.

You Can’t Always Do It Alone

While it may seem like it would be easy enough to do this work on your own, and, to some degree, that is certainly one way to approach this, there is no substitute for what happens when two (or more) people meet in a room with the sole purpose being the understanding and personal growth of one of them. Many psychotherapists have a word for this: the “third,” meaning that something new and unique is created that is the result of the combining of the conscious and unconscious minds of two people. The “third” can only be created by the two specific people interacting. A metaphor from chemistry class might help: oxygen and hydrogen atoms combine to create water, which is greater than the sum of its parts.

Therapy as a Place to Talk and to Listen

Another purpose of therapy is simply to have someone to talk to who will listen, offer ideas for thinking in a different way, and, most importantly, does not ask anything from you in return, other than for you to be there at the agreed upon time and to pay a fee for that time.

The content of what is talked about may vary greatly from week to week, from dealing with pressing problems to understanding yourself and your relationships in a deeper way. Regardless of what is talked about, being able to share your inner thoughts and feelings with a trusted therapist can help you to let go of some of the things that weigh you down and hold you back without the added burden of having to take care of the other person.

Surprising Voices for Mental Health

Although I am admittedly not much of a podcast person, I was recently moved by a podcast that was featured in the Daily Telegraph by Bryony Gordon, a columnist for the newspaper. In her series, Gordon speaks with different guests about their own mental health and how they have dealt with problems. As she introduces us to the podcast, she reminds us that “the point is, mental health issues affect everyone; one in four of us…it is really, really, really normal to feel weird. In fact, it is weirder if you feel normal the whole time.”

In the first podcast of the series, Gordon interviews Prince Harry, who speaks quite candidly about his own experiences with therapy and how talking with a therapist has helped him. (If you are interested in listening to it, here is the link:  https://bryonysmadworld.telegraph.co.uk/e/mad-world-prince-harry/.)

And in another great article, basketball star Kevin Love talks about how therapy helped him deal with depression and anxiety attacks: https://www.theplayerstribune.com/kevin-love-everyone-is-going-through-something/. As more and more public figures talk about how therapy has helped them, hopefully, more and more people will feel comfortable seeking the help they deserve.

Questions about psychotherapy or about my approach to psychotherapy? Please see my website at www.marlacass.com and contact me at: 415-218-2442 (phone link works from smartphones only) or at info@marlacass.com.

Therapy: Not Just For Problems

Therapy: Not Just For Problems

Why do people come to therapy? Therapy, on the surface, can seem like a very strange thing to do (What! Tell my problems to a therapist??) and it is surrounded with misconceptions. It involves a commitment to show up at a certain time at a certain place and pay money to talk to someone you don’t know about things you may have spent years of your life avoiding. It can feel uncomfortable and can stir up things you have tried very hard to ignore. To make matters worse, having made that commitment to spend all that money to talk about things you don’t want to talk about, you will probably put pressure on yourself to change something in your life. After all, if we are taking up time and spending money, we expect something to happen, right? This doesn’t exactly sound like something most of us would sign up for. So why do it?

Ok, Sometimes, Therapy IS For Problems…

Many people see therapy as a necessary evil; as a place to go to talk about a problem that needs solving. Usually, the person coming to therapy has tried a lot of things before picking up the phone or getting on the internet. For example, she or he has likely talked with friends, thought about the problem, tried some possible solutions or distractions, and maybe read some books that might be relevant to their situation. After exhausting everything they can think of to do and discovering that the problem is not resolved, therapy might start to sound like a good idea.

Often, these people come to therapy with a very specific issue and a very specific goal. Coupled with this might also be a very specific time frame in which they would like to accomplish the work and arrive at a solution. This approach can work very well in cases where the problem is well defined and the person has already made some progress with respect to resolving the problem.

Unfortunately, our minds and our problems don’t always work in a linear fashion and, much like a home remodel, it is a good idea to have some room for unexpected things that may surface. At first glance, a problem may look like a problem, but looking under the hood, so to speak, may reveal underlying causes that require deeper investigation. In such cases, the problem may actual be a symptom of another problem.

For example, a couple may come to therapy to look at the way they argue. Helping them find ways to argue less will be helpful to a point, but understanding that they each come from families where every conversation turned into an argument will create a level of understanding that can lead to lasting change that feels more authentic than memorizing a script on how to argue less.

