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Allergy Season – You know it is bad when….

Allergy Season – You know it is bad when….

Published April 16th, 2014 in Allergies

Every year we look forward to spring, the longer days, warmer temperatures, flowers and outdoor activities. What many of us don’t look forward to, are seasonal allergies, sinus headaches, itchy eyes and skin. This year we knew allergy season was going to be a bad one when our Sadie girl dog had to go visit Dr. Blair, DVM for uncontrollable scratching. After several sleepless nights for her and us it was time to call in the big guns for help.

sadieWhat I found interesting is whatever is contributing to her environmental allergy seems to be giving me the special treatment too. I know I don’t have flees…. And after visiting Dr. Blair with Sadie, I broke down and purchased my first box of Benadryl™ for myself, to curb the itching skin, sinus pressure, and so forth.  Now I’m not an over the counter or behind the counter visitor – it is funny it took my vet to remind me about the need for allergy medication sometimes.

I’m glad to report the Sadie and I are both scratching far less now, and this week reminded me of how many clients suffer from allergies and what they can do to minimize their over the counter drug use. Some due to high blood pressure have to be especially cautious of any medications they take. Antihistamines are notorious for elevating blood pressure, causing dry eye and mouth, throat irritation, drowsiness, brain fog, irritability…. Just to name a few of the side effects.

Over the years we have found several nutritional supplements to be useful, elimination of dairy foods and eggs that increase mucus production, Netty pots for nasal irrigation, homeopathic eye drops and herbs to improve lung function. And during especially bad times we break out peppermint oil along with essential oils to put in the diffuser for relief.

Don’t overlook Mold.

Mold, black mold in particular is most active when the weather turns warmer and is damp. Mold sickness and related illnesses from mold exposure are real. Mold has been linked to lung damage, brain damage, cancer and even death.

If mold spores are inhaled or ingested you can become seriously ill. As mold continues to grow inside your body it produces poisons called “Mycotoxins”, these poisons leach into your body day after day.

Different species of mold produce different toxins and people will suffer a wide range of symptoms.

The most commonly reported symptoms of short term mold exposure:

  • Sneezing
  • Itching Skin
  • Redness and skin irritation
  • Watery Eyes
  • Itching Eyes
  • Headache

Here are a few other suggestions:

Bee Pollen: Bee pollen has been used for centuries in China for seasonal allergies. It dries up the nasal cavity and slows or stops that annoying post nasal drip that leads to nagging coughing, sore throat and drippy nose. Clinically, I have found the pollen does not have to come from local sources to work. The two brands used most by our office are Nature’s Way® and Glory Bee®. Make sure it is straight bee pollen, not one with ginseng added.

Chinese Herbs: For years now I have managed the bulk of my allergy symptoms with Chinese herb tea’s blended by a local provider for me. Now, I won’t lie to you and say the stuff tastes great – it doesn’t- but it works and I only have to do between 4 – 8 oz daily to keep my lungs happy and my head clear.

Bioflavonoid Complex from Vitamin Research Products is natures “singular,” the combined benefits of this nutrient product benefit blood pressure, circulation, heart health and the combination of bioflavonoids work as a mast cell inhibitor.

OPC or grape seed extract: All of the antioxidants including Vitamin C and E play a major role in the reduction of inflammation. As we have seen allergies are a form of inflammation and they respond well to antioxidants. OPC stands for “Oligomeric Proanthocyanidin” a very powerful antioxidant found in grape seed and a truck load of other foods.  As with all natural health options synergistic combinations require lower doses and provide more bang for your dollar.

Mullen from HerbPharma™ is my daily go to. This herb has been used since the Middle Ages in Europe for colds, lung ailments, allergies, and ear congestion. It is one of the few herbals I use that doesn’t taste like it came out of some dirty sweat sock….always a good point when taking twice daily. hahahaha

What Therapy Options Work?

Acupuncture: Extensive research supports the use of Acupuncture for a host of conditions, especially those involving inflammation. Over the last ten years research has proven acupuncture is effective in the reduction of sensitivities resulting from allergies.

Chiropractic care is also very useful in reducing the inflammation response within the body; these practitioners as a whole have not only adjustments but Nutraceuticals available to help clients this time of year.

Buy a good air filter for your bedroom, living room, or office areas. This investment helps keep the cost of supplements, medications, and doctor’s visits down. It is especially important in the bedroom where you are lying down and congestion increases. Make sure it is a HEPA filtration system and spend the money for the ultra-quiet ones.  I know Costco has some nice ones on sale generally this time of year, and as a rule are better priced than through other retailers.

To pleasant spring days without Kleenex


Spotlight on Eating Disorders

Spotlight on Eating Disorders

By Erica Goodstone, Ph.D., LMHC, LMFT, LPC

February 23-March 1 – National Eating Disorders Awareness Week

Many of us have some “disordered eating” but do not actually have an “eating disorder” diagnosis. 

With so much information in the media, we are increasingly more concerned about our weight, our diets and our eating habits.  Knowing that certain foods are unhealthy for us, we often cannot seem to stop craving and choosing those foods. We eat too much, we eat too fast, we restrict certain food, we often eat to suppress emotions and we  later pay the price in terms of feeling stuffed, uncomfortable, gaseous or  in physical pain.  What differentiates the average person’s poor eating habits from a more serious and eventually debilitating “eating disorder”?

Early Intervention Can Save Lives.

Eating Disorder is a disease, a serious disease, which can be masked in broad daylight for a long time.  Unlike a drinking or drug addiction, a person with an eating disorder cannot abstain from food. We need food to eat, every day, several times each day.  And this is a progressive disease so that relatives and friends may not quickly recognize the symptoms until the disease has already progressed to a dangerous state.You can catch it early by noticing that someone you care about is having unhealthy thoughts, attitudes and behaviors around food and eating.  No longer just a young person’s problem, men and women of all ages are exhibiting eating disorders, the fastest growing group being middle-aged women and women with diabetes.

Types of Eating Disorders

Anorexia Nervosa

When we talk about an eating disorder, what immediately comes to mind for most of us is the image of a very underweight female in her late teens or early 20’s, who has been starving herself.  But the reality is that Anorexia affects both men and women of all ages. Dieting is the most common behavior that eventually leads to a full blown eating disorder.  The emotions involved have a lot to do with feeling anxiety and low self-esteem yet wanting to please and toperform life activities perfectly. The process may begin with a simple diet, followed by increasing restriction of food, obsession with feeling overweight, and unwillingness to recognize the danger of inadequate food intake.

Bulimia Nervosa

A person suffering from Bulimia Nervosa can often easily camouflage his or her disorder by appearing to be of normal weight and appearing to eat normal meals.  If someone is paying attention, though, they will notice a pattern of over-eating at meal time, binging or excessively snacking, and then either fasting, excessively exercising, purging (inducing vomiting, taking laxatives and enemas) or alternating between all of these actions.  Disturbing the natural digestive functions of the body, increasing the acidity in the throat, and uncontrolled exercising can lead to serious physical problems.

Binging Disorder

Food can be soothing, comforting, and act like a drug.  Binge eating is certainly not just a problem for women.  An increasing number of men of all ages have developed maladaptive coping mechanisms that result in binge eating. This and all the other eating disorders are bio-psycho-social illnesses that can be healed and overcome with mental health, medical and body awareness counseling.

