What is Prepare/Enrich?

Prepare/Enrich is an assessment tool to help couples and parents discover what their relationship needs to grow.

I am a certified Prepare/Enrich facilitator. I offer Prepare/Enrich (P/E) as a lower cost alternative to couple and family therapy.

Prepare/Enrich uses solid research into what makes a strong relationship and developed an assessment to show you your areas of strength and growth as a couple. The assessment is based on FACES, the Family Adaptation and Cohesion Evaluation Scale.

After our initial consultation, I’ll send you links to take the assessment at the Prepare/Enrich website. You’ll each take the test individually- the results will be much better if you don’t work together and if you feel like you can be honest about your answers.

After you take the assessment, I’ll get your results about each area- expectations, intimacy, chores, family, and more. During our sessions, we’ll go through each of these areas, focusing on areas of growth. With this system, you can expect to have 6-8 sessions together, each targeting needs indicated by your assessment results.

At the end, you’ll get your copy of the results along with practical suggestions to grow and develop your relationship. If you feel like you need more support based on your results, I also provide couple’s sessions using the Gottman method.

Ready to take the assessment or have other questions? Contact me today for a free 15 minute consultation or to schedule an appointment.

About Anxiety Disorders

Anxiety disorders are common. Learn about the three types of anxiety and the best ways to treat them in this introductory post.

Anxiety

Along with depression, anxiety disorders are the most prevalent of all mental health problems. The majority of people, sometimes estimated as high as 80%, will experience clinically significant anxiety during their lifetimes.

What Causes Anxiety?
There are a number of possible causes for anxiety. The three general categories are environmental, biological, and psychological. A serious anxiety disorder may involve one source or several. Different treatments will be more or less effective depending on the reason for your anxiety. Talking with a therapist about your anxiety can help you identify the reason for your anxiety and how it can be treated.

Environmental anxiety comes up when you are in a stressful situation. Outside stressors from your personal life, work, school, or home can result in clinically significant anxiety. When you deal with the stress, either by managing the situation or increasing your coping skills, the anxiety usually diminishes or goes away. Therapy can help you find ways to manage your environment to reduce stress. A therapist can also help you develop skills to increase your internal resilience to stressful situations that you can’t control and come up with things you can do to manage your feelings of anxiety in those situations.

Biological anxiety is caused by neurochemical imbalances in your brain that result in you feeling anxious even though there is no apparent reason for the feeling. These imbalances can happen for a number of reasons, and they can be treated by re-balancing your neurotransmitters through medication. There are several different kinds of medications that can be effective, and your doctor or psychiatrist can walk you
through your options. You may also benefit from therapy even with medication because when you experience anxiety, you can learn negative thought patterns that may continue even on medication.

Psychological anxiety is the result of your thought patterns. When you focus on anxiety-provoking thoughts, you begin to feel anxious. The feeling of anxiety reinforces the negative thought patterns which results in feeling even more anxiety. This kind of anxiety is treated best with therapy, though you may need medication to help break the cycle of negative thoughts before therapy is effective. Therapy can help you change the way you think to help you feel better.

Any questions about anxiety you want answered by a therapist? Leave a comment below or send a message and we may feature your question in a future post.

Who Owns Your Feelings

Do you find yourself saying things like “You make me so angry!” Stop blaming others for your emotions and take control of your own feelings.

In therapy, we have an idea called the locus of control. 

Locus means “position, point, or place,” and your locus of control is basically the place where your emotional control comes from. Your locus of control can be internal or external, but everyone has one.

Having an external locus of control means that whatever is controlling your emotions is outside of your own self. An external locus of control makes statements like “You make me so angry!” or “I get sad when you don’t listen to me.” Do either of these sound familiar? An external locus of control relies on others to feel okay.

An internal locus of control means that you are the one in charge of your emotions no matter what happens around you. You are able to respond appropriately to events, but you are able to choose how you feel. If the two statements above were reworked to have an internal locus of control, they would acknowledge the same emotion with a different reaction.

