Readiness for therapy
Our clients are ready, at least to some degree, to engage in the work of therapy. We encourage our clients to understand that progress in therapy takes effort on both the clinician's side and the client's side, and it requires work outside of just our weekly sessions. This means practicing the tools we learn, building on insight you develop, looking at resources we share or that you request, and other things relevant for your process in therapy.
We also want to make sure you are coming to therapy because you want to and not because someone else has asked or is making you do sessions. This is because we want to be careful about not re-enacting or replicating an environment where you feel like you have no agency or control over what is happening.
Frequency of sessions
During the first two-to-three months of therapy work (or more, depending on the individual), we usually see clients on a weekly or even a twice-weekly basis and then we may discuss spacing out sessions to every two weeks.
If you're looking for less frequent sessions straight away then our practice may not be the right fit for you. With the approach we take to treatment and the kind of presenting issues individuals seek to focus on with us, weekly sessions help to build a strong working relationship and create a good foundation and momentum for the work of therapy. The exception to this is in cases of financial hardship and chronic illness when weekly pacing may be hard to access.
We collaborate with our clients to regularly check in about progress, pacing, and how you feel therapy is going and whether the frequency feels right.
Solutions and advice
When you've been suffering or struggling, you may naturally want quick solutions and advice - this is only human! There are a few forms of therapy that explicitly provide these things to clients. In our approach, however, we want to support you in building your capacity for understanding what you need because this is an important part of connecting with your sense of self.
We will explore options with you and help you "try things on" (like when we're building a toolbox of coping skills) but we try not to lean on giving you precise solutions and advice. This also varies based on what we explore about attachment, your particular life experiences, and your pre-existing coping methods.
Unmanaged symptoms of psychosis, substance use, eating disorder, or ideations
We are ethically required to disclose the limitations of our practice and to provide clients with additional/alternative support options. Because we are a small outpatient clinic, we don't have the breadth of resources that would enable us to support certain symptoms and mental health experiences on our own. If you're experiencing symptoms of psychosis*, substance/alcohol dependency, disordered eating, and/or active suicidal ideation with a plan of action, then part of our treatment plan will be to connect you with additional services (if you're not already). In some cases, we may recommend you engage in therapy elsewhere, such as an intensive outpatient program or community healthcare clinic where a higher level of wraparound support is available.
* (Psychosis is not only present in schizophrenia - it can also be present in depression, bipolar disorder, dementia, and as a symptom induced by substance use. Also note that dissociation (as in Dissociative Identity Disorder/structural dissociation) is not evidence of psychosis or schizophrenia.
What's your approach to diagnosis?
In general, we take a transdiagnostic dimensional approach. Transdiagnostics looks at mental health conditions as tendencies rather than exact boxes of symptoms. This is because most symptomatology isn't outside the range of what's normal for humans to experience in response to what they have gone through. However, what we can measure is severity of those symptoms and whether the severity is having an unwanted impact on your life.
Read this NAMI article for further information.
Trauma, PTSD, and C-PTSD
Do I have to be diagnosed with PTSD to get trauma treatment?
Experiencing trauma does not always equate to developing the specific PTSD diagnosis and there are many factors that go into play. Sometimes a history of trauma can influence the onset of depression, anxiety, panic attacks, attachment and trust issues, difficulty controlling emotions and reactions or overly controlling your emotions, and other chronic mood struggles. A trauma history also has strong correlations with chronic pain, inflammation such as IBS and autoimmune disease, neuroendocrine symptoms, and symptoms of stress in the body.
In addition, a diagnosis isn't everything. We see the person first, not the label, and don't believe diagnostic criteria should be a gatekeeper for care.
Do you work with complex trauma?
Yes. Through our therapeutic lens, complex trauma means prolonged, repeated experience of interpersonal trauma in a context in which the individual has limited opportunity to escape (physically or emotionally) and lives through threats to sense of self and/or sense of survival.
We believe there are two forms of complex trauma: one that stems from developmental trauma and one that stems from prolonged trauma in adulthood (such as domestic violence). Often, developmental trauma can be compounded by trauma in adulthood.
What's the difference between shock trauma/PTSD and complex trauma/C-PTSD?
Shock trauma is usually an individual or brief event that poses a threat to life, self, and safety, such as a car accident, traumatic birth or surgery, sexual assault, or natural disaster. Our nervous system responds to this kind of event with acute stress. If this initial survival response doesn't get resolved, we may develop symptoms of PTSD. If we have PTSD and get triggered in the present moment, whatever the stimulus was for the trigger ignites a psychobiological fear reaction. We may experience a fear response such as fight, flight, freeze, struggle with flashbacks, self-blame, feel on edge/unsafe, and may want to avoid anything that's potentially triggering.
In contrast, if we have C-PTSD then we may experience the above trigger reactions as well as ongoing affect dysregulation, negative self-and/or other-concept, and interpersonal disturbances. Often, those with C-PTSD have also experienced shock traumas across the span of the complex trauma timeline.
Our conceptualization of C-PTSD is based on Judith Herman's original proposal and the ICD-11 definition. We're also influenced by Drs. Heller, Fisher, and Fosher's approaches to complex trauma. These approaches believe that to survive the trauma, we develop different adaptive strategies that force us to compromise core experiences such as connection, attunement, trust, and autonomy. The specifics of these adaptions are nuanced and varied from one person to the next; but, underlying them all, is a sense of self that has had to fragment in order to survive from one day to the next.
If I talk about what's happened, I'm worried I'll get stuck in it or I'll feel worse
This is a completely valid and common concern that we hear. Our gentle challenge to this is that you're already living in the stuckness of trauma and trying to cope with its after-effects outside of conscious awareness. The therapy process will bring more awareness to the presence of trauma's effects; but, the hope is that we can work together to move through these.
We never jump straight into reprocessing trauma and we spend a lot of time on resources - resources are all the tools, supports, etc. that help to provide a cushion between you and what you're working through in therapy. Even once we begin reprocessing, we consistently assess and check in with you to determine how ready you feel and to make sure we're not moving too fast.
Will therapy just be about all the heavy stuff?
No, we don't believe every session has to be full of heavy stuff because it's essential to take time to privilege the positive. By positive, we mean something that feels right inside of you. Research shows that exploring positive experiences builds the resiliency and resources needed to deep-dive into processing the harder experiences. Not only that but research also shows change and transformation can actually come from following the positive track in and of itself without doing the deep-dive (or as much of a deep dive).
For example, maybe you're talking to your therapist about a walk you went on and you notice warmth in your chest as you recall the experience. You reflect that this warmth feels good, grounding, and in alignment with who you are. Perhaps it reminds you of other kinds of positive warmth. We might stay with these feelings, noticing the warmth getting larger, maybe being reflected back by the therapist, exploring the connected thoughts, and so on. Doing this broadens your in-the-moment attention, cognitive flexibility, and behavioral options - these all increase our ability to cope right now as well as overtime as we continue to develop this resource.
What about the impacts of witnessing trauma?
Secondary trauma that stems from witnessing or hearing about someone else's trauma has been well studied and is a very real thing. This can be a common phenomenon for healthcare professionals and relief workers, but it's also experienced by many others such as family members and partners of trauma survivors, or those who share an environment in which trauma occurred. Secondary trauma is just as valid and deserving of support.