therapy

The Human in the Helper: This isn’t something essential oils are going to fix.

Gabrielle shows up as vibrant, friendly, and personable, which serves her well as a mental health leader and Licensed Clinical Social Worker. She’s made quite the name for herself as an entrepreneur and consultant serving therapists and professionals around burnout and burnout prevention. With her passion, beautiful tattoos, and love of Zumba, it’s hard to believe she’s already experienced significant professional burnout in her career.

 

“I woke up one day and hated it,” Gabrielle shared. “My clients were no longer my ideal clients. I didn’t have the boundaries I needed. I kept hearing my own voice in my head say, ‘this is how it is.” But Gabrielle found out that things could be different. She was venting about how tired she was to a colleague in another industry one day. Their response? Sell your practice. 

 

“I found myself fantasizing about selling, but with the number we came up with, it didn’t seem worth the work.” At least at first. Gabrielle spoke to how she’d entered the mental health industry while working three jobs, and was subscribing to the hustle and grind culture of being a Millennial. “I believed that the harder I worked, the better it would be.” Which lead to burnout. Gabrielle recalls how she worked a job where she and her colleagues were expected to work long hours, take their work computers home, and come in on Saturdays or Sundays to get caught up.


Gabrielle then moved into private practice, rapidly growing into a group practice serving a community in need. She acknowledged that she built her business fast with the same drive of previous jobs and hadn’t worked on all of her own stuff as a person and professional. “This is what business ownership is about,” she told herself when she felt it catching up to her. Then she got the call to sell her business. “I had to ask myself, what do I want my life to look like?”

 

Gabrielle is a trailblazer in the mental health community by challenging the assumptions that success means a full private-pay practice or group practice ownership. “I have no regrets, this is alignment with my values,” she said of selling her practice. When asked what she wants other therapists to know, she shared, “you can create your dream life! There are so many options.” She warned against comparison to colleagues or listening to the ‘shoulds.’ She named how therapists have set high expectations for themselves, saying “we didn’t talk about the risks of burnout in school.”

 

When reflecting on her current roles of being a business and burnout consultant, Gabrielle shared a story of how an old job asked for self-care tools to be donated to their self-care room for employees. “This isn’t something essential oils are going to fix.” We have to agree.

 

To learn more about Gabrielle and how she can help colleagues and professional communities heal from burnout, visit her website at https://gabriellejulianovillani.com/

 

Things happen to us as humans, even as we support our clients as professional helpers. Do you have a story you want to share with the mental health community? Email us at croswaitecounselingpllc@gmail.com to learn more about The Human in the Helper Series!

A Caution When Setting Different Rates in Private Practice

Disclaimer: I am not a lawyer. This content does not replace a professional consultation with a legal representative.

 

What do I need to consider when setting my rates?

It’s a common question I’m asked as a Financial Therapist to therapists. Although there are multiple factors to explore when raising your rates (join us in our upcoming workshop!), there is another piece to the puzzle that’s been on my mind lately.

 

For therapists in private practice who take insurance, there are parameters they agree to as part of signing a contract and being in-network. One of which is that Balance Billing is illegal in Colorado. Balance Billing describes billing your full rate to insurance, being paid your contracted rate by insurance, and billing the client the difference. This is a no-no in Colorado.

 

An example:

Your private pay rate is $150

Insurance pays you $121

You invoice your client for the difference, which is $29

 

Seems pretty straight forward that this won’t fly. But what about in private-pay practices? Are you allowed to charge different clients different rates?

 

Yes and no.

 

For different services, it is common and accepted to have different rates. For example, your individual therapy rate may look different than your couples or family therapy rate, EMDR intensive rate, or 60 versus 90 minute session rates. Some folks are charging a higher rate for “premium times” like evenings, which feels a little sticky unless it’s in writing and known to all clients when scheduling for them to make an informed decision regarding their therapy.

 

What about charging a client a “supply fee” for being in-person? This feels like a gray area in private pay practices.

 

What feels even more sticky to me is setting different rates for in-person versus telehealth sessions, which has come up more often as professionals explore hybrid practices where they offer both.

