The Breakup: Termination in Therapy

As a therapist in-training, I always have termination in the back of my mind.  Because I am graduating in May, I am keenly aware that come June or July, I will have to say goodbye to the clients on my caseload.  Endings are hard and therapy can be such a close and intimate relationship that the running joke likens the termination process to a "break-up."  In truth however, while some of the same feelings of abandonment and rejection may arise in anticipation of the actual separation, termination is a unique type of ending.  It is one of the only relationships I can think of in which there is a controlled goodbye; there is the opportunity for closure in the way that all the textbooks say there should be.  While an ending, it is also an occasion for growth.  Both therapist and client have to face their own fears and take a magnifying glass to the way they interact in relationships (specifically, what does their history of "terminations" look like?).

The important part though, and the piece I wanted to address through this entry is how to terminate.  We had quite a lively discussion about this in my practicum class tonight: It's almost April, when do we start talking about it?  What do we say?  Is everyone as sad as I am to be leaving?  As I consider these questions for myself, I am realizing that the termination process for children, adolescents - and to a certain extent - emergent adults is precarious.  In this age range, a primary developmental task is learning how to appropriately connect to others.  Psychoanalytic theories would say it's re-parenting, Rogers would call it a "corrective emotional experience," attachment theorists such as Mikulincer and Shaver would see it as building and internalizing a secure base - no matter what you call it, therapy is one way we learn about connecting.  To just cut this off is jarring.

I don't claim to be an expert in this, but my research, reading, trial and error, training, and discussions have helped me to come up with a few guideposts that I use:

1)  As a therapist, take care of yourself during this process.  Address the feelings that come up for you.  Get supervision, go to therapy, consult.  Yalom says that as therapists we should be affected by our clients.  I deeply agree.  However, it nevertheless remains our job to hold the space for our clients.  We cannot do this effectively if we are not "keeping our side of the street clean."

2)  Help your client to understand the process.  "Termination" is a scary word that one would not typically associate with a relationship, let alone the therapeutic process.  We as therapists are sad, but we understand the process.  It makes sense to us because we have been trained in it.  For our clients, especially the ones who have never been in counseling before, the process may be unclear.  This is where I think a lot of the abandonment, anxiety, and sadness comes up - to them, especially the younger ones, we are up and leaving them.  Termination should be an ongoing discussion between client and therapist that addresses goals, achievements, and future directions.  Obviously, per the ethics code, it isn't a one time "well, I guess you're doing well so this is it..." bomb drop in the last ten minutes.  For kids and teenagers, I usually frame this ongoing "discussion" in the form of an activity that lasts over several of the final sessions.  I have them work on creating a transitional object (a collage, a worry stone, a playlist and CD cover, etc.) and use the process of creating this object as a way to talk about ending therapy.  At the end, they get to take their project with them as a reminder of what they accomplished in counseling in the ways in which they have changed.

3)  Pick a final session date.  Don't leave your client hanging.  This kind of goes along with point number two.  In the same way that is important to keep the framework of therapy (return phone calls, same appointment time and day, always end and start on time), it is also important to be clear about the ending.  It is easier to hold the space for your client and process feelings of anxiety and grief if there is not an open ended or ambiguous "event" in the future in which you will leave them.

Now let's switch seats.
From the client perspective it is important that you:

1) Ask questions.  We as therapists should be good at explaining the process, but sometimes (as I mentioned above) we get stuck or leave important things out.

2) Be an active agent in the process.  Have an open dialogue with your therapist about what you hope to accomplish in the final sessions.  Therapy is, after all, about you.  It's our job to work with you.

3)  Wait! But I'm not ready! - If therapy is ending because your therapist is leaving or your therapist believes treatment should end, talk to your therapist about these feelings.  We recognize in situations like this, it feels like we might be just cutting and running with no good reason - or like we don't understand some aspect of what's going on for you at this time.  It is important to differentiate not wanting to end from truly not being ready.  Sometimes we therapists need a little help to clarify.

4) If you are ready for termination, but your therapist doesn't seem to be getting the hint, I will refer you to this article.  It is humorous, however the points the author makes on the second page about knowing when you're ready are solid.

Regardless of where you sit - couch or therapist chair - the takeaway is just as the song says: Breaking up is hard to do.