Orthorexic Nervosa

Not recognized by many as an actual eating disorder, orthorexic nervosa resulting from “clean eating” behavior can actually be unhealthy for the body.  In an attempt to be exceptionally healthy, a person with this disorder may be inadvertently eliminating important foods that contain necessary amino acids, minerals and vitamins.

Eating Disorder Recovery

Treatment of an eating disorder differs depending upon many factors.  Often, a team of practitioners is involved including a physician, nutritionist or dietician, psychiatrist, psychologist or mental health counselor or family therapist.

• Specific type of eating disorder
• How early the eating disorder is detected
• If there is a co-existing addiction
• Whether there is a concurrent mental health diagnosis

There is Life Beyond Eating Disorders. http://www.blogtalkradio.com/drericag/2016/01/19/life-beyond-eating-disordersListen to this recent interview with Johanna Kandel, founder and CEO of The Alliance for Eating Disorders Awareness and find out more about Eating Disorders Awareness Week.http://nedawareness.org/

Have a healthy, happy, forward thinking and successful 2016.

Please feel free to send me your questions, comments, subjects you want to see covered, and topics which you, as an expert, would like to share here.  If you are ready to collaborate and share on social media, join the Marketing Our Practices Facebook group https://Facebook.com/groups/MarketingOurPractices

I look forward to working together with you to strengthen our professions in the coming months.

Erica Goodstone, Ph.D., LMHC, LMFT, LPC

Forgiveness Therapy

 Forgiveness Therapy

Edward Mackey CRNA, MS, MSN, Ph.D., FAPA
Associate Professor
West Chester University of Pennsylvania
West Chester, PA 19383
610-738-0543 emackey@wcupa.edu 

Keywords: Forgiveness, Self Help, Brief Focused Therapy

Learning Objectives:

Upon completion of this course, the participant should be able to:

1.  Describe an informed definition of forgiveness
2. Explain at least one strategy for managing feelings of hurt
3   List at least three responses to a negative affect state
4. Identify how to practice positive self talk

AAIM approves this activity for 1 Continuing Education credit. All certified members are required to complete 30 hours of approved Continuing Education credit in their 3 year recertification period to maintain their certification.


Patients present practitioners with a myriad of complaints. These complaints cover a range from physical to psychological. Many of the presenting symptoms and ramifications of the disease process can be the result of psycho-physical relationships between all human beings. The practice of forgiveness has been discussed throughout history, usually through a religious lens, yet research points to forgiveness as a means to reduce anger and depression, to improve health and happiness, as well as to increase self-esteem (Luskin, 2002). It is interesting to note that it is forgiveness work that enables individuals to enable lasting personal change and move forward in a positive fashion (Enright, R 2001, Ferrini, P. 1991, Luskin, F. 2002).  It is also interesting to note that forgiveness therapy is a crucial part of the hypnotherapeutic interaction when dealing with pain and other discomfort (Mackey 2009, 2010).

Forgiveness Therapy

Forgiveness therapy involves an interaction between an individual (victim) and a perpetrator (cause). This interaction does not need to be one that is a personal encounter, and many times should not be, but rather one in which the victim will ultimately let go of the anger, fear, shame and bitterness toward the perpetrator. When this forgiveness occurs, the victim no longer feels the sting of the past and can begin to move forward. (Luskin, 2002).

There are many definitions of forgiveness, some based in religious belief, others for more pragmatic reasons. It is important to understand some of the more popular definitions of forgiveness. One common definition:  The handling of another person’s real or believed inappropriate and harmful deeds in such a way that it helps the forgiver (the person who forgives, the injured party)  find healing and wellness, peace and tranquility. Another definition: Forgiveness is the refusal to hurt, strike back at, get even with, to prove another is wrong with arguments or protests, violence or to harm the one who hurt you.  Another definition as simple as: “I forgive you.” It is important to distinguish differences in definition as this pertains to individual victims. Robert Enright in his book “Forgiveness Is a Choice” (2011) discusses these and other definitions of forgiveness. Enright states, however, that forgiveness is a process, and if you are willing to use the forgiveness process, you may be able to find freedom from the anger, resentment and bitterness of the past.

Forgiveness researchers have identified that simply saying, “I forgive you,” is not enough. Saying the words does not prevent the anger and resentment and bitter feelings from returning (Enright, 2011; Ferrini, 1991; Luskin, 2002). Individuals must go through the process in order to forgive and move on. I have discovered over several decades of doing hypnotherapeutic work with patients exhibiting many differing problems and diagnoses, especially pain, that one commonality exists in order for them to move forward. The common ground for all these patients is forgiveness.

Therapeutic work can be done in identifying causation for problems both physical and psychological. For instance, it is common practice for many practitioners in hypnosis to use age regression techniques to identify an Initial Sensitizing Event (ISE) (Mackey 2009, 2010). Age regression is one of the phenomena identified in the hypnotic trance (Crasilneck& Hall, 1985: Watts, 2005). Techniques of age regression usually guide a patient back in memory to re-experience an event either vividly, called hypermnesia, or as if they are reliving the event itself, called revivification (Yapko, 2003). Age regression is perhaps one of the most widely utilized techniques in hypnotic work. At the same time, it is suspect for confabulation and thus remains

a controversial technique (Kroger, 1977; Rossi & Cheek, 1988; Yapko, 2003). The use of proper age regression techniques limits confabulation (Cheek, 1994; Ewin& Eimer, 2006).

Despite the controversy, using age regression and Ego State therapy can identify the ISE and then help to identify Subsequent Sensitizing Events (SSE) that occur at various times later than the ISE that leads to development of symptoms both physical and psychological (Christensen, Barabasz & Barabasz, 2009; Watkins & Watkins, 1997; Watts, 2005).  Once the ISE and subsequent SSEs have been identified, then therapeutic techniques can be used to reframe events that occurred in the patient’s life. This reframing many times leads to a more informed or moderate understanding of a particular occurrence. With new understanding the individual begins the process of recovery. This recovery process often progresses to resolution of a particular problem, but at the same time many clients return with familiar symptoms. It has been noted over hundreds of client records that forgiveness work is the key to lasting resolution, that utilizing some form of forgiveness process is crucial to lasting resolution. (Mackey 2009, 2010).

Many patients suffer from grievances for years. These sufferings many times lead to long lasting physical and/or psychological problems. Anger and depressions create harmful effects if not relinquished quickly. Aside from the effects of anger, depression, resentment and other negative feelings, the loss of joy, peace and tranquility as well as love and intimacy are lost during these times. The loss of these emotions and feelings is often as devastating as the trauma itself (Luskin, 2002: Yapko, 2003). Working with these clients has shown how the power of forgiveness helps the individual toward lasting healing. Those patients that did forgiveness work had successful resolution. Those that did not have sustained resolution were those who still need to work through the forgiveness process (Enright, 2001; Luskin, 2002). It is interesting to note that there are a number of individuals that despite all the therapeutic intervention will relentlessly hold on to anger, hatred and resentment. These individuals are seemingly driven by those forces, and it has been my experience that some will hold on to those feelings until death.