The first statement “You make me so angry!” could turn into a direct request- “When you come home late, please text me so I know you’re okay,” or “Please clean your room the first time I ask. If you can’t clean it by lunch, we’ll donate the toys you can’t find a home for.” The statement “You make me so angry!” doesn’t tell the other person what needs to be different. It’s also inaccurate. You are the only one with control over yourself and your emotions. Nobody else has the power to make you angry, only you can do that. In addition, nothing gets solved. An internal locus of control acknowledges that you’re feeling anger in response to the situation, whether it’s because your partner is late or your child isn’t cleaning their room, but instead of reacting in anger you’re able to proactively ask for change that can resolve the situation.

The second statement is one I hear a lot from parents. They’re trying to emotionally manipulate their children or partners into behaving the way they want. The problem is, we can’t control others and most people resent being manipulated. “I get sad when you don’t listen to me” doesn’t teach your child or partner to listen to you, it only teaches them that they can easily control your emotions with their actions. An internal locus of control sees the sad feelings that come up when others seem not to hear you, but it doesn’t blame others for your sadness. Instead, an internal locus of control would say something like “This is really important to me and I’d like to talk to you without the TV on” or “When we need to leave the park, I’d appreciate it if you would come and help me pack up the toys when I ask you, especially when I’ve given you a five minute warning.”

During the process of therapy, I teach people how to move their locus of control from external to internal. This is especially important for people who are sensitive to the emotions of others or who tend to overreact to situations.

Say to yourself, “I am in charge of how I feel.” Try to notice when you make statements that give others control of your emotions. With your observations, pay attention to who has control of your feelings if it’s not you. Many times, we have a certain person we give control to. It’s usually a parent, partner, or child- someone close to us who knows how to push our buttons.

Carefully consider how you are going to take back control of your emotions. When you are feeling calm and separated from the situation, look back and try to figure out what you really want and come up with a way to ask for what you need without giving up control of your emotions. Whether you need better communication, firmer boundaries, or just some peace and quiet, you are the only one in charge of your emotions and you are the one responsible for making sure you get your needs met.

Just like you can’t control others, they can’t really control you- it just seems like they can sometimes. Others can’t read your mind to know what you want out of a situation, you need to ask for what you want in a way that doesn’t blame them for what you’re feeling.

Treating Refractory Schizophrenia

Refractory schizophrenia occurs in about 30% of cases. When medication doesn’t work, traditional therapy can still be effective.

I’ve recently had a few new people come in for therapy with diagnoses on the schizophrenia spectrum. Not only that, but they’ve tried a few different medications with no significant reduction of symptoms. Refractory is just a fancy way of saying treatment resistant.

As a therapist, when I hear that my new clients have treatment resistant schizophrenia, my first thought is this- Can therapy help someone who isn’t helped by medications? After all, schizophrenia is a pretty major mental illness.

It’s not like depression or anxiety where the cause could be either biological or psychological, and the origin of the symptoms shapes treatment. Instead, schizophrenia is understood as a primarily biological disorder with clear ties to dysfunction in major brain systems.

With schizophrenia, medication works to relieve symptoms in approximately 70% of cases. That’s a much lower number than I expected. That means 30% of people who experience schizophrenia get little to no help from medications. There’s a lot we don’t know about schizophrenia though, so we could see that number decrease as we learn more about the brain and how it works in mental illness. In fact, I just read an article today about scientists searching for brain cues related to major mental illness. They discovered tons of tiny factors that all play into the etiology and course of major mental illness.

But that’s a bit of a tangent. My goal was to learn if there were any therapy interventions that were designed to work for people with refractory (treatment resistant) schizophrenia spectrum disorders.

I was actually surprised to find that this has been studied by a few different researchers. I found two different treatment protocols based on CBT that were demonstrated to be effective with refractory schizophrenia. They seemed similar, with slight differences. I figured it would be easy to combine these approaches and create a protocol of my own that will hopefully be effective in my three new clients.

I’ll post the full protocol in a separate post. For now, here are the two studies I used to develop this method of treatment for refractory schizophrenia.

 

Cognitive–behavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication. Lucia R. Valmaggia, Mark Van Der Gaag, Nicholas Tarrier, Marieke Pijnenborg, Cees J. Slooff. The British Journal of Psychiatry Apr 2005, 186 (4) 324-330; DOI: 10.1192/bjp.186.4.324
The omnipotence of voices. A cognitive approach to auditory hallucinations.. P Chadwick, M Birchwood. The British Journal of Psychiatry Feb 1994, 164 (2) 190-201; DOI: 10.1192/bjp.164.2.190

Therapy 101: How to Find a Therapist

In the Therapy 101 series, we’re covering the basics of what you should know before going to see a therapist. This post looks at finding a new therapist and the nine factors to consider when deciding to commit.