Bibliotherapy: I recommend...

Books and other materials are often an important aspect of treatment. I often point clients who are working through a specific issue toward one (or more) of these resources.  Below I have selected some of my favorite books which I feel may benefit my clients (and other therapists) and help promote the process of change.

Parenting/Helping children and adolescents





Death/Grief



Relationships



Eating Disorders



Workbooks




For Therapists



Miscellaneous: Existential and Positive Psychology/Memoir




Do you have any suggestions? Please comment!

Count your Blessings: The Impact of Gratitude on Wellbeing

From birth we are taught to say thank you – thank you for the things that we have, for our health, and for our family. In the exciting field of positive psychology, recent research has linked the practice of gratitude with increased immune functioning, optimism, healthy behaviors, and general wellbeing. There is however some controversy over the extent to which simply giving thanks can impact wellbeing on a long-term basis. This week I ventured into the blogosphere to examine what bloggers are saying about appreciation. My curiosity centers on the method that bloggers employ to cultivate gratitude as well as the impact that gratefulness has had on their lives. The first blog I came upon is entitled Brett Boettge’s Accountability which details Mr. Boettge’s daily actions in his pursuit of personal excellence. In his post “November…The Month of Gratitude,” he discusses the dramatic impact the practice of gratitude has had on his wellbeing. His entry focuses on the process of combating the impulse to dwell on negative life events and emotions. Leo Babauta, the author of Zenhabits, frequently offers his advice in achieving personal goals, staying organized, and being productive. His post, “8 Tremendously Important Ways that Gratitude can Change your Life,” was less of a testimonial than Mr. Boettege’s entry and instead provided a comprehensive list of ways to incorporate appreciation into one’s life.
I too have been taking this month to reflect upon the things that I am grateful for in my life. I have come to believe that simply maintaining a positive mindset, especially in the face of adversity, can work immediate wonders on one’s wellbeing. In fact, stress and negative emotions are associated with poor physical outcomes such as heart disease and poor immune function. In working with clients that are struggling with a great deal o adversity, I have become increasingly interested in the positive psychology movement and recently read a study by Robert Emmons and Michael McCullough concerning the concept of gratitude journals. Their research examines the long term effects of gratitude on health and wellbeing. In their experimental study, they found that participants who kept a daily “gratitude journal (see above left)” engaged in healthier behaviors and felt more optimistic than those who recorded daily hassles or even neutral events. I like this idea for my clients, however I fear that asking a client to keep track of what they are grateful for amidst extreme hardship can be a somewhat awkward homework assignment. Part of me says "who wants to think about rainbows and butterflies when the world seems to be one dark storm after another?" However, the other half of me thinks back to the books I read as an undergraduate and graduate student: Yalom's The Gift of Therapy, Viktor Frankl's Man's Search for Meaning, Martin Seligman's Authentic Happiness... While all of these authors use slightly different terms, the idea remains the same: assigning meaning to a struggle in some way (by being thankful for what you do have, etc.) is a survival skill that has been shown in even the most adverse of circumstances to enhance resiliency.

EQ: The Role of Feelings in Intelligence

Consider 16-year old Danny. Danny just got his driver's license and is out with his friends celebrating. He promised his mom he would be home by his ten p.m. curfew. It is now 10:30 p.m. and Danny has not called and he is not yet home. His mom is pacing the living room as anger bubbles up inside her with each tick of the clock. Finally, at around 11:45 headlights turn into the driveway. A few seconds later, the door unlocks and Danny sheepishly enters the living room to greet his mother. His mom looks at him, tells him she is glad he is safe, and that they would discuss the issue in the morning. The next day, Danny's mom informs him that he has lost his car privileges for the next month. Danny is livid. He can't believe how unfair and unreasonable his mom is being and he begins to yell. Danny's mom listens calmly and then tells him "I can see that you are angry that you can't drive for a little while and I know this is tough for you honey, but you broke your promise and this is the consequence." At the time, Danny could not comprehend that his actions caused his mother to feel angry, worried, and hurt – all he felt was his overwhelming frustration.