But Sometimes, It is for Personal Growth…

For another group of people, however, therapy is not specifically about solving a particular problem, but about looking at the problem of being human in a complex world. There are very few places where our inner life can receive such careful and gentle attention.

For these people, therapy is a place where the noise of their day to day life is quieted, at least for a short time, and they and their therapist become absorbed in the intricacies of observing something that is not always visible. Like a scientist observing the world through a microscope, looking at your life through the lens of psychotherapy can open up worlds that are fascinating and enlivening and can lead to a richer and fuller human experience.

Have you thought about what it might be like to take an hour out of your week to look at yourself? What might get opened up for you? What thoughts and dreams do you

And, Often, Therapy is About Not Having to Do It Alone.

For a third group of people, therapy may not be as much about problem solving as about problem management. Sometimes, things just are what they are and the solution is not necessarily about trying to find a fix to an unfixable problem, but in learning to accept the problem as it is, or having a safe and confidential place to talk so that it doesn’t feel like you are holding onto the problem alone.

People who fall into this category are often similar to people who come to therapy to look at their inner life, but, for people in this third category, there is a specific topic or issue that remains at the center of the therapy work. Talking about it with another person can create the space to manage the problem and let go of some of the overwhelm that may accompany it.

While most people come to therapy with the goal of fixing something or feeling better about their lives, therapy is not always something that needs a goal. Like Zen, the process of being in therapy can, in and of itself, create rewards that we could not have anticipated.

Questions about psychotherapy or about my approach to psychotherapy? Please contact me at 415-218-2442 (phone link works from smartphones only) or at info@marlacass.com.

On Choosing a Therapist, Part 3

On Choosing a Therapist, Part 3

This article first appeared in the former online blog, Psyched in San Francisco, on May 29, 2014. The complete text appears below:

On choosing a psychotherapist (part 3 of 3)

In Part 1 of this series, we looked at the various licenses and certifications that psychotherapists hold and at some of the similarities and differences among them that are wise to consider when choosing a psychotherapist. In Part 2, we explored some of the best ways to find a psychotherapist. In this article, I will talk about some of the many approaches to psychotherapy and when it might be important to consider a therapist who practices from a specific theoretical orientation. I will also offer some ideas to keep in mind when choosing a therapist.

Different approaches

In addition to information regarding licensing and degrees, you may also see other words or letters following the therapist’s name or listed on their website. These words or letters usually indicate that the therapist utilizes a particular approach to therapy. When deciding to work with a therapist, you will want to decide whether their approach resonates with you. For example, some approaches, such as CBT (Cognitive Behavioral Therapy) or Solutions Focused Therapy can be very directive. Therapists who are directive may instruct you to do homework that will be discussed in the next session or suggest techniques designed to help you solve a specific problem. Other approaches, often called “client centered,” offer less direction. In a non-directive therapy session, the client takes the lead while the therapist provides reflection and understanding, leading to greater self-awareness and personal development. Most therapists are somewhere in the middle, utilizing their education, training, and experience to help you find your own path.

Some approaches to therapy offer certifications to document that the therapist has obtained special training in working with people who are dealing with specific issues such as addictions or eating disorders. Therapists may also train in therapeutic approaches such as Gottman Couples Training or Eye Movement Desensitization and Reprocessing (EMDR). The requirements for obtaining a certification can range from taking a few brief workshops to many years of advanced study. Other therapists take a more general approach to their professional development and opt to explore a wide range of approaches, depending on their interests and the populations they serve. Regardless of whether a therapist has sought specific training or not, all California-licensed therapists are required to obtain many hours of continuing education each year, including regular continuing education in the subject of law and ethics.

Should I look for someone who subscribes to a particular theory?

In some cases, seeing a therapist who uses a particular approach or theoretical perspective may be very helpful. For example, DBT (Dialectical Behavior Therapy) is an approach that was created to help people struggling with a diagnosis of borderline personality disorder. It makes sense for a person with this diagnosis to consider whether they should work with a therapist who uses this approach, even if they may ultimately decide to work with someone who uses a different approach. For most people, any number of approaches can be helpful.

One important consideration is whether you feel you would work best with a therapist who is or is not interactive. In other words, would you prefer to work with someone who primarily listens to you or would you rather work with someone who approaches therapy as a conversation? Often, the theoretical approach of the therapist may give you some idea about how interactive he or she may or may not be. For example, analysts tend to speak less and CBT therapists tend to speak more, with most therapists falling somewhere in between. Most therapists are happy to briefly talk about their approach in an initial phone conversation; however, there is no substitute to meeting someone in person to get a sense as to how she or he works.