When working therapeutically with clients that hold on to resentment and not let go, using “Death Bed Therapy” has been beneficial for some (not all) to be able to forgive and let go (Banyan & Kein, 2001). Death bed therapy involves using the hypnotic phenomenon of Age Progression. Age progression involves suggesting to the subject they are progressing forward in time (similar to age regression only now moving forward). The subject is progressed to a point in the future where they realize death is imminent. When this point is reached, the individual is again suggested to let go of the negative feelings and emotions and be free of those bonds. Unfortunately, some patients still refuse to let go.

It is also important to note that when working through past events, both ISE and SSEs, that an individual may find it is not only necessary to forgive others (the perpetrator) but it is also necessary to forgive themselves. The client/patient finds that they have feelings of guilt or anger with themselves for “letting themselves get into that situation” or to feel that “I must have done something to bring this upon myself” or perhaps even “I caused this to occur”. This self-forgiveness is many times overlooked by practitioners. If not resolved those feelings of self-guilt will fester and boil over sometime in the future (Mackey 2010, 2011).

One method of doing self-forgiveness work is to use ego state therapy (Federn, 1952; Watkins & Watkins, 1997). This involves utilizing the ego psychology as described by Paul Federn and further developed by John and Helen Watkins. The hypnotized patient is deepened using a fractionation technique (Barabasz & Watkins 2005; Watkins & Watkins, 1997; Yapko 2003). The subject is then asked while in hypnosis about the part of him/her that may feel some conflict with themselves. The “part” or ego state is then asked to simply announce its presence with verbalization of “I am here.” This may at first seem unnerving to both therapist and client, and perhaps a better method to use at first (to avoid crating artifact) is to simply have the individual imagine going down a safe stairway, with sturdy handrails and anti-slip treads. Suggest to the client that at the bottom they will enter a room through a doorway. In the room they see a plush comfortable chair in front of them. The subject is then suggested to imagine anyone involved with their feelings of guilt. At this point it is not unusual to have the individual age regress to a childlike ego state and describe themselves at a certain age, wearing certain clothing etc. When this occurs, that particular ego state has a need and wants to be heard by the therapist (Watkins & Watkins, 1997). Some individuals may prefer a “safe room” or “safety cocoon” if they have some trepidation or fear about this. In any case, it is important to assist the client to a point where they realize self-forgiveness is needed. They will come to a realization that they have blamed themselves for whatever role they may have played in the particular troubling event. That role may be real or imagined to them, in either case it is the same (Watkins & Watkins, 1997; Mackey 2009). Helping the client/patient with forgiveness of self begins with the individual knowing they need to forgive themselves.

Strategies for feelings of Hurt

Several positive methods for self-management of hurt feelings are available for individuals doing forgiveness work. Management of these feelings is a positive step. Luskin in his text Forgive for Good (2002) talks about not losing sight of the good things in your life. He discusses that all of us do have positive things in each of our lives and we need to refocus on those items. He calls this second step Positive Emotion Refocusing Technique or PERT. It is relatively simple to do and leads to a quick change when one notices negative feelings encroaching.

Practicing PERT is done when one is feeling the effects of an unresolved grievance. There are four steps to this practice as Luskin points out (Luskin, 2002). First: Focus on the stomach as you take in two deep breaths, pushing your belly out as you breathe in. Then as you breathe out, simply relax your belly completely making it soft. Second: Take in a third breath, think about and visualize an image of someone you love or a beautiful scene. This should be one that fills you with awe and as you do this focus on the area of your heart. Thirdly: Continue with the belly breathing as above. Fourth: Ask the relaxed part of you what can be done to resolve the difficulty.  It is a most important to persevere with this practice. Forgiveness is a process and not something that is done in an instant. Through perseverance positive feelings will begin to come through.

Taking responsibility for our feelings is a most important facet in the forgiveness process. We all have choice. We may not have the ability to decide what happens to us, but we do have the choice of how we react to it. If something bad occurs, we always have a choice, we can choose to become angry, enraged, strike back, or we can simply remain still for a while and then make an informed decision on how we will react. In my practice, many patients have had traumatic events occur in their lives in the past. Many of these patients remain angry and resentful that these things occurred to them! I reiterate to them that “yes” a terrible thing occurred on some date in the past (usually long ago, but not necessarily so), but that is no reason to feel angry or resentful today!

An effective method for a patient to manage hurt feelings is simply to focus on positive elements in your life. To stop your focus on the negative items or individuals that have been instrumental in causing these hurt feelings and move beyond to new happy, good, comfortable feelings is something we all can do. This requires us to “let go” of the hurt we seemingly want to hold on to and reach out for the good. In my office, I demonstrate this by holding out my left arm representing holding onto the negative hurt feelings, anger, etc. Then I reach out with my right arm representing reaching for new, better, happy, positive things.  I sit there with both arms outstretched and it becomes evident to the patient that in order to move to where you want to be, you must let go of the other or no movement takes place. Luskin (2002) speaks to “changing the channel” (p.111) in an effort to move away from the stagnant pose. Unfortunately this “stagnation” is what most patients come into the office with.

Effects of Negative Affect

It has been demonstrated that negative affect states lead to physical calamity (Barabasz & Watkins 2005; Enright, 2001; Luskin, 2002). If this negative affect is not remediated, negative effect is sure to occur. Hurt feelings, anger, hatred, resentment become fuel for a powerful engine idling beneath the surface. This powerful engine goes unnoticed many times, yet is causative in so many “psychosomatic disorders”. Using an affect bridge technique, as described in Watkins & Watkins text (1997), a practitioner can follow the negative affect back into the patient’s memory and discover the root cause behind many physical ailments. It is important indeed to have a patient referred to the office for some unresolved neck pain that is not responding well to other treatment, and when using hypnotic ideomotor techniques for questioning, we find it is related to negative self-talk. This negative self-talk is frequently heard in these patients using phrases such as: “This is such a pain in the neck” or other body part. This is then reflected into physical sensation plaguing that individual (Ewin, 2002; Ewin & Eimer, 2006).

Practicing Positive Self Talk

It is important for all of us, not just patients and clients with problems, to use positive self-talk daily. Psychologists have long understood that giving ourselves positive, self-referenced, present tense suggestions continuously through the day is not only invigorating but over time leads to positive outcomes. This is no surprise when one understands that what we expect, we tend to get. This being so, we should desire to always expect the best! Unfortunately, we mostly do the opposite. Why? First: The sympathetic nervous system, which is our fight, flight or freeze system, has a protective function that has served us for thousands of years and has protected us from harm. Secondly, we are being bombarded through our lives with negative suggestion from all sides. Well-meaning parents, significant others, friends, family, etc., all seemingly wanting to help but delivering negative suggestion disguised as sage advice. How many times have you heard: “Expect nothing and when you get something it is a plus?” “If you don’t have any expectations then you will not be disappointed.” These are two of the most common bromides that we have heard one time or another.

