How I Do Psychotherapy: Healing the Mind, Finishing With the Past

Basic procedures, stages, and expected outcomes in my psychotherapy process

by Tom Cloyd, MS, MA - Counselor / Psychotherapist - Bellingham, Washington (360) 920-1226 - email: tc (AT) tomcloyd.com (please read about content licensing)

Settling down to work past enduring internal challenges which have too long been with us clears the way for us to gain new skills. We then finally reach as far as our desires can take us. (Note: The following description particularly reflects how I work with psychological trauma. Appropriate modifications in the approach are made when other sorts of problems are addressed.)

Introduction

Psychotherapy-to change perceptions, thinking, feelings, and/or behavior-occurs in a formal, contractual relationship between a mental health professional and his or her client.

The first stage of psychotherapy as I do it focuses on healing from the effects of one's personal history. The focus is on memories which, when activated, cause disturbing feelings, resulting in an unacceptable compromise of quality of life.

The second stage of psychotherapy focuses on gaining skills needed to make life work. The third stage focuses on optimizing one's performance in a few critically important areas. (I discuss these two stages in another publication.)

When you contract with me for psychotherapy, I will typically focus initially on the following essential concerns, in approximately this order:

Crisis issues

A crisis is something that presents a serious threat to the effectiveness of one's thinking, feeling, behavior, or survival. It requires immediate attention. I will always check for certain sorts of crises that might be present, whether you bring up the topic or not. You might also call attention to other urgent concerns in your life. If you are in a crisis, our first priority must be to act together to get relief for you as soon as possible.

Your goals

Your view of your situation, and how you want it to change, contains invaluable information for me. I will give it careful attention. I will also ask you to keep your statement of your situation brief at this point, as details will be more useful to us later.

Orientation to Counseling and Psychotherapy in general

We will review basic information about my background, training, and way of doing psychotherapy, as well as the basics of counseling ethics, and the rules of privacy and confidentiality under which I practice. You will receive information about this in writing so that you can review it later at any time.

Essentials of your "life story". I only need to know certain things about your personal history, so I will ask you a number of specific questions that I use with almost everyone I work with. I am also interested in anything else you want me to know that you consider important.

This personal history, along with a Family Tree I will develop for you, will give me a useful picture of the people you come from, what your childhood and development was like, what your experience has been with education and with work, what your substance use/abuse experience has been, and so on. I will ask for a brief, very sketchy review of any abusive or traumatic experiences you have encountered. Again, we will not deal with detail at this point.

Finally, we will look at your present life by considering a small number of specific problem areas that can trouble people, to see if these areas are of concern to you.

This information will usually lead to my making a formal diagnosis of your condition, if that is appropriate. It will also allow me to construct a very important problem list, composed of [a] every significant traumatic event in your personal history (see "Effects of minor and major trauma", below) and [b] every significant concern you presently have in your life. This list will be used to direct therapeutic intervention efficiently so that you can experience the healing effects of psychotherapy as quickly as possible.

Your treatment plan

You and I will then consider what we know about you, and what we want to do about it. Here are some examples of concerns on which we might choose to focus our efforts:

Feelings - You may have discovered that the feelings you have most days are not those you most like and need, so that you rarely feel satisfied and content. If so, we will work to discover how your disturbing feelings originate, so that we can change what you are experiencing.

Depression, anxiety, compulsive behaviors - Fundamental problems with energy level or capacity for pleasure in your life (depression), or with worry and fear (anxiety), or misuse of substances or other mood changing aspects of your life (addictions) may prevent you from getting what you want to in your life. If so, we will work to find and resolve the fundamental disturbances that cause these self-limiting symptoms.

Psychological trauma - You might find that your life is consistently disturbed by the effects of your having experienced psychological trauma at some point in your past. The effects of this can be wide-ranging. With the people I most often see, this is the most common problem I encounter. (I discuss this problem in more detail in the next major section of this pamphlet.)