 

For example:

A therapist charges $150 for a 50 minute telehealth individual session.

They charge $175 for a 50 minute in-person individual session.

 

The cost difference is that they want to charge more for in-person to offset costs like office space or rent, or gas and supplies like coffee and tea that are utilized for in-person services. As a business owner, I understand that thinking. And yet, the bottom line is that those expenses are tax deductions and part of doing business.

 

Here are two reasons I would caution a therapist against having different rates for telehealth and in-person sessions.

 

1.     It feels discriminatory

That’s right, this could put you at risk of being accused of discrimination. What if your client has a disability that requires or prevents them from in-person sessions? Does in-person at a higher rate convey a message to an able-bodied person? There are aspects here to think about as a private practice therapist.

 

2.     It encourages insurance companies to follow suit with wanting to pay providers less

I can tell you how upset the therapist community was when certain insurance companies suggested a lower reimbursement to therapists for telehealth after the pandemic. The argument against this? We are still doing quality work via telehealth and continue to support meaningful client outcomes towards their goals via video. So if we support a different fee structure for in-person vs. telehealth in private practice with private-pay clients, are we not encouraging insurance to reignite this initiative too? As you can imagine, this would have a negative ripple effect on therapists who want to be paid fairly by insurance, and in response, might limit their number of telehealth sessions which reduces access to care for clients.

 

So what can you do? Rather than charging different rates for telehealth vs. in person, consider raising your rates overall to address the added expenses of in-person services. Not sure what this needs to look like? Join us August 15th from 12pm-130pm MT to engage in a live webinar workshop on raising your rates.

 

Raising Your Rates Workshop Objectives

1)    Remove money blocks to raising your rates

2)    Identify factors for raising your rates

3)    Explore strategies for implementing new rates

 

I hope I can convey that my goal in writing this is to support you as a business owner AND therapist. To hold space for multiple views while also owning that I’m risk-adverse. Raising rates is one aspect to consider in response to added expenses in practice, while knowing that things are constantly changing, which means revisiting ideas often to support your business growth.

Billing Basics for Medicaid in Private Practice (for Colorado Clinicians)

After navigating the steps of credentialing with state medicaid and Contracting with desired RAEs, you may find yourself unsure of how to start billing. You are not alone!

It’s a question that comes up frequently when providing consultation to colleagues wishing to take Medicaid in their practice. Let’s take a look at some setup steps as well as explore how to avoid common errors so you can start building your Medicaid caseload with confidence!*

1. Use an Electronic Health Record (EHR). Yes, I’m biased in having used one for 6 of my 7 years of private practice so far. I often wonder how I built a group practice that first year without it! For the purposes of this blog, I’m going to focus on the setup steps for SimplePractice.com, a popular option for therapists in my area. Not sure which EHR is the best fit for you? Google comparisons of features and pricing or talk to colleagues to see what they like about each one.

2. Input your Business Data. Under Settings in SimplePractice (SP), be sure to input your NPI, business address, and Tax ID, which will not only populate on claims but will also autopopulate on superbills for clients who request one.

3. Enter your client demographics. Gender, Address, Phone Number, and Date of Birth are all required to bill a Medicaid claim successfully. Enter each client into your client list in SP and fill out their information as thoroughly as you can. You may also give the client access to their own portal, allowing them sign documents and input a lot of this information themselves which could save you time.

4. A Diagnosis is Required. A mental health diagnosis must be entered into the client record to bill insurance for mental health services, including Medicaid. Be sure to record the diagnosis before generating your first claims, otherwise you’ll receive an error message!

5. Choose the Correct Payor ID. This is the most common mistake I see in Medicaid billing for therapists here in Colorado! For Colorado Access, which manages members in RAES 3 and 5, there are two payor options listed to choose from in the “Billing and Insurance” tab. The correct payor ID for Medicaid mental health services with Colorado Access RAES 3/5 is COACC Access Behavioral Care. Choosing the other option will send your claims to the medical department which will either delay payment or get kicked back to you.

6. Enter the Modifier. Required for the past two years, the HE modifier must be included in your claims for any and all mental health services rendered with Medicaid insurance. Claims that are missing the HE modifier, which basically indicates outpatient mental health services, will be rejected and sent back for correction.