Keep in mind that even the most interactive therapist may be reserved until she or he has a chance to hear your story or, conversely, a less interactive therapist may have many questions as he or she begins to work with you. As a result, it is helpful to use the first few sessions as a “trial period” to make sure you are comfortable with the therapist and his or her approach.

OK, so how do I choose someone?

If you are seeking help for a specific issue, you may decide to look for a therapist who has experience in working with that issue. It may seem strange to suggest that you may want to look for a therapist with specific experience, rather than recommend that you should. There are two reasons for this: first, the connection you feel with your therapist is almost always the most important factor to consider. While there are some exceptions to this rule, the research shows that a therapist with whom you feel comfortable will generally be the most helpful to you, regardless of his or her theoretical approach. The experience a therapist has working with your particular issue is important, but it may not be helpful to you if you do not feel comfortable with the person. Second, depending on the therapeutic approach of your therapist, the original problem that led you to therapy may take you in many unexpected directions. A good therapist can skillfully work with you regardless of which direction the path may lead—and will tell you if he or she does not feel qualified to help. In these situations, you will be offered referrals and assistance with finding the right person. While it can be discouraging to hear that a particular therapist is unable to help, it is also an opportunity to make sure that you are working with a therapist who will be right for you.

The bottom line

So whom do you call when you are looking for a therapist? For some situations and diagnoses, finding a therapist who has skills in working with your particular issue may be the most important consideration, especially if you are seeking help for a serious eating disorder, severe alcohol abuse, or domestic violence. If you are seeking help with something that is specific to a particular license, e.g., if you are interested in medications, the only practitioner who can prescribe them is a medical doctor. For most people, however, the biggest consideration should be the fit, not the license. If you don’t feel like the therapist sitting across from you is someone you can talk to, it is wise to keep looking.

Psychotherapy is part science and part art. The science comes from a variety of places, including studies that have been done using various psychotherapy techniques, and current research on the brain using imaging equipment that allow scientists to literally see the changes in neural pathways that are the result of psychotherapy. The art comes from the fact that each therapist and each person coming to therapy is unique and what happens when the two sit down together is also unique. Because of this, there is no precise formula for doing therapy or for finding the right therapist.

While all of this may feel overwhelming as you look for someone to work with, the process also holds the potential to find the person who can be most helpful to you. Take the time to narrow your list down to two or three people who sound like they might be a good fit, speak with them briefly on the phone, and then sit down with each of them and see how it feels. Once you have decided on the person with whom you would like to work, give yourself a few sessions to make sure you feel good about your decision. From there, the possibilities are endless.

On Choosing a Therapist, Part 2

On Choosing a Therapist, Part 2

This article first appeared in the former online blog, Psyched in San Francisco, on May 12, 2014. The complete text appears below:

On choosing a psychotherapist (part 2 of 3)

In Part 1 of this series, I reviewed some of the various licenses and certifications that psychotherapists hold, as well as some of the similarities and differences between them; in Part 2, I will offer some ideas to consider when choosing a psychotherapist.

A world of information

We live in the information era. The World Wide Web offers us endless options to help us find what we need. In addition to being a resource for finding whatever it is we are looking for, the web also offers reviews and opportunities to post to social media pages and listservs to learn about the experiences other people have had with a product, service, or company. These resources are incredibly useful and many people have come to rely on them for making decisions from what kind of car to buy to where to eat dinner. So it may seem obvious that these same resources can help find a psychotherapist, right?

The answer to this question is yes, but with some important qualifications. Technology, of course, can be a fantastic resource. Websites can provide helpful information about a therapist’s approach to therapy, his or her training, the kinds of people she or he works with, and the various issues she or he specializes in. Even if you are given the name of a highly recommended therapist (more about this later), it can be very helpful to start by looking at his or her website.

Searching for a therapist

Search engines offer many ways to look for therapists in your city, neighborhood, or ZIP code. You can search by the topic you need help with, by the kind of therapist you are interested in working with, or by a particular approach you may be interested in, for example, “Spanish-speaking psychotherapist 94102 couples.”

In addition to a direct search using a search engine, you might go to one of the many online therapist databases such as Psychology Today or Good Therapy. These databases can contain hundreds to thousands of therapists who have put together one-page sites highlighting their work. Typically, these pages include a photo, a short description of the person’s approach, and bulleted lists detailing areas of interest and expertise. The databases have their own search engines that allow you to focus your search by location, gender, and areas of specialization.