Self-regulation and clear limits are essential to a child's ability to navigate life experiences and learn from mistakes. This development of emotional self-control has come to be called Emotional Intelligence, or EQ. Daniel Goleman, an internationally renowned psychologist and author of Emotional Intelligence: Why it can Matter more than IQ has recognized that there is a window of opportunity for teaching children EQ. The neural circuitry that allows us to pay attention, calm ourselves, and attune to others’ feelings all takes shape in the first two decades of life. He relates that this shaping can be left to chance, or it can be taught to children and adolescents as in the example of Danny and his mom. Danny's brain is still growing, so learning to identify feelings (see left) and navigate situations in an "adult" manner with the help of his mom becomes essential. These systematic lessons strengthen Danny's budding brain capacity.

“A” for Effort: Unraveling the Myth of the Self-Esteem Movement

Eleven year-old Kate just flunked yet another math test. Over the past quarter, her cumulative grade has gradually sunk to a dismal sixty four percent. She is disheartened for a moment, but immediately forgets the bad grade and cheers up as her teacher reminds the class that there is a math pizza party at lunch. Years ago, the pizza parties used to only be for the children who earned A's in class. Today however, all students get to attend just for giving "their best effort" on homework or activities. Moreover, one popular method of teaching advocates that instructors not correct students’ spelling or grammar, arguing that kids should be “independent spellers” so they can be treated as individuals. These approaches to education originate from the advent of what has been called the self-esteem movement by San Diego State professor of psychology Dr. Jean Twenge. Since its beginning in the 1980s, there has been a marked shift in the classroom from teaching self-control and respect to reinforcing individuality, "good tries," and positive emotions, regardless of the situation. In fact, there have been lasting repercussions from this change in focus: "Self-esteem is on the rise, but it's difficult to find many clear benefits of this when viewing broader cultural changes," says Twenge. "We may think more highly of ourselves, but there's little objective evidence why we should." Her comments stem from a study that she recently published in Personality and Social Psychology Review, in which Twenge and her colleagues found that college students' self-esteem has risen steadily over the past few decades. Conversely, declining SAT scores and rising rates of teen pregnancy, crime, anxiety and suicide in the students provide evidence that academic and emotional regulation skills worsened. While it may seem like an important way to encourage children to be successful and productive, merely working to increase children’s self-esteem takes the focus away from developing more adaptive life skills such as discipline and responsibility thereby rendering them ill-equipped to enter adult life.

Twenge and her colleagues liken self-esteem to a gas gauge on a car; it is an indicator of the abilities one has in their "tank." Ideally, the gas gauge should reflect the actual amount of gas in the vehicle. However, classroom activities such as having an achievement-based pizza party that includes students who are failing or beginning each day by singing "I am special, I am special, look at me!" move the needle to indicate "full" when the child may only have a half-tank. If left unchecked, this misrepresentation can morph into narcissism in adulthood. Twenge’s findings support this trend. In an examination of 16,475 college students nationwide who completed an evaluation called the Narcissistic Personality Inventory (NPI) between 1982 and 2006, she found that more than two-thirds had an above average score by 2006. This is a thirty percent increase from 1982. The NPI is a standardized measure that asks for responses to such statements as "If I ruled the world, it would be a better place," "I think I am a special person" and "I can live my life any way I want to." This concept of narcissism is not new; in Greek myth, Narcissus (see left) saw himself as more beautiful and better than those around him. He eventually fell in love with his own reflection in a pool of water and died. Surely his inflated and inaccurate sense of self was the cause of his demise. Yet, only now has high (and inaccurate) self-esteem been scientifically implicated in the development of narcissism. There is a growing body of evidence to suggest that the problem is that the narcissist's inflated self-image lacks internal support and is fragile; like Narcissus' reflection, it dissolves with the slightest disturbance of the pool.