 

So there you have it, six steps to getting your Medicaid claims submitted for processing through an EHR. Be sure to collect your Explanation of Benefits (EOB) for any claims that are paid out by Medicaid, in order to confirm what clients and sessions have been paid out successfully. Thank you for all you do for our community in serving Medicaid members. Still have questions? Book a professional consultation with me to be one step closer to Medicaid Mastery in Private Practice!

*Khara does not work for Medicaid and the information shared is based on her own experience. Be sure to connect with your Medicaid Liaison for further support and clarification on contracts, billing, systems and process

Satisfactory Self-Disclosure

For many in mental health, self-disclosure is a point of disagreement. Do we self-disclose? Does self-disclosure make it more about us than our clients? Can it get us in trouble? I know my graduate program in counseling urged caution about self-disclosing for a variety of reasons, which were again reinforced by my first job in juvenile corrections. Messages were shared like, protect yourself! Listen, don’t talk! Disclosing could invalidate a client’s experience! Don’t do it! And so on.

 

Therefore it took me several years to see the value of self-disclosure in connecting with clients at a deeper level in their therapeutic work. For example, watching the disclosure help them relax, knowing they weren’t alone. Seeing them take a deep breath to know it isn’t just them. Having clients report they feel seen in receiving reassurance or validation. Witnessing these meaningful shifts, I can now admit I’m a fan of self-disclosure, within reason of course. There’s a time and place for self-disclosure that feels satisfactory to both us as providers and to our clients. Let’s take a look at some of the suggested structure of self-disclosure and how it can be beneficial in client work.

 

#1 Keep It Short

Keeping self-disclosure condensed to one or two sentences keeps us from oversharing.

Example: “Yes, I’ve experienced anxiety too.”

 

#2 Focus on Your Client

By holding the focus on your client, you avoid making the session feel more about you than them.

Example: “I’m curious, with my sharing of having experienced depression before, what does that mean to you and the work we can do together?”

 

#3 Identify the Purpose of Self-Disclosure

Before you decide to disclose, slow down to ask yourself what the purpose of the disclosure is. Is it to build rapport? Provider reassurance? Validate or normalize? These are worthwhile reasons to self-disclose, as opposed to feeling like we have an agenda, a point to prove, or we are oversharing with no therapeutic direction to go.

Example: “In working with other clients with social anxiety, they found being able to talk about it brought them some comfort. How is it for you?”

 

#4 Check in

Once you’ve self-disclosed, check in on how it landed for the client. Notice any shifts in their face or body language that would indicate their current level of comfort. Recognize if they shift to caregiving you or keeping the focus on your experience instead of their own. Ask them outright if the self-disclosure was okay with them.

 

It’s also important to see how the self-disclosure landed for you. Did it feel natural? Worthwhile? Did you find yourself worrying that you shared too much? Perhaps you recognize that you self-disclose with this client more than others in liking them or seeing them more like a friend. These are important elements to notice and track through supervision and consultation to maintain a healthy therapeutic relationship.

 

Self-disclosure can enrich your therapeutic work when embraced and applied thoughtfully. It can help a client open up, build trust, or show up more authentically in session. It can also isolate or discount a client’s experience when used too liberally or when it comes out in a way that minimizes their experience. Therefore I hope these tips can help you identify the sweet spot for self-disclosure in your own work, embracing it when it feels right and holding boundaries to keep the focus on your client and their growth as the top priority in therapy.

When a Client Feels They Aren’t Making Progress

You see an email from a client between sessions that states they don’t feel like they are making enough progress in therapy. You find your stomach tightening and your mind begins to spiral. You catch yourself thinking, “am I not an effective therapist? Am I failing them somehow?” After all, many mental health professionals take ownership over session progress or failure as we have a lot invested in the clients we serve.

 

I want to normalize this experience by stating that an initial emotional reaction to perceived negative feedback is valid. Our desire to help others is valid. Even the client bringing up their progress or lack thereof is valid. To truly embrace this experience as a growth opportunity for our clients and ourselves, consider the following steps to remain grounded and present through the process.

