The You Factor in Psychotherapy

A blog post on making the most of your psychotherapy.

Ochester Psychological Services, LLC

iStock_000014865626_SmallDid you know that you are the most important factor in your therapy?  It may seem surprising given the amount of time we spend searching for the right provider and the right therapy approach.  However, research shows that around 55% of therapy outcome is related to extra-therapeutic factors such as client readiness for change, willingness, commitment, hope and expectations of effectiveness, and resources such as social support.

The client-therapist relationship is the second largest factor associated with treatment outcome (about 30%) and this includes things like the therapeutic alliance and therapist characteristics such as verbal skills, empathy, and warmth. Interestingly, the therapy approach only accounts for about 15% of the variance in outcomes.

This can be viewed as good news on a couple of levels. It means that a wide variety of therapy approaches can be beneficial to most people and we don’t have to be overly concerned if a particular approach…

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When it Comes to Learning, Intensity Matters

No two students are alike – no surprise there, I’m sure! The students we see in our clinic at Applied Learning Processes do have one thing in common, though. They all have a deficit in one or more sensory-cognitive processing functions that support the ability to learn. These processing functions include:

Orthographic Processing refers to the ability to establish and retain visual memory for letters and common spelling conventions.

Phonological Processing is a function of the auditory system that includes sensory perception of the individual sounds that compose spoken syllables. This processing function supports the cognitive functions involved in accurate decoding and spelling.

Visual/Verbal Integration is a processing function in which mental images based on prior sensory perception correspond to units of language and support the cognitive functions involved in both oral and written language comprehension and expression, including number sense and mathematical concepts.

Visual-motor Processing involves the ability to notice visual/spatial detail and retain that information for reconstructing graphic representations. Visual-motor processing supports the cognitive functions involved in understanding spatial concepts in language and in mathematics.

When a student presents with dyslexia, our first job is to figure out which deficits are contributing to the problem. A student might have good orthographic processing but suffer a weakness in phonological processing. This type of student can usually memorize words pretty easily so it doesn’t really look like she has a serious reading or spelling problem until about 3rd or maybe 4th grade. Another might have weakness in both areas, so in spite of an exceptionally high IQ, reading just doesn’t ever seem to “click” for him. The next student might have a moderate phonological deficit compounded by weakness in visual-motor processing so it looks like he can read fairly well for a 3rd grader but spelling and writing are described as “horrible”. So, even if the student has already been tested by another professional and given the diagnosis of dyslexia or specific learning disorder with impairment in reading, we still need to dig a little deeper to figure out which processing functions are involved and how severe the deficits appear to be. Once we get this figured out we are ready to design a treatment plan and begin our work.

The latest research on reading intervention indicates that the students who make the most progress are the ones in a one-to-one setting or in groups of 2 or 3. At Applied Learning Processes we work one-to-one with every student. The 1:1 ratio allows us to pace the student based solely upon her particular needs. It also makes it possible for us to adjust the actual treatment to fit her symptoms and level of severity. For example, if a first grader with dyslexia has a significant deficit in visual-motor processing, it’s likely she is struggling to stabilize her ability to recognize and reproduce letters and numbers correctly. We might need to spend quite a bit of time initially working her brain’s ability to notice the parts of a graphic and how those parts are related to each other. Some letters share the same parts. Lower case b, p, d, and q, for example, all have a vertical straight line with a curve attached. If the brain is not attending efficiently to the parts and how they are related, it is hard to decide which of those letters is which. That makes reading and spelling especially tricky if you’re in the first grade. As the brain gets more efficient at noticing the relevant spatial detail involved in identifying and reproducing letters, the treatment to remediate a phonological deficit begins to move faster and more efficiently, also.

Daily stimulation of the sensory processing system is another critical piece of the puzzle when it comes to remediating a reading disability. This has been our experience through the years and is also validated by recent research. We sometimes use analogies to explain this to parents. For example, if you want to do some weight training, you’ll need to do it everyday in order to build up your muscle mass. If you only do it 2 or 3 times a week you’re not likely to move very fast or get very far. You have to stimulate the growth of the muscles every day in order to reach your goal. This holds true when stimulating the brain’s processing functions, too. If you only receive the treatment 2 or 3 times a week you will be at it for years and may “burn out” before you reach your goal. If you do it intensively every day, it may only take weeks or a few months to get there. A student with a reading impairment needs an accelerated instructional approach – an intensive daily intervention – in order to change the trajectory of his learning curve. Otherwise, his peers will continue to rapidly increase their skills and the gap will continue to widen.