Finding a therapist can feel like online dating. It usually begins with a search- therapists near me, counselors near me, therapy for depression, best counseling group. You scroll through bright, happy websites full of professional photos of well-lit, smiling people. They all say pretty much the same thing. You’re stuck and I can help you. They have lots of buzzwords. Change. Transform. Holistic. Wellness. Some list a fee or insurance networks they accept. Many don’t. It can seem like there’s no real difference between them. But there is, and it’s not something you can see from a website. It’s their personality.

After all the effort you’ve put into finding a therapist, it’s tempting to pick the first one who calls you back. But it’s worth it to find someone who really gets you. Studies of the effectiveness of therapy show that it’s the relationship you have with your therapist that’s the biggest predictor of change in your life. It’s not the methods- results show that the therapy method doesn’t matter so much even though they seem so different.

Treat the first session like a date- it’ll probably be a bit awkward and you don’t really know each other but you’re trying to see if it’s a good fit and trying to make a positive first impression while being authentic about your experiences and struggles.

Many therapists offer a free initial consultation so you’re not dropping a hundred dollars on someone you don’t want to see again. But many don’t offer a free first session or do a free consultation on the phone only, so you may have to make a bit of an investment in finding the right person.

Here are nine signs you’ve found a good therapist:

*note: many of these signs reference California legal and ethical standards for therapists with a state license and may not apply in other states.

  1. They’re above board from the start. Your therapist should go over things like fees, cancellation policies, confidentiality, mandated reported requirements, and other boilerplate details with you. If they don’t mention any of these things, that’s a sign they’re uncomfortable talking about difficult topics, but it also indicates that they either don’t know the law or are purposely ignoring it. Not a good trait in a therapist.
  2. They can explain the process of therapy to you. Every therapist does therapy a bit differently, but the time you spend in therapy generally has a beginning, middle, and end. If the professional therapist can’t tell you what to expect in therapy, watch out! They might not know what they are doing or they might want to bring you in with no defined end so you’re in therapy for years (and paying every week!).
  3. They listen to you. After the required details are taken care of, the therapist should ask you why you’re coming to therapy. Depending on the therapist’s methods and the nature of your problems, they might ask about your childhood, your relationships, your sleep habits, or even your current thoughts and feelings. No matter how they direct the conversation, you should expect to spend a good amount of time talking about yourself and your experience. Stay away from the therapist who hears “I’m depressed” and doesn’t ask more- it shows they don’t really care about your side or how your personal history has shaped the current issue.
  4. You feel heard. Some therapists listen but you’re not quite sure they’ve really understood what you were saying. It’s a good sign when your therapist reflects back what they heard you say and asks if they’ve got it right. That shows they’re actually trying to get your perspective accurately and are willing to ask for clarification.
  5. They ask about your end goals. There are a few ways they might ask about this. Phrases like “if the problem was gone, what would be different” and “how would you like things to be with your spouse” are indicators that your therapist is looking for specific, measurable goals so they know when you’re heading for the end phase of therapy.
  6. You feel comfortable in the room. Therapy takes a while. You should be comfortable on the furniture, feel safe parking your car or taking transit to the office. This may seem like a small thing, but if you don’t feel like you can relax in the room, it’ll be easier for you to skip sessions later when it’s hard to get out the door.
  7. You like the look of your therapist. It can seem shallow to judge someone by their appearance, but it’s actually pretty important. If you feel attracted to them, you might not be completely honest about the weird parts of your past. If they seem too young, too old, or too close to your own age, you might not feel able to trust their judgment. Some people need to see an older therapist who reminds them of their grandparent. Couples may prefer to see a married therapist. Teens often like therapists who are either younger adults or older adults- not someone parent aged. A person who has experienced sexual assault may want to see someone completely different in race and gender from their attacker.
  8. The therapy style seems like a match. If you’re more analytical, look for a therapist who can explain your anxiety in a more technical way. If you’re a creative type, steer clear of the technical therapist and look for someone who will do process art, dance therapy, or music therapy with you. A good therapist can be both- they’ll mirror the way you talk and match their style to your personality and way of thinking.
  9. You’re comfortable with the fee. Most people aren’t comfortable talking about money, especially when it comes to admitting that something is too expensive. If you really feel like this is someone you could work well with, ask about sliding scale fees or suggest a fee you feel comfortable with as long as it’s similar to the current fee structure. It’s no fun for anyone to have a mass of unpaid bills collecting.