 

Notice Your Own Stuff. It’s important to notice our reactions and responses to a client saying they don’t feel they are making progress. We may question our abilities. We may find ourselves hurt or defensive. We may want to argue with the client. Notice how you want to respond and hold space for those feelings. Seek supervision or consultation if it can help you hold and process those emotions in preparation for moving forward to the next step.

 

Remain Curious. It’s important to remain curious about why a particular response is coming up for you. Do you recognize a people-pleasing part of that wants all clients to be happy with the work you do? Are you fearful of a negative review? Did their comment reveal deeper fears of feeling out of your element or incompetent? Perhaps you are feeling blindsided by their feedback because you felt the last few sessions were full of powerful processing. Remain curious about what response is showing up loudest and why.

 

Boldly Brainstorm. Once you’ve recognized your own response to feedback and work through it, you are ready to re-engage your client. What would it be like to explore their bravery at naming how they feel? Can they identify the barriers that prevented them from bringing it into the room in a previous session? Is there an expectation that needs to be clarified for them to feel good about the work? Or do they need a different fit or referral based on their progress to date? By modeling for the client that these types of conversations are welcome, not only can we better understand where they are coming from to brainstorm solutions, we can also encourage transparency in communication going forward.

 

Although a client reporting they feel they aren’t making enough progress can be initially upsetting, it can serve as a powerful opportunity to reconnect and communicate on the expectations and structure of therapy for the better. I hope these ideas can help you navigate unfamiliar territory with grace so that future feedback can not only enhance a client’s therapeutic process, but your clinical skills as well!

Massage Can Be Messy: Considerations for Trauma Survivors

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When we talk about self-care, massage may come to mind. Easily $60-100+ per session, we may also find massage to be a luxury. Some prioritize their service once per month with a membership. Others splurge for a special occasion. Understandably, the cost of a massage as self-care can be a barrier to scheduling and it isn’t the only one.

 

What is massage like for those who’ve experienced a physical or sexual assault trauma? As a therapist, I believe it’s important to recognize the significance of massage for someone who has had their physical space violated. To name how challenging it can be to trust a stranger to touch you and find it relaxing instead of triggering. To acknowledge the effort required to calm the fight or flight reaction with logic, wanting your body to recognize your consent. The involuntary emotions that can surface when a particular part of the body is worked.

It’s something I too can take for granted in embracing massage as part of my self-care. Therefore I want to share some strategies than could help clients find their massage experience healing and empowering in the aftermath of trauma.*

1.     Research the Options

Identifying a service provider with additional training related to trauma can be a helpful first step for trauma survivors. Is the massage therapist trained in Trauma Touch Therapy ™ or identifies as a Trauma-informed provider? Does your client feel encouraged to have a conversation on their needs prior to scheduling an appointment?  Do they feel open to exploring fit and expectations in order to reduce any anxiety that may be showing up? Additionally, reading client reviews can be a strategy for exploring fit along with asking trusted peers or friends who they recommend.

2.     Consider Provider Gender

For some trauma survivors, the gender of the massage therapist may be crucial to their level of comfort. As your client explores their options, can they consider the number of massage therapists available, including skill set, technique, and gender to increase possibility of best fit and feelings of safety?

 

3.     Have a Ritual

Several clients have shared the importance of feeling prepared for their massage experience. This may be as simple as knowing the date is approaching, getting into the right headspace the morning of the appointment, and positive self-talk or visualization to increase their sense of safety and security going into the appointment. 

 

4.     Find Your Voice

Massage therapists expect and welcome feedback on massage technique, pressure, pain, and comfort levels. Encourage your client to explore communication in your sessions so they can feel empowered to speak up if something isn’t quite right.

 

5.     Hydrate

Hydration is important for the body to feel more receptive to the massage experience as well as to reduce possible soreness after a massage. Additionally, drinking water calms the body by engaging the parasympathetic nervous system, which encourages the body to return to a calmer state of functioning after fight or flight systems have been activated.