It is important to begin changing the prevailing suggestion flow for ourselves and others. Positive self-suggestion is important for our wellbeing both physically and mentally. This leads (Ferrini, 1991; Turk & Gatchel, 2002, Mackey 2009). The authors tell their students and clients to “focus on what you want in your lives” rather than focusing on what you do not want. Patients are in my office constantly telling me what they do not want to happen, what they do not want in their lives, and I tell them bluntly to stop!  “Tell me what it is that you do want,” I ask. Many times, this makes them pause and think. For most clients and patients, they must admit they have not given thought to what they want.  It takes a few minutes, but I get a response sooner than later. It is refreshing for most individuals to begin changing their thoughts to positive outcomes to a new feeling for most. Sometimes the most positive feeling they have had for some time.

Forgiveness work goes hand in hand with positive thought. There can be no negative feelings, no wishing for revenge, no focusing on the past hurts, feelings. There can only be a new focus on a comfortable future free from past negativity, a more comfortable feeling inside oneself without the fear and frustration of wondering if it is going to happen again? (Enright, 2011; Luskin, 2002). Positive self-suggestions such as, “I forgive all others, I forgive myself, I am forgiven,” repeated to oneself frequently every day go a long way to solidifying forgiveness of others and forgiveness of self. This work is a process, and this process takes time and perseverance. Only with perseverance and a positive goal for the future will one be successful in letting go of the chains of the past.


Forgiveness work is an essential part of therapeutic intervention for those suffering from past transgressions. Emotional as well as physical baggage from the past can haunt individuals causing present day physical and emotional problems. Identifying the need for forgiveness work is an essential tool in the armamentarium of the practitioner. Successful resolution of these troublesome past events consists of a process of forgiving the perpetrators (real or imagined) and then the process of forgiving oneself (Enright, 2011; Luskin, 2002; Mackey 20012; Turk and Gatchel 2002).


Banyan, C. & Kein, J (2001). Hypnosis and hypnotherapy basic to advanced techniques for the professional.

Barabasz, A.(1977). New techniques in behavior therapy and hypnosis. South Orange, New  Jersey: Power Publishers.

Cheek, D. (1994). Hypnosis: The application of ideomotor techniques. Needham Massachusetts: Allyn and Bacon.

Christensen, C., Barabasz, A., & Barabasz, M. (2009). The effects of an affect bridge for age regression. International Journal of Clinical and Experimental Hypnosis, 57, (4).

Craslineck. H.B., & Hall, J. M., (1985). Clinical hypnosis: Principles and applications. (3rd ed.). Boston: Allyn & Bacon.

Enright, R. D. (2001). Forgiveness is a choice: A step by step process for resolving anger and restoring hope. Washington, D.C. APA Press.

Ewin, D. (2002). Ideomotor signals: Their value in hypnotherapy. American Society of Clinical Hypnosis Newsletter, 43, 6-7.

Ewin, D. M., Eimer, B. N. (2006). Ideomotor signals for rapid hypnoanalysis. Springfield Illinois: Charles C. Thomas Publisher.

Ferrini, Paul (1991). The twelve steps of forgiveness. Brattleboro Vermont: Heartways Press.

Luskin, F. (2002). Forgive for good: A proven prescription for health and happiness. New York; New York, Harper Collins Publishers.

Mackey, E. F. (2010). Effects of hypnosis as an adjunct to intravenous sedation for third molar extraction: A randomized, blind, controlled study. The International Journal of Clinical and Experimental Hypnosis 58(1): 21-38.

Mackey, E. F. (2009). Age regression: A case study. Annals of the American Psychotherapy Association 12(4) 46-49.

Mackey, E. F. (2012). Forgiveness Therapy. Workshop Given at West Chester University of Pennsylvania.

Turk, D., C. & Gatchel, R., J.(2005). Psychological approaches to pain management: A practitioner’s handbook 2cnd ed. New York: The Guilford Press.

Watkins, J.G. & Watkins, H.H. (1997). Ego states: Theory and therapy. New York: W.W. Norton and Company

Watts, T. (2005). Hypnosis: Advanced techniques of hypnotherapy and hypnoanalysis. Eagan, MN: Network 3000 Publishing.

Yapko, M. (2003). Trancework: An introduction to the practice of clinical hypnosis 3rd ed. New York: Brunner-Routledge.

About The Author

dr0edward0f0mackeyDR. EDWARD F. MACKEY, CRNA, MSN, Ph.D.

Dr. Mackey is an Approved Consultant in Clinical Hypnosis for the American Society of Clinical Hypnosis (ASCH), is a Fellow in the American Psychotherapy Association® (FAPA), and maintains a long standing private practice in hypnosis/hypnotherapy/psychotherapy in Kennett Square, Pennsylvania. Dr. Mackey is an Associate Professor in the Department of Nursing at West Chester University of Pennsylvania.

Dr. Mackey is a member of the American Psychotherapy Association® (APA), The Association of Applied Psychophysiology and Biofeedback (AAPB), The American Association of Nurse Anesthetists (AANA), The American Society of Clinical Hypnosis (ASCH) and The Greater Philadelphia Society of Clinical Hypnosis (GPSCH). Doctor Mackey is a Diplomate in the American Board of Hypnosis in Dentistry (ABHD) and the American Board of Hypnosis in Nursing (ABHN).

Salt Vindicated-a personal case study

Salt Vindicated-a personal case study

Published February 27th, 2012 in Hormones for His & Her Health, Minerals & Vitamins, Eat for Health, Heart Health, Alternative Therapies

by Tammera J. Karr, PhD, BCHN, BCIH

In 2005, I thought I was developing hypothyroidism; I was tired, overweight, with high triglycerides, and muscle pain, all symptoms. I was eating real food, but I was under a lot of stress. Remember I have said several times over the last three years that stress is the number one cause of illnesses, and can kill you.

I saw a doctor I had confidence in, had her run a battery of tests and found out – nothing. So I cut back on salt, red meat, grains, and cut all sugar out of my diet. By 2006, I was running very high heart rates, triglycerides as well as my LDL’s were still elevated, I felt like crap, and my stress had doubled. Now my thyroid test began showing elevations in my TSH (thyroid stimulating hormone), my free T4 and free T3 numbers changed also.

This scenario would have continued to escalate and in fact did – my TSH levels reached 8, my doctor told me I was too difficult of a patient and I needed a specialist, I couldn’t tolerate thyroid medication due to my elevated heart rate, and refused to take medications to slow my heart rate for the rest of my life.

I kept looking till I found the answers that made sense to me, and am very pleased to say today my thyroid numbers are all perfect without medication. My current nurse practitioner, when reviewing my labs from the last 7 years, admitted she had never seen anyone turn their thyroid around. Oh and my heart rate is normal again!

Dr. James Wilson told me in 2006, “If you don’t treat the Adrenal Glands before the thyroid, the client will never get better.” I went back to eating Celtic sea salt, lean red meat, and took supplements for thyroid support and stress. The hardest part was acknowledging what the major stress triggers were, and over time cleaning house so to speak.


In 2011, the medical communities called on food manufactures to cut sodium in commercial foods. GOOD, why, because the forms of salt used in commercial foods are nitrates and nitrites, not natural salt with all the trace minerals for health.

A study released October 2011, in the American Journal of Hypertension, brought into question the time honored belief salt is bad for you. When I first viewed this article on Medscape the opening sentence was, “critics don’t believe study findings”, and of course after reading the conclusion of the study I can see why – it is throwing salt in their eyes. The study titled – Effects of Low-Sodium Diet vs. High-Sodium Diet on Blood Pressure, Renin, Aldosterone, Catecholamine, Cholesterol, and Triglycerides.