If they’ve got all these factors, you’ve found a match! Just remember, first sessions are often like first dates, and if you can afford it, give a maybe therapist a few sessions to get to know you before making a final decision. Of course, a red flag therapist shouldn’t get a second session- get out of there right away if you feel uncomfortable or if they’re clearly doing illegal or unethical things.

When is Medicating Your Child a Good Idea?

It’s hard to know when medication is the right step for you and your child. This guide will walk you through the main issues to consider.

Mental health is a delicate balance of the holy trinity- biological, psychological, and social factors. Medication acts primarily on the biological side.

If only it were that simple. Mental health medication is still highly stigmatized. I’m sure we’ve all heard horror stories of the kid who was put on something that turned him into a blank zombie. Sure, he wasn’t bouncing off the walls anymore, but he also lost his personality.

On the other side, maybe you’ve seen the kid whose parents chose to give her only natural medicine for her ADHD. She’s completely unable to focus in class and she’s falling farther and farther behind grade level each year.

Or maybe you know a kid whose medication is helping him get through seventh grade. For the first time, he’s able to be present and participate in class. Too bad it couldn’t have happened earlier. His parents have been trying different meds and combinations since kindergarten. Between the nasty side effects and ineffective dosages, he’s been held back already, and he’s missed a lot of school.

Here are some guidelines I use when suggesting that medication might be the next step in mental health care:

  1. You’ve tried therapy. Therapy can be great. As a therapist, it’s my go-to solution. But therapy should show progress after a few months of consistent sessions with a person your kid has a good relationship with. This is why it’s important to set concrete goals with tangible benchmarks- so you’ll know if there’s change.
  2. Your child is not able to perform normal tasks of daily life without assistance at a level compared to other children of the same age. They should be able to follow a string of logical instructions- for example, asking your child to finish their bath, brush their teeth, change into pajamas, and then come tell you they’re done so you can read a story. If you need to remind your child of their tasks every few minutes, there’s a problem.
  3. They’re falling behind in school. This is the most important reason I recommend medication. Being held back affects a child’s self-esteem, their peer group, their reputation, and their sense of self-efficacy. It’s one of the most damaging and devastating experiences at that age. Many of my adult clients who have been held back listed it as a pivotal event, even as young as kindergarten.
  4. They are isolated from friends. Kids who have dramatic outbursts from ADHD, bipolar, psychosis, and other disorders tend to attract labels, and not very nice ones. This keeps them from normal social activities with peers and may make them a target for bullying- or turn them into a bully if loneliness shifts to anger.
  5. They recognize there’s a problem and want a solution. Lots of kids I’ve talked to over the years have told me they want to be able to sit down and concentrate on their work but they just can’t. This is the big difference between the class clown’s acting out and the disruptions from a mental disorder. Most children don’t want to interrupt, do poorly, or fail classes. When there’s a problem, they know.

Medication isn’t all-or-nothing. It’s possible to give your child a dosage that will take them through the school day and wear off in the evening. Many kids take medication holidays when school isn’t in session. Some kids need the additional help so they are able to try therapy and are able to stop the medication once things are under control.

But advice from the internet can only be vague. I don’t know your child or your situation. The best way to find out how medication could work for your family is to talk to someone in person.

The first person I always suggest is your pediatrician because they know your child and they know about normal child development. Doctors aren’t as well trained in mental health as a therapist or psychologist, but they can diagnose and prescribe psychiatric medication. You can ask during your child’s routine appointments, and this is usually covered by insurance.

The next person to talk to is your school’s psychologist, if your child qualifies for services through a 504 or IEP. These services are usually free through the district. Although the school psychologist won’t prescribe medication, they can assess your child, describe the diagnosis, and discuss the possibility of medicating.

The last person I recommend is a psychiatrist. This is because most communities have very few psychiatrists, so it can take months to get an initial appointment, if you can get one at all and aren’t placed on a waiting list. When you get there, the psychiatrist likely doesn’t know you or your child, so you have to explain the history of the problem. And if there are any issues with the dosage or side effects, it can be a while before you can get in for a follow up appointment.