 

Massage can be a powerful tool for healing and health for trauma survivors.* By exploring the strengths, challenges, and barriers, your client can feel more confident when deciding if massage is right for them.

 

*Clients have the right to determine what is best for them and should consult their professionals as appropriate.

Seven Tips for Building Rapport with New Telehealth Clients

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Telehealth is a necessity in the face of COVID. Professionals and clients alike are feeling grateful to have this option to provide space for services and support clients with change, uncertainty, and the unknown. If you are like me, you weren’t fully prepared for the shift to telehealth back in March. Perhaps it wasn’t part of your business model as a therapist. Maybe it wasn’t an interest for you as a professional. Nevertheless, as we adapt to continue this meaningful work, let us take a look at some helpful tips for rapport and by-in when engaging new clients through telehealth.

 

1.     Look at the Camera Frequently. It’s hard not to feel self-conscious being on a screen. Invest in a light ring and elevate your camera so you are looking forward instead of down. Be sure to look at the camera directly when asking questions and when closing the session, as it encourages connection in feeling like you are truly looking at the client instead of looking at an image of you or them.

2.     Explain Loss of Eye Contact. You don’t have look at the camera the whole time. In fact, you need to be able to glance down from time to time to see how the client is presenting when it comes to body language. Be sure to name why your gaze is shifting, such as writing notes or referencing something in their initial paperwork.

3.     Review Documents. Review their initial documents beforehand and reference them in session. Not only does this show you are paying attention, it prevents your client from feeling like they have to repeat themselves.

4.     Obtain Consent for Telehealth. Engage your client in reviewing the telehealth software and protocols to obtain their consent. This includes emphasizing how their information will be protected and what to do when a call is dropped or requires another method due to connectivity issues.

5.     Encourage Questions. When building rapport via a screen, encourage your client to ask questions. This allows them to address any anxiety or worry about the work and permits them to feel like the conversation isn’t one-sided. Summarize goals and next steps for feedback and to demonstrate active listening.

6.     Explore Therapy History. A powerful question in building rapport can be normalizing that therapy is not a one-size-fits-all approach. Encourage your client to open up about what works for them by asking what they liked or disliked about past therapy experiences. Are they brand new to therapy? Ask how you’ll be able to gauge if something you say or do upsets them. This highlights our humanness as providers and encourages new clients to be honest and self-aware about triggers for upset as well as opportunities for therapeutic repair.

7.     Be Transparent. As the intake session comes to a close, summarize what you’ve heard them share, including what they want to work on and scheduling needs. Are they open to weekly therapy? Biweekly? Did you capture their initial goals? Scan and share your intake notes for complete transparency, inviting them to provide corrections or feedback as appropriate.

These tips are by no means an exhaustive list. However, the hope is that they compliment your own experiences as a professional adapting to telehealth. Allow these ideas to support your best work by providing a meaningful first impression. Your clients will be grateful for your attention to detail and your efforts will encourage their active participation in scheduled telehealth sessions going forward.

Exploring the Difference Between Sliding Scale and a Range of Rates for Therapy

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In growing your private practice, it’s not uncommon to have questions about how a sliding scale works. In fact, for many clinicians, the concept of sliding scale gets confused with offering a range of rates for client services. We tend to use sliding scale and a range of rates interchangeably when in reality, they are very different approaches to running your mental health practice.

 

Sliding scale describes an income-based calculation to determining what the client will pay for each session. The client must report to you their income in order for you to set a rate they can afford based on that income. This is a clear-cut option in having the transparency of a table of rates and the calculations used to determine them in your state of practice. It demonstrates that there is no discrimination against clients of diverse backgrounds in having set rates that are predetermined. Take a look at the Khalil Center which shares sliding scale rates for their therapy services in Illinois, New York, California, and Toronto, Canada.

 

Although the charts are easy to interpret and are uniform to use, sliding scale does put you as the therapist in a position of asking the client to report on their income, which can make some people uncomfortable. Not only that, but what if they report an income that is incongruent with their reports of their lifestyle in sessions? I have seen colleagues struggle with unspoken resentment wondering why the client is taking vacations every other month but reports an income level where they can only afford $90/hour therapy sessions.  How often would the therapist re-evaluate the rate based on income changes for the client? Is the therapist prepared to offer the lower rate when the client comes in stating a change of employment such as a loss of job or layoff? Would the therapist introduce a re-evaluation of income and session fees when a client discloses a promotion or new job?