At this point I need to tell you several of the aforementioned named in the study title are either manufactured in the adrenal glands or in the liver –salt, is a detoxification agent for several glands and organs. Cholesterol and triglycerides are also elevated by poor thyroid function. Beginning to see the connection here? This is what the study found to my hearts delight.

“sodium reduction resulted in a significant increase in plasma cholesterol (2.5%) and plasma triglyceride (7%), which expressed in percentage, was numerically larger than the decrease in blood pressure of 1%. These results do not support that sodium reduction may have net beneficial effects in a population of Caucasians.”

Aldosterone is a steroid hormone produced by the outer-section of the adrenal gland, and acts on the functioning unit of the kidney, to cause the conservation of sodium, secretion of potassium, increased water retention, and increased blood pressure. The overall effect of Aldosterone is to increase reabsorption of ions and water in the kidney — increasing blood volume and, therefore, increasing blood pressure. So if this hormone goes up, so does your water retention and BP, salt prevents this from happening according to the study.

Renin is an enzyme released by the kidneys that breaks down proteins and helps regulate blood pressure. This enzyme is the key to activating a complex process in which it increases the secretion of Aldosterone, and stimulates the hypothalamus to activate the thirst reflex, each leading to an increase in blood pressure.

Catecholamine is a compound that acts as a neurotransmitter or hormone; neurotransmitters are used in the brain. They include dopamine, as well as the “fight-or-flight” hormones adrenaline. Dopamine is the neurotransmitter lacking in Parkinson’s patients, and when under stress our fight or flight hormones increase. That’s why Dr. Wilson and Dr. Brownstein believe salt to be critical for adrenal health, when under constant stress the adrenal glands dump salt through the kidneys, creating an imbalance in electrolytes. When potassium levels elevate, tachycardia can result. (An excessively rapid heartbeat, typically regarded as a heart rate exceeding 100 beats per minute in a resting adult)

Cholesterol, is painted as the evil one, in fact it is far from it. Without cholesterol we would not be able to think or make hormones. All forms of cholesterol are important to the body as a constituent of cell membranes, and involved in the formation of bile acid. Cholesterol is necessary for the synthesis of vitamin D and the steroid hormones, including the adrenal gland hormones cortisol and aldosterone.

Now this doesn’t mean you can eat all the salt you can stuff in, but the reasonable use of high quality salts from Selina Naturally and Redmond, are indeed a recommendation for everyone living with stress. It won’t fix all of your health challenges; you will have to take back control of your health just as I did with the right supplements and dietary changes.

There is more to good health than the Status Quo.

Tammera J. Karr, PhD, DAAIM, BCIH, BCHN, CGP, CNC, CNW, CNH, is an author, public speaker, educator, and clinician. Tammera has served as a nutrition advisor for several wellness programs and groups. Additionally she writes a weekly health column, reviews and contributes to national board exams, and is a contributor to online newsletters.

A Native Oregonian, Tammera established an Integrative Medicine Partnership in 2006 and currently works in a clinical setting with DO’s, FNP-C, Bio-Feedback Specialists, and others to provide clients with tools to take control of their health. Tammera provides personalized nutrition consultations, in states not restricted. Her clinical and education practice is ever-evolving to meet the needs of clients, the public and fellow practitioners striving to empower those they meet.

She received her PhD with Honors in Holistic Nutrition from Clayton College of Natural Health and holds national board certifications through the National Association of Nutritional Professionals (BCHN), the American Association of Integrative Medicine (BCIH), American Naturopathic Certification Board (CNW), and the American Association of Drugless Practitioners (CNH). Tammera has served as Committee Chair for the Wellspring School of Natural Health, Holistic Nutrition Education Review Board, 2012-2014.

Tammera became a Certified Gluten Practitioner (CGP) in 2013 through Thomas O’Bryan, DC and theDr.com gluten awareness/education program. In 2012, she became a Diplomate of the College of Biologically Based Practices in the American Association of Integrative Medicine.

Additionally, she serves on the Board of Directors for the National Association of Nutritional Professionals, the Accreditation Commission for the American Association of Integrative Medicine (AAIM) and works as one of many in Oregon promoting National Food Day to communities. Tammera has actively promoted local food awareness and sustainability through her service on the Think Local Umpqua Executive Board, 2010-13.

tammera-karrTammera J. Karr, PhD, BCHN, BCIH
Certified Gluten Practitioner

Author of “Our Journey with Food”

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“Patients with autoimmune diseases should avoid health care professions who make them feel pessimistic about their condition.” Dr. Andrew Weil

“Every patient carries her or his own doctor inside.”
– Albert Schweitzer (1875 – 1965)

Please Note:

The information provided in this communication is for informational purposes only and is not intended as a substitute for advice from your physician or other healthcare professional or any information contained on or in any product label or packaging. You should not use the information in this communication for diagnosis or treatment of any health problem or for prescription of any medication or other treatment.

Consult with your healthcare professional before starting any diet, exercise or supplementation program, before taking any medication, or if you have or suspect you might have a health problem.

You should not stop taking any medication without first consulting your physician.

“A Different Kind of Pregnant”

“A Different Kind of Pregnant”

Wendy Iglehart, MA, LCPC, LLC
Cockeysville, Maryland


One out of 15 couples experience infertility (National Institute of Child Health and Human Development, 2013). According to the medical model, infertility is diagnosed when a couple has struggled to conceive and carry full term after one year of unprotected sex. Treatments for infertility focus solely on the deficiency of the body. When a psychotherapeutic approach is implemented, the patient or couple explores the meaning and experience of infertility, gains insight and becomes empowered to understand his or her thoughts, feelings and behaviors. The research presented demonstrates how the psychotherapeutic alliance and the treatment process increase rates of pregnancy and overall well being. In addition, as therapists, we need to understand personal and ethical considerations while working with the specific issue of infertility.

Key Words: Infertility, Couple Counseling, Grief, Stress, Psychotherapy

Learning Objectives:

1. Explore significance of fertility and recognize taboo of disclosing about infertility.
2. Understand the science of conception.
3. Define infertility and treatment according to the medical model.
4. Access psychological grief and loss of infertility.
5. Examine ethical considerations in working with patients or couples who struggle with infertility.
6. Describe the use of counter transference as a way to deepen the therapeutic relationship.

Conception and Pregnancy

Conception happens when the man maintains an erection and releases semen carrying sperm to unite with an egg. The embryo is carried to a 40-week full term. In healthy couples under the age of 30, who have intercourse at least twice a week, the chance of getting pregnant is about 25% to 30% per month (Medline Plus, Feb 2014). A woman’s fertility peaks in her early 20s and after the age of 35, especially she turns 40, the chance of pregnancy begins to decrease. A man, however, continues to produce sperm from puberty at around age 15 and continues to do so well into his eighties.

