Sometimes, you’re actively focused on a problem and successfully working on the solution. Other times, you know you have a problem, but you’re not feeling ready to act on it. And then there are times when you are suffering, but you haven’t yet brought into your own consciousness the reality of what’s going on. One way to make sense of all this—and lead yourself forward into a healthier place—is to look at the Transtheoretical Model and discern where you might fall.

It works like this. When a person has a problem, let’s say, with alcohol, she is somewhere on the following list of attitudes and behaviors in relationship with alcohol:

1. Precontemplation: she may not be admitting to herself that she has a problem, or if she is, she’s not ready to work on it.
2. Contemplation: she intends to change, and is beginning to come up with some first steps she wants to take.
3. Preparation: she’s much closer to taking action.
4. Action: she’s working the problem!
5. Maintenance: having achieved success, she’s working on preventing relapse.
6. Termination: (for the alcohol example, this does not apply) she has solved her problem and no longer needs maintenance.

This all sounds good, but it gets complicated because, even if you’re already in counseling, you may not be at the action stage. I’ve had many clients who work with me while still in the precontemplation stage. When you’re in that stage, you’re not yet serious about your problem, and perhaps in active denial about it. You may be in counseling because someone recommended it, or because you yourself have a sense that something’s wrong and you should talk to someone. But it can be a frustrating and confusing experience.

As a therapist, I’ve always believed that I need to work with my own therapist to be sure I’m focusing on my own personal issues, if only so they don’t get in the way when I’m working with my clients on theirs. And I’ve often seen myself moving through all six of these stages of change while working with a therapist. After many years of this, I’ve come to realize that it’s never over: if I’m terminating one problem, I’m in precontemplation on another issue. If I’m active and successful in one area, I’m lost in the “contemplation forest” on something else. We are dynamic, ever-changing, living beings. There’s always something coming up.

So if you’re feeling confused or frustrated, it might help to take a look at this model and see where you might fall. That insight can lead you to ask yourself, “Where should I go next?”

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I was working with a couple a few weeks ago, and we were discussing how some of their fights get out of hand. In the course of our discussion, I said something like, “So, when you can tell that the other person is about to bring the crazy, you should…” And one of them interrupted me. Laughing, she said, “Oh, I’m so glad you use the ‘crazy’ word! We had a therapist who never used words like that and thought it was offensive when we did.”

I was glad to make this personal connection with my clients, but I then reflected on why I use the word ‘crazy,’ and other slang words from our long history of marginalizing people with mental illness. Is it really okay for me to use these words? People refer to psychiatric hospitals as “funny farms,” and their words for the patients are worse. Shouldn’t I affirm the dignity of people with mental illness by not using these offensive terms?

I do want to affirm the dignity of all people, especially those who suffer serious mental and emotional problems. But I think the best way to do that is to reclaim these words and use them to describe ordinary, everyday, batsh*t-crazy behaviors that we all do…that I do. There are times (rare, I think, but you’d have to ask him) when I am acting crazy with my partner. I’m sucking my thumb (no, not literally) in a sulk about something I think he did, or I’m bringing my bad mood home, or I’m just generally being unconscious or irrational. I can go bonkers. And so can he. And so can you!

My client is right: it’s okay to use these terms, particularly if we’re trying to work on our crazy behaviors. If everyone is crazy some of the time, then no one need feel ashamed of it. We can get it out in the open and go to work on it. So here’s my question for you: are you staging a Nutty with your partner? If so, come sit by me. I’ve got some ideas about how we can shrink your head!

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I just received written feedback from a client who found our work together helpful, and I have a chance to share it with you. (The client gave permission.) Here is the feedback, with editing to protect the client’s identity:

“Stephen, thank you for working with me. I have enjoyed getting to know you, and talking with you. It may not have seemed like it at times, but I found our work together helpful. I’m not good at expressing myself, and I need time to mull things over before they sink in, so I wanted to let you know that I always left your office with challenging, comforting, enlightening thoughts to think. You wrote on your blog recently that therapy should be more like massage than CPR, and I agree. Leaving your office felt more like leaving a massage appointment: I felt a little exposed, and my (mental and emotional) muscles were a little sore, and it wasn’t until some later situation in which I had a chance to use those muscles that I truly appreciated the work we had done. It has made a difference to me and you have my gratitude. Thank you.”

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I get this question a lot, and the answer is one of those yes/no situations. First, the yes part: I am a preferred provider with Uniform Medical Plan, and I also can be reimbursed up to 80% by Group Health Options. (But it has to be Options!) In both cases, the client is responsible for the part of the fee not covered by insurance. In addition, if your employer offers an EAP as part of your benefit package, you may be able to see me for a few sessions under that benefit.*

If you are covered by another insurer, there may still be a chance that your sessions with me are partially covered. It depends on your specific plan. I’ve worked with a few clients who paid me out of pocket, then filed claims with their insurer and received partial reimbursement. If this is possible in your case, then you would need to do it this way: 1) pay me the fee; 2) then file your claim. I’ve found that if I file the claim as an out-of-network provider, reimbursement doesn’t happen.