 

You can see why it can feel like a sticky situation to navigate client income as the fee determinant for private pay rates in private practice. It takes a lot of attention to detail to maintain a sliding scale. A second option to consider is a range of rates in your business as another viable option. 

 

Range of rates means that the business owner, in this case the therapist, identifies a range of rates they are comfortable charging for their services. For example, perhaps the clinician identifies that $120-$150 is an appropriate range that 1) feels fair to them as a licensed professional accounting for expertise and their current location and 2) feels accessible to the population they are trying to serve. Once the range of rates is set, the therapist can share it openly on their website and in initial calls with potential clients for client consideration. The client is encouraged to pick a rate that they feel they can afford, allowing the client to demonstrate financial autonomy. The agreed upon rate is recorded in the client file and both clinician and client are comfortable to move forward with sessions at that rate.

 

Similar to sliding scale, the range of rates may need to be revisited if the client experiences a loss of employment or other financial hardship. Recently, some of our colleagues have reduced rates to help individuals impacted by COVID-19. Others have had conversations with existing clients to adjust their rate as they look for new jobs or wait for news from their employer after being furloughed. Although these decisions can occur on a case by case basis, the biggest question that arises in private practice is what to do when you are ready to increase your rates.

 

Rate increases for private pay therapy are commonplace in January as the start of a new year. Will you raise your rates for existing clients? For new clients only? How will you notify existing clients of the change if the rate change applies to them? 

 

Some important elements to consider include:

1)    When and how current clients are notified of a rate increase. In writing is the ideal method.

2)    Documentation of the client decision including agreement to the new rate effective January 1st and beyond.

3)    Documentation of referrals provided within the client’s price range if the client is unable to continue with you at the increased rate.

As a business owner, you get to decide if sliding scale or a range of rates works better for you. As you move forward with your decision, clients will be deciding to either move forward with you in sessions at the higher rate or may require a transfer with referrals. Therefore notifying clients of the upcoming change 2-3 months ahead of time can be helpful to both the therapist and client in support of a seamless transition. My hope is that this blog will support therapists in exploring their options while encouraging them to navigate rate changes in ways that feel empowering and authentic. 

Estrangement Energy: A Cycle for Ruptured Mother-Daughter Relationships

It’s a pattern of devastating hurt. Safety and security are risked again and again. First introduced as the evil step mothers in Cinderella and Snow White, we have even more extreme portrayals of unhealthy mother-daughter relationships such as in White OleanderFlowers in the Attic or The Sixth Sense where Mrs. Collins poisons her daughter Kyra to get attention from others. Characters we learn to hate due to their psychological and sometimes homicidal behaviors and repeated abuse of their offspring. These characters represent dramatic examples meant to produce an emotional reaction and feelings of protection by the audience for the daughters who are survivors of such abuse.

 

What about the real-life experiences of attachment trauma? The phenomenon we see for complex trauma survivors who open up about their experiences of their mothers being less than loving? In working with dozens of women over the years, it has become clear that the damage done in a ruptured mother-daughter attachment has long lasting effects. Powerfully captured in Dr. Karyl McBride’s book, Will I Ever Be Good Enough?, daughters go through patterns of grief and loss, questioning their own worth due to the spoken and unspoken messages of their mothers. If young children worry that their parents’ divorce is their fault somehow, it’s not surprising that an adult child of an estranged mother may also feel some sense of responsibility for the damaged relationship.

 

The responsibility and grief they feel may spur them to come to therapy to find some peace with the estrangement. Let’s take a look at several examples of adult women who are estranged from their mothers after the painful realization that the relationship was unhealthy, unsafe, or unable to shift in ways that felt empowering and worthwhile.