As a volunteer teacher in a preschool, I admit I have a hard time coming to terms with the idea that teaching children to feel good about themselves is so detrimental or that it can lead to maladaptive behavior in adulthood. Intuitively, it seems like a little unwarranted boost in confidence here and there cannot hurt. In fact, we even sing the "I’m Special Song" right before story time each morning. Research nevertheless indicates that there is no correlation between high self-esteem and meaningful relationships, achievement, or perseverance in work. In fact, Twenge and colleagues suggest that there might even be a negative correlation between unduly inflated self-worth and social interaction. University of Florida psychologist Ilan Shrira and his colleagues Joshua Foster and Keith Campbell agree. In their study that surveyed 485 undergraduates at the University of Georgia who were in romantic relationships, they found that those who scored high on the NPI expressed extremely low commitment to their partners. Shrira concludes that "narcissists tend not to value relationships unless it’s for self-serving purposes." The researchers warn that egotistical individuals can appear confident-but don’t be fooled! The defining characteristic of the narcissistic college-aged individuals that were studied was "game-playing love." They were more likely to have romantic relationships that were fraught with dishonesty, infidelity, and over-controlling and/or violent behaviors. The narcissism that is fostered in early childhood produces individuals who "aren’t playing by the same set of interpersonal ‘rules’ that most people are" notes Harvard University post-doctoral research fellow Seth Rosenthal. During his fellowship at the John F. Kennedy School of Government, he too found narcissism to be problematic in relationships. At first, in groups where there is no designated leader, members are likely to name the narcissist among them as a leader. “[Narcissists] are the people who show off the most, make the most noise, have the most ideas, or at least are most likely to keep throwing them out there,” Rosenthal says. After awhile however, group members become annoyed with the narcissist. This type of vanity leads to complications in the workplace as well. Young adults are entering the work force with a false sense of entitlement. They were taught in elementary school that everyone has a right to feel good even if they fail, cheat, or steal. Shrira adds "if all you get is positive feedback as a child and your success is not based on any sort of real accomplishment, you’re not going to be motivated...” Further, their method of interaction leads to a lack of collaboration with coworkers. Employers may be facilitators though. There is little motivation to work hard when competition is outlawed in favor of celebrating mediocrity.

The solution it seems is to intervene at the school age and teach children self-regulation and self-respect instead of just self-esteem. Building a repertoire of appropriate coping skills is an important part of maturing and it is necessary for children to be allowed to fail sometimes if they are going to learn to manage difficult situations. Additionally, there is one personality trait that is definitely linked to achievement, and that is self-control. Although the words "discipline" and "obedience" have garnered negative connotation within the education establishment, people with high levels of willpower are the most likely to succeed. In her book Generation Me: Why Today’s Young Americans Are More Confident, Assertive, Entitled–And More Miserable than Ever Before (see right), Twenge argues that “Self-control predicts all of those things researchers had hoped self-esteem would, but hasn’t.” Thus, teaching regulation is key. That is not to say children should never be praised. Positive reinforcement however should be reserved for actual achievement or improvement in ability, not just the "good effort" despite the failing grade.

Friend Me: The Impact of Social Networking Sites on Friendship

Do you know anyone with 1,734 friends? If so, they are probably on Facebook and are probably a little overzealous with the "accept friend request" button. From July 2007 to July 2008, the worldwide audience (age 15 and over) of Facebook (see left) has gone up 153%. Traffic on similar webpages such as Myspace and Friendster has increased drastically as well. Given this explosion in the global use of social networking sites in the past year alone, it is not at all surprising that there has been increased attention placed on the ways in which visitors utilize these services as well as the potential impact of online friendships. The general consensus is that social networking seems to be changing the face of relationships. However, the extent to which this shift is positive is still up for debate. A study released last year surveyed 200 individuals about their digital activities. Psychologist Will Reader from Sheffield Hallam University found that "although the numbers of friends people have on these sites can be massive, the actual number of close friends is approximately the same in the face to face real world." However, new research presented by Assumption College professor Maria Kalpidou at the APA's 2008 convention proclaimed different results. Professor Kalpidou found that university freshman who began school with 200 or more individuals as part of their internet cohort scored lower on measures of self esteem and adjustment than did students who started the fall semester with a smaller online peer group. While these findings may point us toward divergent interpretations, I think that it is the nature of conversation rather than the face of friendship that is evolving with the increased use of sites such as Facebook.