The “no” part: couples counseling is not covered by any insurer I know of. This means that even if you have insurance with Uniform, I can’t bill them for couples sessions. If you’re an individual client of mine and we decide to invite your partner in for a session or two, then I would only be able to bill that to insurance if the work we’re doing still focuses on your individual issue. If it’s a true couple problem, then for those few sessions I would ask you to pay out of pocket. To not do so would be, alas, insurance fraud. (I personally think they should cover couples counseling, since I believe it’s helpful and I also think that a person’s relationship has a lot to do with their emotional health and life functioning. But…I don’t make the insurance rules.)

Finally, a recommendation: consider not using your insurance and paying out of pocket. There are several advantages to this:
1) All of your information will be kept confidential. No third-party onlookers will know that you’ve even seen a counselor.
2) I won’t have to diagnose you with a mental disorder. We’ll be able to let your chart reflect who you are, pure and simple. (And even if you have one of the ‘mental disorders,’ like ADD or anxiety, it won’t be a matter of record.) Plus, we’ll have absolute freedom to structure your sessions exactly how we want.
3) In my many years of experience with clients—and as a client myself—I’ve learned that out-of-pocket clients are more invested in their work, tend to get better results, and enjoy the satisfaction of putting their hard-earned money to good use.

It’s up to you. But if those three points sound convincing to you, think about paying out of pocket. And it helps to put it in perspective: therapy is expensive, yes. But how much do you spend per month on your cell phone? Or your cable? Maybe therapy would be money very well spent!

*This sentence was edited from the original content.

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Today I’m attending a workshop of John and Julie Gottman that’s all about trust and betrayal in relationships. I’ll let you know what they’re working on these days, and new insights they’ve found. For now, I’ll share a quotation from John Gottman that I love: “Altruism is a highly adaptive norm across all mammalian species.” LOL. Watch this space for more!

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If you’ve ever had counseling, you most likely experienced negative or critical thoughts and feelings about your therapist. I’ve worked with fantastic therapists myself, and even they will strike a wrong note, or just say the wrong thing, in our work together. What to do?

Simple: tell the therapist. If you think I’m taking us into a topic or issue that’s not interesting, not helpful, or just plain irritating, let me know. Hard as I try, I’m not perfect and might take us down a path that just isn’t right. Not only is it okay for you to let me know, it’s actually a fundamental dimension of good therapy. It could even be a breakthrough moment for you: by confronting me with your concern about our work together, you gain experience connecting with another person on a difficult and painful topic. It’s a chance to practice courageous and healthy honesty. It’s good for both of us!

Often enough I can sense that we’re off track, and I’ll beat you to the punch. “Are you mad?” I asked a client a few weeks ago. “Yeah,” she said. “Are you mad at me?” “Yes,” she replied. And the conversation that followed was probably one of the most helpful experiences she had in our work together.

So…let me have it!

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I’ve recently been contacted by a number of prospective clients, and several of them asked me how many sessions they can expect to have if they work with me. This is a common question, and a good one: it’s important to have an idea of what you’re getting into when you hire a therapist.

I typically offer this response: it’s hard to say, but we’ll probably meet several times, depending on what you’re working on. Some people only need two or three sessions, and others like to meet with their therapist regularly for years. And then there’s the broad middle—the large group of people who need a dozen or so appointments before they determine that they’re ready to stop.

This seemed too vague, so I did some calculations. I added up the number of sessions I’ve done since I started my practice in September 2007 and divided it by the number of clients I’ve seen. The result: the average client sees me about nine times. Depending on who you are, that’s either a too-small or too-large number. If it seems too small, don’t worry: I have several great clients who see me regularly over a long period of time. And if it seems too large, don’t worry: I’ve gotten positive feedback from clients who experienced significant change in as few as one or two sessions.

Is this still too vague? Perhaps. I can crunch the numbers a bit more. But if you’re wondering how long you might have to work with me, it’s probably safe to assume that you’ll see me a couple of times and have a much better idea of what you’re interested in doing, and roughly how long you might want to be my client.

Finally, I can speak from my own experience. As a therapist, I think it’s essential that I do the work of therapy myself, and I’ve been working with a therapist since May of 2006. These days we meet every other week, though in the first couple of years it was a weekly arrangement. I find my time with her invaluable. It keeps me mindful of what it feels like to be on the “receiving end” of a counseling session, and she challenges me to stay sharp in my ongoing development in both my personal and professional life. Expensive? Well, I suppose. But so are cell phones. For me, it’s money well spent.

How many sessions do you need? It’s hard to say, but you’ll have a lot more insight on this question fairly early in our work together.

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Sometimes all the words and ideas and methods of counseling just don’t cut it, and all you can do is be there for another person who is going through a hard time. I was reminded of this today when a client told me that the inspirational quotation I had on my whiteboard in the office was annoying her. So I quickly changed it, as you can see below. “Much better!” my client said.

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I don’t do this too often – seems like horn-tooting, I guess – but I got a piece of positive feedback from a client* recently and thought I’d share it here. It’s always gratifying to hear that my work is making a difference! Here’s the comment -

“Stephen, I think you do amazing work, as you quickly and effectively got J. and me through the biggest challenge in our relationship. We were miserable and on the verge of breaking up in early January, but now we really are better than ever. And we’ve learned a lot about ourselves along the way.”

*The client has given me permission to publish this comment.

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If you’ve had trouble navigating my site lately, it’s because I’ve been making some changes to both content and layout, and also moved the site to a new server. Things should be smoother going forward, and thanks for your patience.

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