 

Kendell* has been estranged from her mother for more than 16 years. She left home at 15, got pregnant at an early age, and consumes alcohol daily to calm her nerves. Kendell is a committed mother to her four children, stating she wants to provide for them in ways her mother couldn’t. When engaging Kendell in her trauma work, she recognizes her mother’s mental health challenges prevented affection and her mother saw her as competition for the men she dated, leading to conflict and verbal or physical altercations until Kendell left the family home.  Kendell struggles with being gaslit by her mother who still tries to call her occasionally and has enlisted Kendell’s younger sister to convince her that it’s all “water under the bridge now.”

 

Nicolette* is celebrating seven years sober from heroin. She has identified her childhood consisting of her mom criticizing her looks, weight, and intelligence. Nicolette’s experience with her mom captures a pattern of manipulation through her teenage years which led her to believe she was flawed, unlovable, and mentally ill. She found herself marrying a controlling man and suffering from various addictions until she was able to get a divorce when the relationship turned violent. Although Nicolette entered substance recovery programs voluntarily to get well, her mom accused her of relapse throughout her sobriety, even physically assaulting her and getting Nicolette arrested under false charges due to her stigmatized label as a former drug addict. Nicolette struggled to release herself from family ties in spite of the abuse, believing she had to work harder to earn her mom and other family member’s love. She has been estranged for four years now and finds herself questioning the estrangement 1-2 times per year, asking herself if there was more she could have done.

 

Sophia’s* father reconnected with her as a teenager, dying of a rare cancer not long after. Raised by a mother who struggled with poverty, mental health, and substances, Sophia was left to take care of herself and her younger brother in their rural upbringing. Sophia was determined to find independence, moving out on her own and pursuing a career as a helping professional. Sophia currently struggles with high anxiety and demands for control. She doesn’t like change and finds herself on edge and reactive when anticipating outreach by her estranged mother every holiday. She struggles with perfectionist tendencies and rigid thinking. Sophia’s goal is to have stability for herself and her family and she maintains strong conviction to remain estranged from her mother. Sophia prides herself on building other meaningful relationships that feel supportive and loving. 

 

Each of these women’s stories is unique and their own yet they have something in common, the grief and loss patterns associated with the ruptured mother-daughter relationship. Some daughters are left wondering if they could have done more to salvage or repair the relationship with their mothers. Others hold anger and determination to be nothing like their mothers. Their therapeutic work could begin with questioning their own role or actions. Or perhaps they have concerns about other relationships present in their life. They may work through the core beliefs of feeling unlovable, unworthy, or a failure in believing they were unable to earn their mother’s love or affection. And eventually, with time, they may redefine their identity without a mother in their life, embracing their strengths and boundaries to support healthy, meaningful relationships with others. 

 

Estrangement Energy, what I call the process for individuals doing this deeper work, can feel exhausting. Here’s the pattern I’ve witnessed in many clients over the years. 

·      There is a cycle of abuse or patterns of negative behavior that have happened for years between daughters and their mothers.

·      The cycle of negative interactions contributes to how the daughter measures her self-worth.

·      There is questioning if this pattern will ever shift, improve, or change for the better, especially when the daughter is aware that other mother-daughter relationships look different than their own.

·      The relationship rupture happens when the daughter has had enough. She makes moves to distance herself from the pain or abuse experienced in the relationship. 

·      With space or at the urgings of others in her life, the daughter is prompted to remove the relationship, labeling it as “toxic” and estranged.

·      The daughter tends to pursue therapy after the estrangement has happened or is in the process of happening in response to immense hurt, pain, and grief reactions that result from the estrangement.

·      Grief and loss followed by new identity development is done in therapeutic settings or through self-discovery over time.

·      A new sense of self emerges, with deeper work on self-worth related to core beliefs of being lovable and worthy in relationships.

·      The Estrangement Energy Cycle can be triggered to continue if current relationships mirror the estranged mother-daughter relationship, leading to resumed questioning of self-worth.

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As you can see from this cycle, it can be an emotionally challenging if not draining process to work through estrangement and what it means to an individual. It’s not an easy or fast process, so here are some ideas to help clients do this meaningful work:

·      What’s Your Impression? Understand that some clients will be worried what you think of them as they share their grief and loss of the mothering relationship. Remain curious and neutral, exploring how these worries can become part of the therapeutic process.