There is no question that the first day of school is difficult for many individuals because it is not always easy to make new friends. Friendships require work and develop only as people contribute tidbits of personal information and share laughs. For shy or inhibited newbies, online forums can be a less threatening medium in which to take risks and open oneself up for possible rejection. In fact, many universities encourage students to "meet" hallmates and choose their roommates through forums. For example, USC now uses an online profile and forum to assist students in finding roommates for student housing. As Dr. Kalpidou's research illustrates, it is nonetheless important to note that problems can arise when internet communication is one of the only modes of interaction an individual engages in. If someone has more than two hundred acquaintances on Facebook prior to even arriving at their university, there is a two-fold problem. First, it is possible that the two hundred friends are from high school and difficulty leaving these relationships behind can lead to what has been called "friendsickness," the preoccupation with and concern for the loss of or change in precollege friendships. This theory has been shown by psychologists Elizabeth Paul and Sigal Briar to be a "significant source of distress for college students [and] affecting college adjustment" because it is characterized by a steady focus on past relationships that have changed or been lost . This type of "backward focusing" leaves the individual feeling incompetent as a friend and often so grief-stricken that they have no energy or want to invest in new relationships. Paul and Briar estimate that 50% of college students experience feelings of friendsickness and 40% of these individuals did not have new college friends ten weeks into their first semester. These results are so important because the first semester of college lays out the framework for attainment and completion. If the student becomes low-functioning during this time, their future success in college is at steak. Further, the preoccupying nature of the Facebook website only exacerbates the issue by enabling depressed students to stay secluded and refrain from engaging in any face-to-face activities with their new schoolmates.

Prosocial behavior is a necessity when trying to develop a peer group, and provided that most people are not keeping themselves isolated, the advent of Friendster and Facebook can actually aid in this arena. The conversation started over coffee can be continued via a wall post. Further, communication with peers that are studying abroad is no-longer just an over-the-phone or pen-pal ordeal. Rather, two individuals cannot only chat, but also share pictures of their adventures or give a virtual gift in real time. In Dr. Reader's study, participants had met 90% of the contacts they regarded as "close friends." Other research confirms the assertion that networking sites facilitate and expand conversation. Ellison and colleagues found a strong relationship between Facebook use and the formation and maintenance of social capital. They go on to note that "for individuals, social capital allows a person to draw on resources from other members of the networks to which he or she belongs. These resources can take the form of useful information, personal relationships, or the capacity to organize groups." Similarly, in an endeavor to discover the profile of the "typical" social networking site user, Eszter Hargittai of Northwestern University found that students who did not live on campus were less likely to utilize web-based services. She concluded that this trend implies "Facebook use is mostly for keeping in touch with students on one's campus whom one sees during day-to-day college life." Thus, it seems as though for most people, websites such as Myspace are simply used to continue the conversation, not to start it.

With over 21 million registered members and 1.6 billion page views each day, there is no question that Facebook and related social networking sites are at the epicenter of communication among college-aged individuals (and even some older adults). For an alarmingly large number of students mourning the loss of their high school friendships, Facebook might be inhibiting their adjustment to college life by enabling them to remain isolated. Recognition of the problem and intervention for these students probably lies in the hands of high school counselors who can be trained to recognize early warning signs of friendsickness such as avoidance of post high school decisions and withdrawl. Nonetheless, it is important to note that friendships and the work necessary to create and maintain those relationships have not changed. Trouble with the transition to college cannot be blamed on Facebook. While it may be enabling students, individuals who are using it as a replacement for "live" friendships are not exhibiting prosocial behavior to begin with. Research nevertheless indicates that for the majority of college students, social networking sites have catalyzed the rapid evolution of the ability to communicate and the essence conversation which has lead to more engaging social capital.

The List: A Compilation of Online Resources in Psychology

The field of psychology was originally created out of the curiosity of physicians. Wishing to expand upon their knowledge of the body and explore new conceptualizations of illness, they endeavored in research projects focusing on the mind as the root of certain classes of symptoms. Thus, I feel the field of psychology demands that claims be informed by current research. This week I ventured into the blogosphere in search of spirited and stimulating resources with which to supplement my posts here as well as provide my readers with additional sites of interest pertaining to the field of psychology. Using the IMSA and Webby criteria for evaluating blogs and other Internet sites, I have compiled a cluster of twenty exceptional organizations, research engines, blogs, and informational sites. These sites have been added to my linkroll (right), but I will also evaluate them below based on content, aesthetics, interactivity, structure, and liveliness.

The first site that I found is by far my favorite. A division of Scientific American, 60-Second Psych is a fun and quick way to catch up on current events. Each "post" is in the form of a one minute podcast that usually integrates elements of psychology into current events. While riddled with promotions, the overall layout of the site is visually pleasing and extremely easy to navigate. I enjoyed the podcasts I listened to so much that I would have liked to see more frequent posts. However, I think that for information on current research findings in psychology smoothly blended with current events in the media, 60-second Psych is a perfect spot for on-the-go information.