One consideration in using technology to find a therapist is that many excellent therapists do not (yet!) have websites. If you have been referred to a therapist who does not have a website and you are interested in learning more about his or her approach, you will need to call. Most therapists are happy to speak with you on the phone for a short period of time and answer some of your questions before meeting in person. Regardless of how you found the therapist, take advantage of this opportunity to learn more about whether the person might be a good fit for you.

The pros and cons of using insurance

If your insurance covers psychotherapy services, the insurance company may be able to provide you with referrals. While insurance can be very helpful when seeking services, you should also consider some of the downsides of using insurance, such as limitations to the number of sessions covered by insurance, the need for the therapist to provide a diagnosis that will become a part of your medical file, the possible loss of confidentiality when information about the work you are doing in therapy gets passed along to the insurance company, and the possibility that only “medically necessary” diagnoses will qualify for treatment.  Also, while there are many excellent therapists who accept insurance, the screening process done by the insurance companies typically looks at things that may or may not be important to you and your situation, for example, years of experience, languages spoken, or expertise in a particular technique. Some insurance companies will only authorize short-term therapeutic techniques, so you will want to clarify what your plan covers. Once you have obtained a list of therapists who accept your insurance, it is still wise to interview the therapist to make sure that his or her approach is one that makes sense for you and your situation.

Some plans offer out of network coverage, which may allow you to select your own therapist and submit receipts for reimbursement. When using insurance, whether in or out of network, be sure to check your plan and make sure you are familiar with what is and is not covered.

Can’t I just ask someone?

It may be tempting to ask friends or family members about their therapists. After all, if you and your best friend agree about everything, perhaps you will like her therapist as much as she does. The answer to this is…maybe. First, each person brings his or her own unique history and perspective to therapy and what works for your friend (or family member or neighbor or co-worker) may not work for you. Second, it may feel strange to work with someone your friend knows. Will it be distracting to imagine your friend sitting in the same chair that you sit in when you talk to your therapist? What if you ran into each other before or after your session? What if you have an introductory session and don’t like the therapist your friend thinks is terrific? Most therapists will avoid seeing people who know each other, but even if the therapist is fine with this, you should carefully consider whether this would work for you. A better approach might be to ask your friend to ask his or her therapist for a recommendation. Therapists are happy to recommend trusted colleagues and you and your friend can avoid some potentially awkward situations.

Can I trust the reviews?

If you like to read reviews before you make a decision, you may already be thinking that you will start your search by turning to your favorite review site. Again, the answer here is…maybe. Many people consider psychotherapy to be a private endeavor and even people who are active users of social media and review sites may refrain from writing about their experiences in therapy. For this reason, you may find few, if any, reviews for a given therapist. Even if you find many reviews, each person is unique and the experience each person will have with the same therapist will be unique. As a result, using therapist reviews to decide on a therapist can be tricky. It is helpful to keep this in mind when doing your research. This is one arena where the opinions of others should be read with caution and your own sense of the therapist will likely be your best guide.

By the way, technology is not the only way to find a therapist. Some other options include: asking trusted friends and family members; asking your doctor, OB/GYN, or psychiatrist; asking a therapist, if you know someone in the field; or contacting your insurance company or Employee Assistance Program representative.

Take your time

Whether your search includes technology or word of mouth, the best recommendation is useless if you do not like the therapist or do not feel he or she can be helpful to you. Don’t “try” to like someone just because they sounded good on the web or because someone you know liked or recommended them. Use your best judgment and give the experience a few tries before making up your mind. Check in with yourself to see how this feels, think about the things the person is saying and whether any of it feels helpful, and give yourself some time to sit with your decision. Try not to be discouraged if you decide not to work with the first person you meet. Your time and efforts will be worth it.

In Part 3 of this series, we will look at some of the ways therapists approach their work and when this might be an important consideration.

On Choosing a Therapist, Part 1

On Choosing a Therapist, Part 1

This article first appeared in the former online blog, Psyched in San Francisco, on May 1, 2014. The complete text appears below:

On Choosing a Therapist (Part 1 of 3)

If you have made the decision to seek psychotherapy, congratulations on taking this first step! The journey on which you are embarking can offer a world of possibilities. Despite its many benefits, however, the subject of how to find a therapist may not yet be a conversation at your dinner table or on your favorite social media site. In what may seem like a vacuum of information, how do you find the right person to work with? What should you be considering when making your decision? In this series of articles, we will explore some of the things that may be helpful to think about as you begin what will hopefully be a useful, fascinating, and enlightening exploration.