·      I’m Second-Guessing Myself. It’s not uncommon for a client to question if the estrangement is still valid after a period of time. Like Nicolette mentioned above, perhaps they find themselves checking in to see if the estrangement still feels right. Normalize the experience of questioning and hold space for them to evaluate the pros and cons of resuming contact.

·      Reconnection or Relapse? Some of your clients will move from thinking about rekindling an estranged relationship to giving it a try. As therapists, it is important that we do not force our own values on our clients, instead supporting them through the process of outreach and connection with their estranged parent while encouraging healthy boundaries, safety needs, and deeper processing in weekly sessions if needed.

 

The bravery of daughters and clients who choose to work on themselves in order to heal the attachment trauma they’ve experienced is both powerful and inspiring. My hope is that this introduction to theEstrangement Energy Cycle can support both clients and clinicians alike in the journey to being one step closer to healthy self-worth and a renewed, empowered sense of self.

*Client information has been changed to protect confidentiality.

Canine Assisted Substance Abuse Treatment

puppy

Imagine that you have a guarded new client with a history of substance use. You try everything to make them feel comfortable and they still show reluctance to engage in treatment.  There may be several valid reasons for being closed off. This can lead to an increase in the stress hormone cortisol, possibly causing cravings for relapse. The next session you bring your certified therapy dog. The dog is welcoming, non judgmental and accepting of your client and is happy when they arrive. What has just happened in the client’s body? Meeting the dog caused their cortisol level to decrease. Their bonding hormone, oxytocin, has increased. They used to get the release of dopamine from their drugs but now they are getting oxytocin from your dog instead. Their heart rate has stabilized, their blood pressure has reduced and their frontal lobe is back online (Odendaal and Meintjes, 2003). Now, they may feel less guarded and more comfortable in therapy.

Often times, clients are more willing to trust a canine therapist versus a human therapist. They are more open to touch and comfort when it comes from a dog. They feel the attunement from the therapy dog and get to experience what a healthy attachment feels like. They finally feel heard and seen. As a certified canine assisted therapist you notice when your client and dog have bonded. The therapeutic relationship has accelerated and you are ready to try many different interventions over the course of their treatment. You come up with a few interventions to try. One might be having the client teach the dog a trick to help them practice healthy communication and relationship skills. Another intervention to try might be discussing what they have in common with the therapy dog. This can be drawn out to increase empathy for the dog and themselves. Now that they have the experience of a healthy attachment with your dog, they can move on to practice attaching to healthy people in their lives. Now they are ready for canine assisted family therapy to start. Eventually the desire to use substances begins to diminish.

Practicing animal assisted therapy comes with many challenges and it’s no easy feat. I have been practicing canine assisted therapy since 2005. I’ve seen 65% of my clients obtain sobriety which is double the national average. I incorporate it in individual, couples and family therapy sessions. It is extremely important that you and your dog have proper training and that your dog enjoys the work. It is necessary that you know your dog’s calming signals and can advocate for them. In order to ethically practice canine assisted therapy you need to follow the recommended animal assisted therapy competencies written by the American Counseling Association. They suggest attending a canine assisted therapy training, having your dog pass the canine good citizen test and obtaining regular consultation among many other things.

If you want to learn more about canine assisted therapy go to my website:
http://www.pawsitivetherapeutic.org/aat-qa/

References
Odendaal, JS and RA Meintjes. “Neurophysiological Correlates of Affiliative Behavior Between Humans and Dogs.” Veterinary Journal, May 2003, pp: 296-301.


Guest post written by Amanda Ingram, LCSW, CAC III

Guest post written by Amanda Ingram, LCSW, CAC III

Amanda Ingram, LCSW, CAC III, graduated from the University of Denver (DU) Graduate School of Social Work with an Animal Assisted Therapy (AAT) Certificate in 2007. She also trained Guide Dogs for the Blind for seven years. Ms. Ingram currently owns Pawsitive Therapeutic Interventions, LLC where she trains mental health providers in animal assisted therapy and also offers individual, couples and family therapy in the Stapleton community.