The next set of sites I found, while not as interactive as 60-Second Psych, are wonderful resources for those wishing to find more information on specific sub concentrations and professional practices that fall under the umbrella of psychology. Psychology Campus and A Guide to Psychology and it's Practice offer a comprehensive analysis of several disciplines. I particularly like the question and answer section of A Guide to Psychology and it's Practice because of its practical information on graduate school and becoming a successful practitioner in clinical psychology. The author of the site is a practicing Psychologist and much of the information found on the site, especially regarding the graduate school admissions process might need verification as it is based only in his experience. While I would have preferred a more interactive experience at Psychology Campus, the wealth of information I found there was admittedly impressive. Following up on my earlier post about evidence-based practices, I was able to use this site to further explore some of the current therapies that have been approved by the American Psychological Association as "empirically tested." The Society of Clinical Psychology, while much narrower in its focus and clearly meant to be viewed as only a subdivision of the American Psychological Association's homepage, supplements the information I found at Psychology Campus and allowed me to verify the account of the author's experience on A Guide to Psychology and its Practice. Similar to the Society of Clinical Psychology, The American Association of Marriage and Family Therapy is narrow in focus, but provides a comprehensive picture of how to study to be, and eventually become, a successful practitioner focusing in treating couples and families. Many of the links regarding career development, the licensing exam, and the divisions of the AAMFT are open to the "everyuser," however much of the site is restricted to paying members which proves frustrating when trying to get specific information on a topic.

Psychology is only a subset of a the broader field of Mental Health which encompasses social work, some nurse practitioners, and even policy makers. The National Institute of Mental, Health (NIMH), the National Council for Community and Behavioral Healthcare, Mental Health America, and HealthyMinds.org are similar to the cluster of sites in the previous paragraph in that they are more informative than interactive, however they take a broader approach when providing information which can be really useful as a jumping-off point for research. For example, NIMH has an arm in policy and research as well as practice. Because of this, the site is mostly dedicated to mental health-related news headlines. The National Council for Community and Behavioral Healthcare is organized in the same fashion. This site, like AAMFT's page, is largely restricted to members. Thus, it takes some work (and money) to unlock all of the resources that this site has to offer. Mental Health America is almost solely devoted to updates on mental health policy. Formerly known as the National Mental Health Association, this agency is dedicated to helping all individuals receive cost-effective mental healthcare. The information on this site is particularly interesting because the site and the agency are run by current and former mental health consumers. Once again however, this site is mostly dedicated to members of Mental Health America. The site primarily seems to serve those who are already "in the know." Following up on my earlier post about phone therapy, HealthyMinds.org is a wonderful resource run by the American Psychiatric Association and meant for the consumer seeking information about mental health. The information is presented in a clear and concise manner with a focus on making it understandable to individuals who are not professionals within the field of mental health. This is the only site thus far that I have come across that has a section specifically dedicated to minority mental health.

The last site in this cluster of professional organizations and societies is NARSAD. Formerly known as the National Alliance for Research on Schizophrenia and Depression, NARSAD has expanded its boundaries and become the largest donor-supported organization in the world that supports research on brain and behavior disorders. While the agency is largely dedicated to funding research, the site does have some limited information on disorders which can be found under the "diseases and conditions" tab clearly labeled on the navigation across the top of the page.