Infertility Medical Model

One out of 15 couples experience infertility, which is diagnosed when a couple has struggled to conceive and carry full term after one year of unprotected sex. For women who are over the age 35, it’s diagnosed after six months. Within this ratio, chances are related to a third of either the woman, the man, or unknown causes. (American Pregnancy Association, 2014)

Causes and Medical Treatments for Infertility

The science of pregnancy entails hormones, healthy organs, healthy lifestyles and age. Furthermore environmental factors such as, pollution, cancer, or toxins consumed like smoking or alcohol, could impact the ability to conceive and carry a full-term pregnancy. (Medline Plus, Feb 2013) For women, common causes for infertility are related to the inability of the ovaries to produce healthy eggs or the eggs to move from the ovaries to the womb. Another cause could be the fertilized egg does not attach or the embryo does not survive once stuck to the lining of the uterus.

Usually the first option in treatment is a daily injection of medication stimulating the ovaries to develop eggs and the follicles, which is the structure in the ovaries that contain developing eggs. The side effects of such treatment can include bloating, weight gain, headaches, and nausea. If unsuccessful, In Vitro Fertilization (IVF) might be the next step. This entails having eggs surgically removed from the ovaries and combined with sperm. Weekly ultrasounds and estrogen blood levels drawn twice a week to assist the doctors in determining the best time to retrieve the eggs. The last resort for infertility treatment is the egg donor cycle, where an embryo formed from another woman’s egg is transferred to the uterus of the woman trying to conceive. More coordination and time is involved since two women are being monitored for a transfer.

Male infertility may be due to an inability to have and sustain an erection. The testes might not be maintaining the right temperature. Sperm could be low in volume, blocked from the testicles, limited in mobility, or even deformed. There also might not be enough semen to carry the sperm to fertilize the egg.

Medications are available to help sustain an erection or help with hormonal levels. Types of treatment for sperm analysis include retrieving the most mobile and best shape sperm from the testicles. Surgery sometimes is an option. For example, if a tube is allowing blood to flow into the testicle, which increases the body temperature, surgery could be a viable option (Hambleton, Aug 26 2013).

Cost for Infertility Treatments

Based on the Shady Grove Fertility website the average cost for one cycle of IVF is $9,500. For six completed IVF cycles, which includes the cryopreservation, thawing and transfers, the cost ranges between $20, 000 to $26,000. For six completed donor egg cycles, the cost is from $18,600 to $52,000. For the Intra-Cytoplasmic Sperm Injection (ICSI) the average cost is $11, 000 per cycle.

Couples may utilize several options to pay for treatment. Depending on which state they live in and what type of insurance they have, a maximum of IVF or egg donor cycles could be covered. Clinics sometimes offer a share-risk-refund, which is an option for reimbursing for cost if treatment is unsuccessful. This is a limited option that some clinics offer and it usually has various requirements for use, such as the age of the patient. Some couples take out loans such as a second mortgage, home equity line or dip into their 401k. There could be a tax benefit to buffer the medical cost, depending up the state.

Demystifying Impact of Stress

Schenker explored if stress is the cause of the inability to become pregnant via IVF (Schenker, Jun 1992). The biological interaction of stress was measured by the stress hormone at the brain level. Infertility causes stress as times passes. Usually by the time the couple comes in for treatment, they are already highly stressed, especially if they’ve been trying to conceive for a long time.

Infertile women expressed higher rates of suffering and anxiety than fertile women, which peaked in a 2 to 3 year period (Domar, 2000). Domar and her colleagues gathered 184 women who were trying to conceive for between 1 to 2 years. The women were randomized into a cognitive behavioral (CB) group, support group, or control group. Interestingly, the dropout rate within the control group was significantly higher during the study due to the dissatisfaction of having minimal relief. However, those who participated in the CB and support group reported an increase in overall well-being and had a higher pregnancy rate.

The relationship between mental state and fertility continued to be explored by Clay (Sept 2006). Researchers believed biological factors are the primary source of infertility. So what is the impact of stress? In 1993, Domar affirmed the same levels of distress in infertile women compared to women with conditions such as cancer, HI V or chronic pain. Stress might also trigger negative coping skills such as drinking or smoking, increase marital conflict, reduce libido and social isolation.

Is Psychotherapy a Viable Cure?

Research showed that psychotherapy had a positive impact on pregnancy rate. (www.ncbi.nlm.nih.gov). There is a significant correlation between depressive and anxiety symptoms and the decrease in sperm mobility, lower number of retrieved eggs and lower pregnancy rates (Pearson, 2010). Furthermore, Pearson showed women who coped poorly with stress during the infertility treatment had higher rates of first trimester miscarriages and depressed men had decreased sperm concentration. Chen emphasized the importance for proper assessment, diagnosis and treatment of anxiety and depression since his study showed a higher prevalence of the disorders in the infertility treatment clinics. (2004)

Ramezanzadeh evaluated the effect of psychotherapy and pharmacology intervention on the pregnancy rate of infertile couples (Jan – Mar 2011). One hundred and forty couples with at least one spouse who was diagnosed with depression were assigned into either the treatment or control group. Pregnancy occurred in 47% of the couples in the treatment group with 5% success in the control group. Faramarzi determined both psychological and pharmacotherapy is effective treatments in reducing the stress created by infertility (2013). Eighty-nine infertile women with depression were separated into 3 groups: CBT, antidepressant treatment and the control group. Based upon the completed study, the CBT group reported a significantly higher rate of quality of life and reduction of stress than the antidepressant group. The antidepressant group reported a lower level of depressive symptoms, yet concerns such as marital or financial strains were still significant problems.

Boivin (1999) examined the sources of support patients utilized while experiencing infertility or the treatments. Majority of the patients relied on their spouse or family when distressed. The function of distress determined the quality of coping. Less distressed patients found the support system of the spouse, friends and family sufficient while more distressed patients did not engage in formal counseling due to cost and uncertainty of how to initiate such treatment.

The Value of Fertility

The value of pregnancy, procreation and fertility expands across religious and cultural arenas. Some religious faiths hold the theological belief that producing a linage of children is evidence of divine approval. Biblical stories tell of women in agony and envy of the other women who have their husband’s children. The barren women are ostracized and humiliated by the community.
In various cultures such as Latin American or African American, being fertile is a reflection of the obligation a woman has to produce children especially a son. Having a son was a reflection of the husband’s manhood and their authority or right. For some couples, a child reflects a shared experience or produces a lineage of family to care for the aging parents or family members. (Jennings, Jun 1970)

In some countries fertility compensates for losing children in high-risk military activity. Having a family is typically valued as an important social institution. In an example of this, in Tel Aviv, Israel, infertility treatment is free and unlimited for up to two babies until a woman is 45. (Kraft, 2011)

The Health of Collaboration and Good Grief

Research demonstrated talking improved overall well being and increased pregnancy rates. Effective therapeutic treatment facilitates healing and strengthening the connection between the couple. Our role as care providers is to help educate patients about the myths of stress, empowering them to cope with a challenging journey, facilitate good choices and enhancing their coping skills, all within a safe environment.

The emotional complexity of infertility begins before the formal medical diagnosis. The dream of starting a family or the maternal desire to be pregnant is the vision that keeps the couple and a woman excited about the future. After a year of possible miscarriages or unsuccessful conception, grief and loss could create a sense of distraught, anger and helplessness.