Once we have discussed your treatment goals and options, and have reached an agreement about how we want to proceed, we will have a plan for your treatment. It may include a recommendation for the use of supportive psychotropic medication, for medication can significantly speed the progress of psychotherapy. However, I always emphasize that the decision to use medication must be made by the person who will take it, given full knowledge of the costs and benefits of this psychotherapeutic option.

Effects of minor and major trauma

Because I find that people's problems are so often due to psychological trauma, I look carefully for such disturbances in a person's mind. Stage I psychotherapy-trauma resolution-consumes much of my clinical time. Often, when the effects of psychological trauma are resolved, people's objectionable secondary symptoms (substance abuse, compulsive behaviors, depression, anxiety, etc.) simply vanish.  

Psychological trauma can occur in any situation in your life that produces large amounts of negative feeling. When the amount of feeling produced by your response to the situation exceeds what you can adapt to, your internal function is disrupted-clear evidence that you are traumatized.

Ideally, the disruption is brief. But if the disruption endures for a number of days, you are experiencing Posttraumatic Stress (PTS). If your PTS is serious enough, you can be diagnosed with Acute Stress Disorder (ASD). If the post-traumatic stress lasts longer, you may develop Posttraumatic Stress Disorder, or PTSD. The most common causes of ASD and PTSD are automobile accidents, physical and sexual abuse, traumatic personal loss, and military combat situations, but there are many other causes, including chronic childhood neglect.

There is a lot of PTSD in the general population. (Some estimates suggest that as much as 10% of the population has PTSD at one time or another.) There is even more PTS-enduring, disruptive, posttraumatic stress reactions that are not serious enough to be diagnosed as ASD or PTSD.  

Posttraumatic stress can also lead to dissociative disorders, which always gravely inhibit a person's life performance and satisfaction.

Most of these stress reactions are undiagnosed or mis-diagnosed. Because most mental health professionals are inadequately trained in diagnosis and treatment of these disorders, and most psychotherapy clients know very little about them, effective treatment rarely occurs. The pain of post-traumatic stress then continues unnecessarily, long past the time of the event(s) causing the traumatic stress.

Preparing for treatment of trauma

Our first concern will be to look at the degree to which you can manage your Posttraumatic Stress symptoms. Only after adequate symptom management is achieved may trauma treatment begin.

There are a variety of ways in which people can successfully manage their symptoms so that the degree of disruption experienced is minimized. Most people already have some way of doing this, but most people can also quickly learn to do a significantly better job of symptom management, with training.

Treating the effects of trauma

To treat your Posttraumatic Stress, I will be guided by the chronologically arranged problem list we have developed for you. We will consider each significant traumatic event on the list, carefully desensitizing you to its memory, so that the memory becomes "just a story".

Desensitization can be done by several means. I use the quickest, least disturbing method, which usually yields superb results. Divulging details of a traumatic incident is usually not necessary for such results, and desensitization, when achieved, is obvious and verifiable, by both of us.

Effects of resolving traumatic memory

The effects of treatment are permanent and often quite remarkable. Typically, after treatment (a) you can recall traumatic events without experiencing significant emotional disturbance; (b) your sleep improves (sleep onset is easier, sleep is longer and deeper, and nightmares disappear); (c) your ability to cope with stress improves dramatically; and (d) your mind becomes clear and capable of prolonged concentration (dissociation and "mental noise" typically cease to be a problem).

Structure of the typical psychotherapy session

Each psychotherapy session typically begins with a report from you about significant events in your life, negative or positive. These events may require a response by your therapist in the session, or by you, outside of the session. Then, we focus on processing your problem list.

Concluding Stage I of psychotherapy

When the traumatic items on the problem list are processed, we will look at the "current concerns" which we listed there, before psychotherapy began. Once these are resolved (often a quick job), we will summarize the changes we have seen occur during this stage of psychotherapy.

We then consider the question of continuing on to Stage II of psychotherapy-the stage of "counseling" or "personal coaching", focusing on gaining skills needed to make your life work so that it pleases you.