The Therapeutic Process (Beginning, Middle, and End)

By Jessica J Witmer, MA, Ms.Ed., LMHCA

Before Beginning Therapy

Before beginning therapy, it is important to understand the therapeutic process:  i.e. how therapy starts, what happens in the middle, and how it ends.  

Before therapy begins, you will be asked to submit consent forms, medical information (such as if you are under psychiatric or medical care treatment), and insurance and/or payment information.  These forms and paperwork can seem daunting, but this information confirms your legal consent for treatment and insurance benefits (if you are using insurance).

Your therapist will also request information about your personal and family history.  Providing information about your family of origin and about the people and events that have been important in your life helps your therapist begin to develop a “big picture” of your story - about how you got to be the person you are and possibly about the origins of the problem for which you are seeking help.

The First Few Sessions

The first few sessions of therapy are “intake sessions”.  During these sessions, your counselor will review the consent forms, detail any office policies and procedures (such as cancellation policies), and answer any questions you have.  Your counselor may also share her qualifications and experience, and describe the therapeutic approach, interventions, or modalities she uses.

These first few sessions help both you and your therapist to determine if you are a good fit for each other. It is important for you to know that there are many different kinds of therapeutic approaches and theoretical orientations for therapy.  For example, there are cognitive behavioral therapists, “parts of self” therapists, psychoanalytic therapists, and experiential therapists - just to name a few!  Your therapist should be able to describe her approach and inform you of some of the interventions she will use to assist you in your change process.  

If your therapist thinks someone else will be a better fit for your needs, she may refer you to someone else; and if you feel that what your therapist offers isn’t what you need or that your personalities don’t mesh, you may decide to look for another therapist.

During these sessions, your therapist will also take the time to learn about you: about your family of origin, the people who matter to you, the events that have shaped you, and about your goals for beginning therapy.

After your therapist has a grasp on your personal history and goals for therapy, you and your therapist will develop a treatment plan; in other words, you will together decide what you are working on changing about your life.  This is important because if you don’t know what you want to change about your life, you won’t know when treatment is completed.

The Working Stage

After the initial intake stage, you and your counselor will begin working on the change process in earnest.  You will really begin focusing on the problems that brought you into her office.  

Your therapist may offer you interventions that will help you reprocess difficult events in your life, or assist you in learning new skills. You may practice new behaviors both in and out of the therapeutic setting, you may experiment with new experiences, or even have homework.   Whatever you work on, this stage can last from a few months to a year or two, depending on your needs.

During this stage of treatment, the relationship between the client and therapist intensifies, trust develops, and you may feel safer to talk about things that you have avoided dealing with in the past.  You or your therapist may bring up issues that you have been reluctant to explore, and sometimes that can be painful.  Over time, you may realize that your avoidance of distressing memories or problems is decreasing, and that you are gaining a new level of self-awareness that is necessary for change and growth. 

Sometimes during this stage, there can be difficulties or conflict in the therapeutic relationship.  Your therapist may say something that bothers or offends you, and you may lose trust in the relationship.  This is called a therapeutic breach, and it is a common experience.  When therapy is done well, a therapeutic repair will follow.  This is an important part of the therapy process, because many people have not had the opportunity to practice repairing relationships after a conflict in a healthy way.  Learning how to assertively communicate about a conflict, by asking for what you need or want, is an incredibly healing experience.

If you experience therapeutic breach during your therapeutic process (and you likely will at some point), you are encouraged to confront the problem.  The best outcome is that your therapist will accept responsibility for their part in the problem, and facilitate resolution.  Many people find that after a therapeutic conflict and repair, their trust in the relationship becomes even stronger, because they know that they can confront problems and still remain securely in the relationship.

The Late Stage

The late stage of therapy happens as the client approaches the achievement of their initial goals for seeking help.  They may begin to feel like there isn’t as much to talk about or work on in sessions.  They may also notice that they are feeling more confident in confronting and managing their problems and their interpersonal relationships. 

During this stage, the work often includes celebrating success,  integrating the work that was done during the working stage, and exploring maintenance and prevention strategies. Sessions may be reduced from weekly, or bi-weekly, to monthly or to an as-needed basis.  

Termination Stage: the Ending of the Therapeutic Relationship

As the late stage of therapy comes to a close, goodbyes are in order as the relationship heads toward “termination” (end of therapy).  When therapy ends in an ideal way, it ends because both the client and the therapist feel that the client has achieved the therapeutic goals agreed up in the treatment planning stage.  While this is the ideal outcome, and what you and your therapist are working toward, therapy doesn’t always end that way. 

Sometimes the relationship ends for more practical reasons.  For example, sometimes therapy ends because the client changes insurance companies, or has new hours of work that the therapist cannot accommodate; or, perhaps the client encounters financial strain and can no longer afford therapeutic services.  Sometimes the relationship ends for clinical reasons, like if the client no longer feels that the therapist can provide what they are looking for; or if the therapist feels that problems have been uncovered for which she lacks expertise in treatment. 