When a person’s vision of an ideal world is shattered, emotions like guilt and blame can arise. These feelings can interfere with the couple’s connection creating isolation and withdrawal from each other. For example, the husband might withdraw from his wife because he is ashamed he cannot impregnate her. In turn, the wife starts to feel alone and vulnerable while coping with the situation.

Emotions can appear erratic between the intervals of medical treatment. Numbness represses the desire or hope to conceive or become a parent. In other words, the lack of feeling overpowers the rage of the unfulfilled desire to be a parent. For example, after an unsuccessful IVF a woman doesn’t want to attend her sister’s baby shower because she is envious and distressed.

Understanding the conflict of family obligations and the suffering from infertility, the woman could explore options which empower her to utilize internal and external strengths. Also, it could be helpful to explore how detachment is or is not useful. For instance, lack of anxiety facilitates endurance for another round of hormones, which have unpleasant side effects. The therapeutic work would be to discuss how to plan for the anticipated migraine or various other effects she might feel. Ideally have the couple share this experience together.

Edginess and negative thoughts like “I won’t survive another treatment cycle,” initiates an important discussion about feelings. For example, the husband has anxiety about dipping into the retirement fund to pay for treatment while his wife believes using the 401K is a viable option.

Creating a plan to bear the grief and/or anxiety associated between treatment cycles or previous miscarriages empowers the couple to cope with the anticipated stressed and possible loss. For instance, if the couple is spiritual, they could write a prayer for the endurance, guidance and healing.


For an authentic alliance with our patients, as therapists we need to understand our counter transference and its impact on the treatment. Should we lose sight of ourselves, the treatment and the alliance fail. Thus, it behooves us to understand our patient’s value in pregnancy and having children and to also understand our own beliefs and values about fertility and infertility.

Infertility converges on multifaceted political, personal and medical beliefs and values. Politically, infertility falls under the category of disability, touching on the categories of physical causes with medical interventions, psychological aspects and social implications (Khetapal, Jun 2012). The case of a California woman, who had octuplets after using IVF, motivated doctors and couples to attempt to lower the rate of multiple births. According the Centers for Disease Control and Preventions, forty-six percent of IVF babies are multiples with majority twins and 37% are born premature. (Marchion, 2013) Therapy sessions would be one forum to discuss the desire for single or multiple births, the risks and preferred quality of life.

What is the best way to handle the disruption of treatment? For example, phone sessions or Skype are not billable for insurance and not ethically or legally defined within parameters in certain states. Furthermore, payments for missed sessions or cancellations should be discussed in sessions. A well-meaning therapist might believe it would be compassionate to not charge for a missed session. But therapeutically, the unilateral decision may not be in the best interest of the couple. A conversation about what policy should be is powerful and insightful in understanding the couple. It also allows them the opportunity to be involved in decisions and expressing feelings during a difficult and sometimes helpless journey.

If you are inclined to provide referrals, such as to an acupuncturist, it is imperative in your consent and contract to state you are not accountable for how treatment progresses with another provider and you are not receiving any payment for the referral. The couple shares a story about their friend who used massage therapy to assist in becoming pregnant and they ask you if you are familiar with the positive results of massage. Before giving the information, ask the couple if they are looking for support or information.

When the therapist is pregnant during the treatment, it could be painful for the patient. Do not assume it would be in the best interest to transfer or terminate working with the patient. If the patient is open to explore, you could provide the forum to continue a safe and insightful exploration.

Self-disclosing one’s own struggle with infertility is a blurry line. The APA guidelines emphasize not interfering with one’s autonomy and life direction (2014). Before any self-disclosure, it would be useful to do an inventory of transference and counter transference.

There is a lack of research regarding the LGBT community who desire to have a family and the accessibility to treatment. The therapist could support the couple in deciding who donates the sperm if the gay couple decides to use a surrogate. For lesbian couples who want to be involved in the conception of the child, through IVF one could donate the egg and have the embryo implanted into the social mother, who would be the carrier.

Case Study

For several years I had been seeing Claire for psychotherapy. She was married and a successful professional in her mid-thirties with a significant history depression and anxiety. She had a warm sense of humor and loved to learn about herself. During the first couple of years working together, she feared her future children would be genetically predisposed to suffer from similar aliments and struggled between the desire to feel a child growing inside of her and her desire to adopt.

During the course of our therapy, Claire forgave herself for having a diagnosable mental illness and she realized the illness did not define who she was or her ability to love and care for a child. She and her husband decided to conceive naturally. After one year of not getting pregnant, Claire was diagnosed with infertility. The medical doctors had no clear diagnosis about why she didn’t get pregnant and she suffered throughout that time from a continual sense of loss. She had always dreamed of being a mom and having a family and now she had to face the fact that it might not happen.

With the bond of pregnancy most valued, Claire and her husband pursued infertility treatment. Claire got her period for several continuous months during the course of IVF, which launched her into an instinctive survival mode of emotional detachment to endure the treatment. This came at a cost which lead to her becoming isolated, emotionally and sexually detached from her husband.

She did her best to function at work, but the clock ruled over her as she anticipated lab results. Her job performance began to suffer and the cost was guilt, shame and embarrassment. Work started to feel heavy and dreadful. Her depression ignited, leaving her brooding in isolation and sleeping for 17 hours or more every day. Her “should” cognitions were in overdrive and they kept her paralyzed.

As I witnessed Claire’s physical and emotional agony and the suffering in her marriage it caused, I began to judge her harshly. How could she brutalize her body from treatments and spend so much money just to conceive and carry a child. I hated her for choosing to participate in the infertility treatment process and for holding faith in the medical model. I felt lonely and betrayed that she conformed to society’s pressure to attempt pregnancy, no matter the costs. I wanted her to join me in rejecting this awful and debilitating process and to redirect her energies toward adopting a child and connecting with her husband.

It was disturbing to have such an intensely negative reaction to a patient, so I began to repress these feelings and thoughts in an attempt to protect both of us. In the process, however, I became increasingly disconnected from Claire.

What was happening between us strained my belief in the Humanistic approach, which emphasizes that we are in control of our destiny, our choices and the discovery of meaning for our life’s narrative. This approach makes use of the relationship created between the therapist and patient as a catalyst for exploration and change. A safe arena was vital for Claire to share her narrative and to discover the meaning of her experiences, the energy in the room could then provide an atmosphere conducive for healing. Regardless of my opinions and beliefs, I wanted to support her destiny and choices.

In order for me to have the freedom to accomplish this, I disclosed the pain of my challenges with my weekly peer supervision group. My peers validated me and understood why I felt threatened, but also challenged me about my counter transference and helped me to work through it. Other colleagues were offended by the infertility treatment process and called my patient “greedy.” A few of them had been adopted and were exasperated that it wasn’t Claire’s first choice. Others were sympathetic with her plight and could relate to her need to biologically conceive a child. Through the group process, I was able to witness all the different parts of myself being voiced through my peers and I felt safe and free enough to get to some of my own core fears and doubts about infertility. Ultimately this freed me up to be much more present with Claire in the coming months.