Families are busy. Children have school all day, then extra-curricular activities, social events, and homework in the evenings. Fitting anything else into the schedule requires significant adjustments and commitments on the part of the whole family – especially if we’re recommending a remediation approach that involves two hours of treatment per day and five days a week. However, our goal with the treatment process is to get the student’s brain processing functions developed and stabilized so that she has the “toolkit” in place to benefit like her peers do from traditional instruction. Students who receive this kind of intervention experience renewed self-confidence in their ability to learn, improved self-esteem, and success from their efforts to build good reading and spelling skills. Their grades improve, they spend less time on homework, and they become independent learners. Their parents report that their children are happy again, their anxiety levels are much lower, and they no longer fight going to school. These are some pretty cool benefits that aren’t reflected in test scores and research reports!

Melinda Buie, M.A.Ed.
Clinical Director
Applied Learning Processes

Mental Health Professional Alphabet Soup

There are so many different kinds of mental health providers available today and more are being added all the time. This results in an alphabet soup of letters behind each providers name that can seem about as decipherable as hieroglyphics to the average person. So, how does the average person decide which type of provider is right for them? This post will attempt to translate the alphabet soup of provider credentials so you can make an informed choice. Keep in mind that some of the designations, requirements and functions you read about here can vary from state to state and the contributors to this post are from the Kansas City area.

Types of Mental Health Providers

According to psychiatrist Carolina Aponte Urdaneta, MD, psychiatrists are physicians who “specialize in the diagnosis and treatment of mental disorders. In order to be able to do psychiatric residency training, one must first attain a degree of M.D or D.O. The residency is 4 years long and the experience includes comprehensive training in psychiatric diagnosis, psychopharmacology and different types of psychotherapy. Psychiatrists can therefore prescribe medications, perform psychotherapy and suggest other forms of treatment. The total amount of time required to complete the education and requirements for psychiatry is 12 years after high school.”  If you live in the Kansas City area, check out our list of local psychiatrists.

Most clinical, counseling or school psychologists have earned their doctoral degree (PsyD or PhD which will be described below) and completed a one to two year post-degree residency focusing on assessment, diagnosis, and psychotherapy. Clinical and counseling psychologists primarly provide psychotherapy, but one thing that distinguishes them from other providers is they can conduct psychological testing. Psychological testing can be useful for clarifying diagnoses and helping to generate tailored treatment recommendations. Psychologists cannot prescribe medication in most states, but with additional training they can earn this privilege in a few states. It typically takes around 10 or more years beyond high school to complete the requirements for licensure as a psychologist.

An independently practicing counselor typically has a degree that is somewhere between a masters degree and a doctoral degree as well as two years or post-graduate supervised clinical experience. According to the American Counseling Association, “Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health.” An independently practicing counselor has typically studied and trained for around 8 years beyond high school in order to become licensed.

A social worker has at least a bachelors degree, but in most states they need a masters to practice independently. They also need two years of post-degree supervised experience. According to the National Association of Social Workers, “Social workers help individuals, families, and groups restore or enhance their capacity for social functioning, and work to create societal conditions that support communities in need. Social workers help people overcome some of life’s most difficult challenges: poverty, discrimination, abuse, addiction, physical illness, divorce, loss, unemployment, educational problems, disability, and mental illness.” A social worker has typical studied and trained around 8 years beyond high school by the time they can sit for licensure.

Degrees

Most states require some sort of licensure in order for a mental health provider to practice independently, but first there are educational requirements that must be completed that lead to a variety degrees. For example, in most states you have to earn a doctoral degree such as a PhD or PsyD to apply for a license to practice psychology independently.

The following are some of the most common degrees people earn on their way to becoming a mental health provider:

BA, BS, BSW
The Bachelor of Arts, Bachelor of Science and Bachelor of Social Work degrees typically involve about four years after high school of higher education including a core curriculum of general requirements plus electives and courses related to the major. For the most part, mental health providers cannot practice independently with a bachelors degree.