In these situations, termination should include an exploration of the client's needs, and a referral should be provided to a therapist who can provide what the client needs.

In any case, termination means saying goodbye.  It is normal for both client and therapist to experience some ambivalence about the termination process.  There may be a feeling of sadness or some anxiety about “graduating” from the therapeutic process. Those feelings can be explored and addressed in sessions.

Ultimately, however, termination is an exciting time as have been reached and a new sense of confidence has been attained. It is a time to celebrate a chapter in your life. Your therapist may offer some suggestions such as rituals or interventions that help you to recognize how far you have come, or to assist you in embracing what is coming next. 

Termination isn’t just an ending: it is a new beginning and should be approached with some excitement and optimism about the future.

Integrative Mental Healthcare 101

By Jessica J Witmer, MA, Ms.Ed., LMHCA

What is Complementary & Alternative Medicine (CAM)?

Complementary and alternative medicine, otherwise known as CAM, is any medical and healthcare system, practice, and/or product that is not presently considered to be part of conventional medicine [1].  Conservative estimates suggest that at least 50% of people in the US, and more worldwide, use various CAM interventions as a part of their healthcare [2].

What is Integrative Healthcare?

Convention western medicine is considered to be highly effective for emergency medicine, but less effective or curative for the treatment of chronic illnesses or symptoms. Increasingly, healthcare consumers are aware that western, allopathic healthcare is not the only form of treatment available to them, and are investigating other healthcare approaches for symptom-relief [3], particularly for issues that are chronic.

When healthcare consumers choose to forgo allopathic treatment in favor of other treatment modalities, they are said to be using “alternative healthcare”.  When people choose to utilize allopathic treatment in addition to other treatment modalities, they are considered to be using “complementary” or “integrative healthcare”. 

Why Integrative Care for Mental Health? 

Evidence suggests that some patients withhold their use of CAM modalities from their medical providers because they believe that their prescriber will be unsupportive or undereducated about the benefits of CAM [4].  When patients hesitate to disclose the use of CAM to prescribers, they can experience adverse effects on overall treatment, including delays in treatment, poor outcomes, and safety issues [5].  

Bridging the Gap

While licensed mental health counselors (LMHCs) are not licensed to practice medicine, to prescribe pharmaceutical medications, or to offer medical advice, these healthcare providers can play an important role in integrative healthcare.  Integrative mental health counselors have qualifications, such as licensure and/or certifications, training, and experience in assisting clients in exploring the variety of treatment modalities that are available to them for their mental healthcare.

These providers help bridge the gap by providing a place for consumers to explore over-the-counter and/or self-directed use of CAM, and also by providing them with referrals to licensed and/or certified CAM-informed medication prescribers, such as psychiatrists or psychiatric nurse practitioners, who are knowledgeable about potential supplemental/herbal/drug interactions.  

Integrative mental health counselors can also refer their clients to other practitioners who are proficient in treatment modalities that can form a comprehensive and holistic treatment plan.  When the treatment plan integrates modalities available, both allopathic and alternative, the best results can be achieved, sometimes even eliminating the need for medications with potentially risky side effects. 

Complementary and Alternative Treatment Modalities

In our increasingly medically diverse world, people have a variety of treatment modalities available to them. The modalities listed below are some of the most widely used and effective forms of CAMs that are available for healthcare consumers.  As can be seen via this list, there are numerous systems of medicine available for healthcare, many of which are highly effective in treating the whole person.  

• Functional medicine: a systems biology–based approach that focuses on identifying and addressing the root cause of disease [6]

• Naturopathic medicine:  emphasizes prevention, treatment, and optimal health through the use of therapeutic methods and substances that encourage individuals’ inherent self-healing process [7]

• Culinary medicine: helps people reach good personal medical decisions about accessing and eating high-quality meals that help prevent and treat disease and restore well-being and often focuses on optimal assimilation of necessary nutrients [8]

• Herbal medicine: the ancient art and science of using plants to support health and wellness [9]

• Environmental medicine: the comprehensive, cost-effective, proactive cause-oriented, patient-centered and preventive strategic approach to medical care dedicated to the evaluation, management, and prevention of the adverse consequences resulting from environmentally triggered illnesses [10]

• Chiropractic medicine: emphasizes the body’s ability to heal itself and often involves manual therapy, spinal manipulation, and nutritional and/or dietary counseling [11]

• Homeopathy: utilizes the principle “like cures like” and utilizes extremely diluted substances to invigorate the body’s natural healing response [12]

• Ayurvedic traditional medicine: the ancient Indian healthcare system that relies on a natural and holistic approach to physical and mental health [13]

• Traditional Chinese medicine: understands the body as an integrated whole and seeks to restore and maintain harmony throughout the body through the use of herbs, acupuncture, and other interventions [14]

• Indigenous/traditional medicine: the knowledge, skills, and practises based on the theories, beliefs, and experiences indigenous to different cultures used in the maintenance of health and in the prevention, diagnosis, improvement or treatment of physical and mental illness [15]