While general information is helpful when doing research, psychology is a profession of opinion. Thus, I have found what I believe to be six outstanding blogs all focusing on different aspects of psychology. Research Blogging and Cognitive Daily are perhaps the most professional of the bunch. Informed by current research, author and psychology professor Greta Munger's posts on Cognitive Daily are both informative and stimulating. Research Blogging is a little bit broader than cognitive daily. Where Cognitive Daily simply focuses on research furthering our knowledge of the brain, posts on research blogging are farther-stretching. This site is an amalgamation of blogs from different authors and serves as an excellent resource when looking for current findings related to a given topic within the field of psychology or neuroscience. Following along the same lines as Research Blogging, the blogs at Psychology Today are also a centralized group of a variety of different blogs written by Psychology Today staff members. What I particularly liked about this site was the ease with which the reader can search through the group of blogs in pursuit of posts on a given topic. It is in essence like a compressed version of a blog engine. I was however disappointed to find that many of the blogs only have one or two posts. On Our Minds is the official blog for the National Council for Community Behavioral Healthcare which I mentioned earlier. Contrary to the homepage for the the National Council for Community and Behavioral Healthcare, On Our Minds is easy to navigate and is not restricted. The layout of the site is somewhat cumbersome as it has a relatively large sidebar that does not house any pertinent information, but it does offer some interesting information on a variety of current events within behavioral health with a specific focus on healthcare coverage. PsyBlog's layout is also quite bulky. Two large sidebars with clashing orange, yellow, and blue accents are distracting from the posts. However, the sidebars are not without purpose. This is perhaps my favorite blog simply because of its "Explore" section. Housed in this section are links such as "10 Weirdest Psychology Studies" and "7 Sins of Memory." While their location on one of the sidebars adds to the distraction from the actual blog entries, I found the inclusion of these links to really enhance the information in the entries as well as the interactivity of the site as a whole. Run by Psych Central, a site that provides comprehensive mental health information to consumers, World of Psychology is a blog that compliments the information provided on the home site by offering opinions and expanding on the topics that are merely touched upon in the information section of Psych Central. The layout of the blog is pleasing and the tags to the left of the entries are well organized and varied in topic. Last, but certainly not least in the group of blogs I discovered is Positive Psychology News Daily. Positive Psychology is a newer branch of psychology that focuses on mental health instead of mental illness. This blog is definitely one of the most comprehensive sites I have found thus far on positive psychology. The blog is written by a large array of authors, each specializing in a specific application of positive psychology. I did however find the site to be difficult to navigate. The homepage is so cluttered that I found it hard to know where to look first (see above left) There are also some problems with the html on the site as one of the sidebars overlaps the text making it difficult to read. Despite these formatting faux pas however, the themes discussed delve deep into this new approach within psychology.

For any information or topic not included in the above websites, look no further than PsychSplash, mindsite, and MedlinePlus. Many of the sites I mentioned in the previous paragraphs were aimed at practitioners and students, but these sites were created solely for consumers. All three are meant to assist the consumer in diagnosing and seeking treatment for mental health-related ailments. What WebMD is for colds and muscle sprains, MedlinePlus is for depression, eating disorders, autism, and just about any other mental health disorder or malady one can think of. I would personally hesitate to encourage self-diagnoses of mental illness, however I firmly believe that the informed consumer is the best consumer. While all three of these sites are search engine-like, I found mindsite to be the easiest to navigate and the most interactive (see right). The available information is somewhat limited, but this shortcoming is more than made up by the ease with which the visitor can find whatever information is of interest. PsychSplash is an interesting variation on the psychology website search engine. It provides a snapshot of the home page, relates the target audience of the site (for example, professionals), and gives a brief description of the kind of information that can be found. I enjoyed this site so much that I was disheartened to learn many of the links, especially on the older listings, were no longer live.

It is my sincerest hope that the above explanation of websites and blogs will serve as valuable resources when exploring the expansive world of psychology and mental health.

Therapy on-the-Go: Surprising New Evidence on Over-the-Phone Support

Last Monday, I investigated the potential effects of Evidence-Based Practice on the therapeutic relationship. This week I chose to explore the blogosphere in search of practices that, while not necessarily approved by Division 12 as "Empirically-Based," utilize innovative approaches to connecting with clients. As a counselor on a local crisis hotline, I was thrilled to discover the publication of a new study offering compelling evidence that phone therapy is just as effective at improving mood as traditional, sit down, face-to-face therapy. In my search for reactions to this recent publication, I realized that this publication has sent waves through the mental health field and many bloggers have already formed strong opinions around phone therapy. The first post I came across was written by Dave Turo-Shields, a Licensed Clinical Social Worker and current provider of telephone therapy. His post was published in the blog of Dr. Kathy Sifert entitled Preventing Violence Among Children and Families. Dr Sifert is the CEO of Eastern Shore Psychological Services, a private practice specializing in the assessment and treatment of at-risk youth and their families. Her blog is an interesting amalgamation of posts by various specialists within the field of Mental Health. Mr. Turo-Shields' post within Dr. Sifert's blog presents a Question-and-Answer style analysis of his extremely positive experiences providing phone therapy. The second post I came across was in the Blogging Therapy section of GoodTherapy.org. This post entitled Research Compares Telephone Therapy with Face to Face Therapy: More Surprising Results, was written by Licensed Clinical Social Worker, David Brezenoff. Mr. Brezenoff's post takes a more critical eye to the phone therapy craze, pointing out that while the phone therapy study does have some powerfully compelling attributes, the results must be viewed through a slightly skeptical lens. I offer my comments to Mr. Turo-Shields' and Mr. Brezenoff's analyses below as well as on each author's post.