MA, MS, MSW
The Master of Arts, Master of Science, Master of Social Work degrees, etc. typically involve two years of additional education beyond the bachelors degree. Independently practicing social workers and counselors typically have this as their terminal degree.  In a few states, psychologists can practice with a masters and there are still some masters level psychologists who are “grandfathered in” practicing locally.

EdS
The Education Specialist (EdS) degree is meant to provide additional training beyond the master’s level that allows students to develop their leadership skills, broaden their knowledge and skills, and prepare for professional certification. According to professional counselor Martha Childers, EdS, “Most programs require around 30 credit hours above and beyond a masters degree. The EdS is a terminal degree, but sometimes it is earned along the way to a Doctor of Education (EdD) degree.”

PsyD
The Doctor of Psychology (PsyD) degree typically involves four additional years of study beyond the bachelors degree plus a one year supervised internship. It differs from a PhD in that hands on clinical practice is emphasized over conducting original research. Although there are opportunities in many PsyD programs to conduct original research, more importance is placed on understanding, knowing how to critique, and being a good consumer of research.

PhD
The Doctor of Philosophy (PhD) degree also involves an additional four years of study beyond the bachelors degree and a one year internship. It differs from the PsyD in that the emphasis is on learning how to conduct original research. The dissertation is often the capstone of PhD programs.

MD
The Doctor of Medicine (MD) degree involves four years of medical school beyond the bachelors. After earning their MD, most physicians complete a four year residency in their area of specialty. Psychiatrists are often MDs who completed a residency focusing on psychotropic medication and the assessment, diagnosis and treatment of mental illness.

DO
The Doctor of Osteopathic Medicine (DO) also typically involves four years of medical school beyond the bachelors and a four year residency in the chosen area of specialty. They differ from an MD in that they receive additional hours studying “manipulative” or hands-on medicine and the musculoskeletal system. Some psychiatrists have a DO rather than an MD.

Licensing & Beyond

Once a potential mental health provider earns their degree, they must apply for licensure if they wish to practice independently. Licensing usually involves providing proof of education and supervised experience, examinations on knowledge of the field as well as ethics and state laws, there are fees to be paid, and sometimes there is a face to face interview. It is interesting to note that psychologists are currently required to have a one to two year residency after earning their degree in order to apply for licensing.

Psychologists and physicians typically do not have to have additional designations beyond their degree to show they are licensed, but they cannot practice independently without a license. The letters after their names just have to show the degree they earned, such as PhD or MD. Social workers and counselors typically have letters after their names that denote their licensure status, such as LPC or LCSW.

Providers can also gain certifications and earn specialty board designations that add additional letters at the ends of their names after the degree or licensure designation, such as Jane Doe, PhD, ABPP or John Smith, LCSW, RPC.

The following are some of the most common licenses and certifications mental health providers must earn in order to practice independently:

LSCSW or LCSW
According to social worker Evalyn Van Valkenburgh, LSCSW, who has held these credentials in several states, the Licensed Specialist Clinical Social Worker (LSCSW) or Licensed Clinical Social Worker (LCSW) designation and requirements vary by state. She says in Kansas where she currently works, “A LSCSW requires a minimum of a Masters degree in Social Work with 4000 post graduate hours of supervised clinical work experience and a passing score on the clinical competency test. An LSCSW is required for Social Workers to engage in the private, independent practice of psychotherapy.”

LMFT
The American Association for Marriage and Family Therapy describes Licensed Marriage and Family Therapists (LMFT) as “mental health professionals trained in psychotherapy and family systems, and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples and family systems.” They have “graduate training (a Master’s or Doctoral degree) in marriage and family therapy and at least two years of clinical experience.”

LPC, LCPC
According to the Kansas Behavioral Sciences Regulatory Board (KSBSRB), a Licensed Professional Counselor (LPC) must have earned a Masters degree in counseling which includes 60 hours, with credits distributed among the 9 core areas of professional development, and includes a supervised practicum. They must also pass a nationally standardized competency exam. In some states, the Licensed Clinical Professional Counselor (LCPC) designation requires specific coursework supporting diagnosis and assessment in their educational programs. The KSBSRB defines the Licensed Clinical Professional Counselor (LCPC) as someone who is licensed as an LPC and has 4000 hours of supervised clinical experience under an approved clinical training plan.