• Energy medicine: uses an energetic or informational interaction with a biological system to bring back homeostasis in the organism [16]

• Bodywork:  body-based approaches to treatment that emphasize manipulation and realignment of the body's structure in order to improve its function as well as the client's mental outlook [17]

• Somatic psychotherapies & mindbody medicine: recognizes the continuity and the deep connections that all psycho-corporal processes contribute, in equal fashion, to the organization of the whole person [18]

• Spirituality / Shamanic medicine: works within a holistic framework to address the spiritual side of illness in a complementary relationship with the nonspiritual treatment of illness and injury, sometimes utilizing rituals, psychotropic herbs, medical marijuana, etc. [19]

• German new medicine:  understands physiological symptoms, commonly understood as diseases, as “special biological programs” that are initiated by the brain/body as an emergency adaptation response designed to assist an individual through a conflict or time of stress [20]

Mindbody Connection

In one groundbreaking study, the Adverse Childhood Events study (ACES), it was discovered that there is a strong correlation between childhood stressors such as abuse, neglect, or even divorce, and chronic illnesses later in adulthood [21]. One weakness of the current, mainstream medical model is that many conventionally-trained physicians are not adequately trained in assessing for ACEs and/or recognizing the effects that ACEs have on physical health [22].  

Thankfully, that is changing as healthcare practitioners from a variety of disciplines are increasingly becoming aware of the complex relationship between traumatic experience and chronic illness.  Many integrative healthcare approaches seek to understand the bidirectional impact of physical and mental wellbeing, or what is sometimes known as the “mindbody connection”.  Mounting evidence suggests that mindbody approaches such as biofeedback, relaxation therapy, hypnosis, guided imagery, and psychoeducational approaches are effective treatment interventions for a variety of conditions, from arthritis to headaches and chronic pain [23].  

Controversy

There is an occasional friction between proponents of CAM and allopathic medicine schools of thought, usually centering around the concept of “evidenced-based medicine”.  Exclusive supporters of allopathic medicine sometimes display concern about the lack of evidence to support the use of CAM modalities, while CAM practitioners display concern about the lack of funding for the research of CAM modalities, and/or financial or philosophical conflicts of interest of the pharmaceutical/medical industry [24].  

From an economic perspective, there is little incentive to prevent dis-ease, or treat it naturally, when large profits are gathered from the treatment of symptoms. The lack of financial incentive to invest in CAM-oriented healthcare infrastructures puts CAMS practitioners at an economic disadvantage; unfortunately, this makes CAM approaches financially out of reach for many people. 

The Ethics of CAMs

When it comes ethical considerations, it is important to note that healthcare providers are faced with a sometimes contradictory obligation: one the one hand, to protect people from potentially harmful practices, and on the other hands to protect peoples’ right to autonomy and to choose their own healthcare approach.  Healthcare providers have an obligation to protect clients and patients from potentially harmful interventions; yet, in order to determine which interventions are helpful or harmful, studies must be performed.  

Central to the controversy, and sometimes rigorous debate, between conventional, western approaches and CAM approaches is the “uniqueness of the individual”.  Evidence-based practices, which are typically based on statistical information, can improve the likelihood of successful outcomes for the majority of people; however, it doesn’t necessarily follow that a given intervention is the best choice for a particular individual.  Even if evidence suggests that a particular healthcare option is the best choice for 7 out of 10 people, there is still the question of what is best for the remaining three individuals. As one healthcare provider and researcher stated, “No matter how large the study and how detailed the subgroup analysis, we will never have data detailed enough to provide with absolute certainty the answer for our one unique patient” [25].  The appeal of CAM healthcare choices, for many people, is the attention to the uniqueness of the individual that is central to many CAM systems, such as homeopathy or TMC, but is sometimes lacking in more conventional healthcare orientations.

Furthermore, in a postcolonial and culturally diverse world, there is an increasing awareness that individuals from across cultures have a human right to practice healthcare that is consistent with their ancestral traditions, whether that be eastern, herbal, shamanic, and so on [26].  For example, native and indigenous peoples have the right to their traditional ancestral medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals, and minerals. Indigenous individuals also have the right to access, without any discrimination, to all social and health services [27].  

Mental health counselors are obligated to follow the ethical guidelines of the American Counseling Association, which are formulated out of the following eight values: 

• “autonomy, or fostering the right to control the direction of one’s life;

• nonmaleficence, or avoiding actions that cause harm;

• beneficence, or working for the good of the individual and society by promoting mental health and well-being;

• justice, or treating individuals equitably and fostering fairness and equality;

• fidelity, or honoring commitments and keeping promises, including fulfilling one’s responsibilities of trust in professional relationships; and

• veracity, or dealing truthfully with individuals with whom counselors come into professional contact” [28]

By providing their clients with access to integrative, holistic methods of symptom relief, integrative mental health counselors are taking seriously the ACA’s guidance by following the principles of nonmaleficence (do no harm), beneficence (do good), and autonomy (respect client’s freedom to choose).  

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