It helps to know the language.

Like most professions, the world of psychotherapy has its own language, which can be daunting to people who are looking for help. How do you sort the MFTs from the LPCCs and the Behaviorists from the Analysts? We will begin with a brief introduction to some of the terminology so that you can make an informed decision about whom you might want to see and how that person may be able to help you.

It starts with a license.

California has five different kinds of licenses for therapists: psychiatrist (M.D. or D.O.), Marriage and Family Therapist (LMFT, MFT, or MFCC), Licensed Professional Counselor (LPCC), social worker (LCSW), and psychologist (Ph.D. or Psy.D.). What are the differences and why should you care? While people who hold any of these various licenses can all practice psychotherapy, there are differences that could be important with respect to obtaining the help you are seeking.

If you are interested in medication, the person to talk to is a psychiatrist. While your regular doctor may write prescriptions for any medication, psychiatrists are medical doctors who have extensive training in the use of psychotropic medications, the medications that are used to help people with depression, anxiety, and related problems. Most psychiatrists see people who are seeking prescription medications, although some also offer general therapy services. More typically, psychiatrists work in conjunction with psychotherapists: the psychiatrist manages the medication and the psychotherapist meets regularly with the patient for psychotherapy. Psychiatrists work in hospitals or in a group or private practice.

Although the name is confusing, Marriage and Family Therapists (MFT) work with a wide range of people, including individuals and children, as well as couples, families, and groups. MFTs usually hold master’s level degrees in counseling psychology and their training focuses on providing psychotherapy; in fact, the path to MFT licensure is the only one that focuses primarily on the practice of psychotherapy. Most MFTs are in private practice, but they can also be found in agencies and hospitals. This license is the most common mental health license in California.

The Licensed Professional Clinical Counselor license is new to California (although it is very common in other states), so you are not likely to run across it very often, at least not yet. The training of LPCCs is very similar to that of MFTs: they hold master’s level degrees in counseling psychology and work with primarily with individuals in private practice. They also have special training in working with career issues. One difference between LPCCs and MFTs is that LPCCs must complete additional training in order to work with couples and families, as LPCC training focuses on working only with individual adults and children.

Social workers (LCSW) have a master’s degree in social work. They are trained to work with people who are in need of assistance from the community. While many social workers are in private practice or work in a setting where they may see clients for psychotherapy, they are more likely to be employed by agencies where they do child welfare assessments, assist people with getting help from social service agencies, or otherwise connect people with resources. Many social workers do not practice psychotherapy at all and, instead, are in leadership roles in community and mental health service agencies.

Psychologists hold doctoral level degrees that are designated by the initials Ph.D. or Psy.D. following their name. A Ph.D. usually indicates training that focused primarily on research, while a Psy.D. indicates training that focused primarily on clinical practice. Both Ph.D.’s and Psy.D.’s have extensive experience with psychological testing. Psychologists work in a variety of settings, including private practice, hospitals, and agencies. While some psychologists choose to focus on testing, many practice psychotherapy.

In California, psychotherapists are required to be licensed to practice. A psychotherapist in training who is working on qualifying for licensure must work under the supervision of a licensed psychotherapist and must disclose this information to you prior to beginning therapy. Pre-licensed psychotherapists are called trainees, interns, associates, or assistants, depending on which license they are seeking and where they are in the licensing process.

Wait, there’s more!

Many therapists have considerable post-licensure training that allows them to include additional credentials after their names. Analysts are licensed therapists who have spent an additional four or more years studying psychoanalytic theory, usually focused on the unconscious. Therapists may say that they have a “psychoanalytic approach,” even if they do not have full training in psychoanalysis. This means that they have an interest and background in psychoanalytic thought, which may be helpful to you if, for example, you are interested in understanding some of the underlying motivations to your thoughts, feelings, and behaviors.

In Part 2 of this series, I will talk more about how to choose a therapist. Keep in mind that no matter what license a therapist holds or what their theoretical orientation may be, there is nothing more important than how you feel when you sit down to talk. Often, people seeking therapy are doing so during a difficult time in their lives, but taking the time to make sure you are working with the right person can make all the difference in getting the help you are seeking.