RPT
A Registered Play Therapist (RPT) is a licensed mental health professional who has earned a certification documenting that they have a certain level of experience providing play therapy to children, which is a type of treatment in which the therapist helps children express their feelings and resolve conflicts through play. The Association for Play Therapy grants and oversees these credentials. Providers must be licensed and have earned at least 150 hours of instruction in play therapy as well as 500 hours of play therapy specific supervised experience plus 50 hours of concurrent play therapy specific supervision. They must also maintain 18 hours of play therapy specific continuing education every three years.

ABPP
According to psychologist Emily D. Warnes, Ph.D., ABPP, “Board Certification by The American Board of Professional Psychology (ABPP), is intended to certify that an individual psychologist has completed specific educational, training and experience requirements of a particular specialty area (e.g., Clinical Psychology, Clinical Child and Adolescent Psychology, School Psychology). Certification involves an extensive examination process designed to assess the competencies required to provide the highest quality services in a given specialty area.”

Continuing Education

Most licensed mental health professionals must also complete a certain number of approved continuing education credits each year or two in order to maintain their licenses and practice independently. The number of hours required and the types of credits approved differ according to state and type of license.

For example, in Kansas, Psychologists must accumulate 50 hours of approved continuing education credits every two years, 3 of which must include professional ethics and 6 of which must be related to the diagnosis and treatment of mental disorders. Social Workers must accumulate 40 hours every two years, with the same requirements for ethics and diagnosis. Professional Counselors must accumulate 30 hours every two years, with the same requirements for ethics and diagnosis.

Tracy Ochester, PsyD is a psychologist in independent practice in Leawood, KS. She specializes in cognitive behavior therapy, mindfulness informed practices, and psychodiagnostic testing. Dr. Ochester also teaches at the university level, supervises aspiring psychologists, and provides consultation services to the community.

Finding the Mental Health Services You Need

When life concerns seem fairly typical and routine, it may not be all that difficult to find help.  If it’s just a check-up that’s required, we often go to our insurer’s provider list and pick the closest general practitioner in-network.

But, what about when your needs are unique, complicated, or confusing? What if “treatment as usual” hasn’t brought desired results? Sometimes picking the most convenient provider from the top of the insurance list doesn’t get us what we need.  When the stakes are high, it is important to get the best help available.

In the world of mental health care, finding a provider you really click with is of utmost importance.  Research has shown that your relationship with your counselor is one of the most important factors in treatment success.

It is also very important to have a provider who understands your particular concerns and has experience treating them.  Depression and anxiety are very common and most mental health practitioners get a lot of experience working with these disorders.

But some disorders are relatively rare and some concerns are highly sensitive, so it may be harder to locate a provider who has the experience and open-mindedness needed to effectively address them. In addition, some disorders have only one or two methods of treatment that have been supported by research.  In that case it may be important for you to find a provider who is experienced with that particular form of treatment.

For adults, there are empirically supported treatments for Attention Deficit Hyperactivity Disorder, Bipolar Disorder, Borderline Personality Disorder, Chronic Pain, Depression, Eating Disorders, Generalized Anxiety Disorder, Insomnia, Obsessive-Compulsive Disorder, Panic Disorder, Post-Traumatic Stress Disorder, Schizophrenia, Social Phobia, Specific Phobias, and Substance Use Disorders. For children and adolescents there are empirically supported treatments for many of the same disorders as well as Disruptive Behavior Problems like Oppositional Defiant Disorder and Conduct Disorder.

Fortunately most mental health providers now have websites where you can read about their credentials, experience, and approach.  Many of us maintain blogs where you can get to know our views and get a taste of what it might be like to work with us.  Most of us are also willing to speak with you over the phone for a few minutes to introduce ourselves and answer your preliminary questions.

You can find mental health professionals in your area through any number of online therapist locators such as those hosted by the American Psychological Association, Psychology Today, Network Therapy and Good Therapy. Lower cost and subsidized services are also available for those with financial need, so no one should feel that professional help is beyond their reach.

Tracy Ochester, PsyD is a psychologist in independent practice in Leawood, KS. She specializes in cognitive behavior therapy, mindfulness informed practices, and psychodiagnostic testing. Dr. Ochester also teaches at the university level, supervises aspiring psychologists, and provides consultation services to the community.