"Phone Counseling - It's What's for Dinner!"
My Response:

I would like to thank you for your organized analysis of the phone counseling craze. The recent meta-analysis of twelve phone therapy-focused studies published in Clinical Psychology: Science and Practice has triggered my interest in this alternative to face-to-face treatment. I was excited to read an entry written by a clinician who actually employs this practice. Efficiency seems to be a common theme in 21st century life: order your groceries (and have them delivered right to your doorstep), conduct a meeting, buy or sell stock, and now receive therapy - all over the phone. While I admit that with the attrition rate for traditional psychotherapy nearing 50%, the convenience offered by phone therapy does appear promising, I think that there is a careful balance to be struck between convenience and enabling. Under your "Phone Therapy Fits Busy Schedules" section, you briefly touch on how phone therapy can benefit clients with logistical barriers to receiving face-to face therapy such as a hectic work schedule. I agree that phone therapy brings new meaning to the term "client-centered." Half the battle of keeping clients in therapy can center on scheduling a convenient time for both client and therapist. However, the clients who are simply too busy to sit in a therapy office for 50 minutes a week seem like the clients who may most need that 50 minutes of relaxation in the neutral environment that can be achieved in the therapist's office (see above left). An important part of time management is making some time during the week for self-care. It seems as though phone therapy might maintain poor time management skills by allowing the ultra-busy client to brush aside self-care in favor of attempting to juggle the world news report, therapy, and dropping the kids off at school, all in the span of their morning commute. Perhaps some loose ground rules for when and where a phone session should take place are in order. Ultimately, I really enjoyed reading your take as a clinician on phone therapy. While I maintain many reservations about hailing it to the extent that you did in your post, I do believe you offered some crucial advantages of phone therapy and have inspired me to continue to explore this increasingly popular form of treatment.

"Research Compares Telephone Therapy with Face to Face Therapy: More Surprising Results"
My Response:

Thank you for your informative synopsis of the recent publication in "Clinical Psychology: Science and Practice." In the face of an ever-increasing need for mental health services to be available and accessible to the community at large, I was excited to learn of a form of therapy that can potentially transcend some of the traditional logistical and emotional barriers to seeking treatment . I find it truly amazing and very much promising that this form of treatment can boast an impressive 7.6% attrition rate. I do agree with you in your opinion that even though the results of this study are promising, they do need to be viewed with a certain degree of skepticism. As you point out, phone therapy could be an easy out for clients who are too anxious or too depressed to meet their therapist face-to-face. Often, one of the first steps in treating depression is to get the client up off the couch or out of the house. Phone therapy seems like it might skip this important step. However, I do believe phone therapy might show some promise as a tool in the treatment of severe anxiety. For example, anxiety often inhibits the individual's ability to properly describe their feelings to another person, especially in the initial stages of therapy. The client might be embarrassed or feel as though they are being judged. Is it possible that phone therapy could be successfully used for the first couple of sessions to make the client feel more secure through the added element of perceived anonymity? I liken phone therapy to hotline counseling. Millions of people each year call local hotlines during a time of crisis, depression, or confusion (see right). The hotline often serves as a way of "testing the waters." That is, realizing the problem by speaking it and having the counselor validate while still having this element of anonymity that allows for a quick hang-up should the need arise. I do however recognize that one of the best predictors of positive outcome in longer-term (as in more than one call to a hotline) therapy is the rapport between client and therapist. It might be difficult for many client-therapist pairs to build a secure and trusting relationship over the phone. Clearly this is an area of therapy that needs more research. Thank you again for carefully pointing out the controversies surrounding the recent publication of the findings related to phone psychotherapy.