You can talk to your regular therapist about medication too. Therapists in California are trained in psychopharmacology- knowledge of medications for mental health issues. But therapists can’t prescribe medication or even suggest medication. They’re available for you to talk about your thoughts or feelings about medicating your child, and they can help you find local referrals for doctors, psychologists, or psychiatrists.

What is Mental Health?

How do you define mental health? We use the biopsychosocial method to define mental health with our clients.

It’s important to develop a working definition of mental health because that’s the language we use when we decide that what we’re experiencing has slipped from mental health to mental illness. Defining mental health also lets us set a benchmark to know when therapy is done.

Here at Makarios, I believe in planning for the end from the first session. To do that, I use the biopsychosocial model for mental health. Just like it sounds, the biopsychosocial model has three parts: your physical biology, your internal psychology, and your external social community. You need to have all three parts in balance to be mentally healthy. Let’s break it down.

Your biology is your physical health, the genes you got from your parents, any physical disabilities you have, the food you use to fuel your body, the drugs you choose to use or avoid, and details like your height and weight.

Your psychology is your self esteem, the way you think about the world, your social skills, your ability to cope with stress, the way you are in relationships with others, tendency toward optimism or pessimism, and your memories.

Your social community is your family, friends, and neighbors. It’s choosing to join a church, synagogue, or mosque. It’s the people you meet taking a painting or welding class for fun on the weekend. It’s any people you interact with in person or online.

Here’s how therapists use this information. When you first come to a session, your therapist will ask you about yourself, your family, maybe a bit about what you do, and your habits. It’s not just small talk- they’re trying to assess for how your biopsychosocial system is functioning.

Let’s say you come in to your first therapy session because you’ve been experiencing symptoms of anxiety and you’d like to go back to the way things were before the symptoms started. Here’s what your therapist would probably ask about:

  • What changed in your life around the time your anxiety symptoms started?
    • Did you start a new medication or start drinking more caffeine (biological)?
    • Did you have an experience that was more stressful than usual or did you go through something traumatic (psychological)?
    • Did you just begin or end a relationship, job, or hobby (social)?
  • What have you tried so far to deal with the anxiety and how has it worked?
    • Did you self-medicate with “downers” like alcohol or marijuana?
    • Have you tried pop-psychology methods like mindfulness, meditation, going gluten free, or tapping?
    • Have you tried therapy before? What methods did you like or not like?
  • Do you have other people in your life you feel comfortable talking to about what you’re experiencing?
    • Some people isolate themselves when they aren’t feeling well
    • It’s important to identify people in your life you can talk to, or to find those people if you don’t have anyone you can trust

I used anxiety as an example because it can come from any one of a number of causes. You could have a chemical imbalance (biological) from substance use, poor eating habits, or genetic predisposition. Or it could come from psychological factors such as a change in the way you think about yourself and others, experiencing a new trauma or being reminded of a past trauma. Anxiety can also stem from social changes like a major loss, an identity shift from job transitions, or a relational rejection.

This is important because where your anxiety comes from shapes how we’ll treat it in session. Anxiety following the death of your favorite grandmother is very different from anxiety that comes from stress or from an overactive brain.

Most people experience stress-related anxiety. That’s why anxiety disorders are more common in people who are going to school or who have high pressure jobs. Stress is a psychological symptom, so the treatment will focus on realigning your psychology through reframing your thoughts. Cognitive Behavioral Therapy is one of the most popular methods because it has been empirically proven to work for most people, and if you’re using insurance to cover the cost of therapy, it’s one of the methods your insurance provider will pay for.

If you have a genetic predisposition toward anxiety, you likely have an imbalance in your brain chemistry. Medication can adjust the levels of neurotransmitters so you have normal brain functioning. People with biological anxiety can also experience anxiety from psychological stress and social factors, so you may need to combine meds with therapy for the best results.

The examples about anxiety are intended to illustrate how therapists use the biopsychosocial model of mental health to evaluate new clients. These examples are not intended to diagnose anxiety or any other mental disorder, and are not intended to suggest a course of treatment. See a qualified mental health professional for a diagnosis and treatment plan.