During a subsequent session, Claire tearfully shared how painful it was to have no control during the infertility process. My inner voice whispered, “Ask her if she feels she has the ability to choose to stop the infertility process.” Before working through counter transference with my supervision group, I would have suppressed this voice, believing it was my own “stuff” and would not be helpful to Claire. Now my heart pounded and I couldn’t help but speak up, “Who says you need to continue to fail with the pregnancy attempts?” Something in the room shifted. After a pause, Claire affirmed, “I could stop.” I exhaled. We had finally found a moment of empowerment and connection.

Therapy is not immune to the disruption of the infertility treatment process. The scheduling of appointments revolved around Claire’s menstrual cycle and she canceled appointments due to the side effects of medications and clinic appointments. We had lapses between appointments while waiting for the doctors to contact her for the next treatment cycle. All of this meant that I needed to figure out what would take care of me during her infertility series. That involved answering questions such as: How do I cope with my anger? How do I keep from getting stuck in her holding pattern of waiting? Do I charge for missed appointment?

With the ongoing support of my supervision group, I continued to explore my emotional reaction. Claire and I collaborated about payment for missed appointments. She willingly paid and the joint collaboration made her an active participant in an otherwise helpless period.

The Breakthrough

“I’m afraid you’re mad at me for the last minute cancellation last week,” Claire said. “I’m failing at everything.” In fact I was angry about the appointment. Missed appointments touch on my vulnerability around not being recognized as valuable. But our agreement for her to pay for missed sessions, combined with my own awareness of the reasons behind my counter transference, made it possible for me to process my response outside of session. This allowed me to bring my full attention to figuring out what she was enacting and what it meant for her. I responded, “You think you should be able to manage life better. But things are dropping all around you. Your relationship with your husband, your work, your friendships and especially not getting pregnant. You’re feeling so alone.” I watched her reach for a tissue, look down at her lap, and wipe her tears. “What are the tears saying right now?”

In her soft voice, Claire answered, “I’m afraid my husband will be angry at me for not controlling my emotions. My anxiety is through the roof. I want to be in my bedroom with the covers over my head. It’s unfair to expect my colleagues to do my work. I want to be with my friends but it hurts too much because they have babies or are pregnant.” She believed she needed to be perfect and worried about disappointing everyone around her, including me.

But this conversation about failure and disappointment positioned Claire to begin healing her marriage and bring her husband, family, and friends back into her life. Through addressing her loneliness, Claire articulated her envy about her friends being pregnant or having newborns. She felt conflicted about whether to maintain her connections or isolate herself because it was too painful to be subjected to swollen bellies and to the innocent scent of newborns.

She also acknowledged she pushed her husband away because she did not want to be perceived as a “burden.” He had a demanding job that made him unhappy, but it provided them with medical insurance to pay for the infertility treatment. She secretly fantasized about him attending medical appointments with her and being readily available to abruptly leave work to provide comfort when she received bad news. I encouraged her to share her emotional burdens with her husband, to let him feel her burden, as that is part of what it means to be intimate with another person. She began to feel less guilty and apologetic about her struggles and to share the craziness of the process with him. They became closer and her sex life began to thrive again.

Over the two-year period of her IVF treatments, Claire’s visits to the reproductive health center would evoke a sense of helplessness and lack of emotional safety. She often felt rushed because she didn’t get satisfactory information to her questions and the clinic became increasingly more uncomfortable and sterile. As our work progressed, she was more assertive and less apologetic about demanding the attention of the nurses and doctors until she was satisfied with the gathered information. To increase her comfort at appointments, she brought her own pillow and blankets.

Unfortunately, Claire was given a lot of unhelpful advice from her own support system of family, friends and even medical doctors. She was told, for example, to “just relax” because her stress could be interfering with the infertility process. In the therapy sessions, we worked on how to handle unwanted and sometime hurtful advice and not absorb the harmful implications. When she deemed it appropriate, she informed people about what would be helpful or harmful.

Different Kind of Pregnant

When the IVF failed, Claire and her husband opted for the final remaining option, an egg donor. Our sessions were spent with her describing how a donor was selected and the various reasons they donated their eggs. It was a surprisingly fun process for both of us.

After her second cycle with the egg donor, she curled up on the sofa in my office, hugging a pillow with a distant look in her eyes. Her lip trembling, she said, “For four days, I was pregnant. Now I’m pissed off.” Her rage demonstrated no guilt. She did everything right but was unable to carry her first pregnancy.

The following month, her third attempt was successful.

One day, well into her second trimester and beaming with life, Claire elated, “My boobs are huge!” She shared her ultrasound pictures of her healthy son and we talked through her stress about finances with the arrival of her baby. In her desire to save money and prepare for the baby’s arrival, she requested a break from therapy. I encouraged her to go and create a loving home for her son. Tearing up, she said, “I can’t believe I can hear ‘my son’ after all of these years.” Claire would soon be a mom.


Research demonstrated the success rate with quality of life and increased pregnancy rates with psychotherapeutic treatment. However, before the endeavor of medical infertility treatment it is apparent, screening for depression and anxiety need to be mandated. Ideally a couple would be collaborating and working with a therapist during the journey of attempting conception. Lastly, as therapists, we need to understand the personal and ethical considerations while working with the specific issue of infertility, ultimately having the psychotherapeutic work remain fertile.


  • http://americanpregnancy.org/infertility/what-is-infertility/ (Sept 2014)
  • http://www.counseling.org/Resources/aca-code-of-ethics.pdf
  • Boivin J, Scanlan LC, Walker SM (1999) Why are infertile patients not using psychosocial counseling? Human Reproduction 14 (5) 1384-1391.
  • Chandra A, Copen C, Stephen E (Jan 2014) Infertility service use in the United States: data from the national survey of family growth, 1982 – 2010. National Health Statistics Reports 73.
  • Chen T-H, Chang S-P, Tsai C-F, Juang K-D (2004) Prevalance of depressive and anxiety disorders in an assisted reproductive technique clinic. Human Reproduction 19 (10) 2313-2318.
  • Clay R, (Sept 2006) Does stress hinder conception? American Psychological Association 37 (8) 46.
  • Domar A, Clapp D, Slawsby E, Kessel B, Orav J (2000) The impact of group psychological interventions on distress in infertile women. Health Psychology 19 (6) 568-575.
  • Faramarzi M, Kheirkhah F, Esmaelzadeh S, Alipour A, Hjiahmadi M, Rahnama J (Nov 2008) Is psychotherapy a reliable alternative to pharmacotherapy to promote the mental health of infertile women? A randomized clinical trial. European Journal of Obstetrics and Gynecology and Reproductive Biology 141 (1) 49-53.
  • Faramarzi M, Pasha H, Esmailzadeh S, Kheirkhah F, Heidary S, Afshar Z (Oct-Dec 2013) The effect of the cognitive behavioral therapy and pharmacotherapy on infertility stress: a randomized controlled trial. International Journal of Fertility and Sterility 7 (3) 199-206.
  • Hambleton, L (Aug 26, 2013) Not pregnant: sometimes it’s the man. The Washington Post.
  • Jennings G (June 1970) Cultural factors affecting human fertility. Journal of the American Scientific Affiliation 52-59. [www.asa3.org/ASA]
  • Khetarpal A, Singh S (June 30 2012) Infertility: why can’t we classify this inability as a disability? Australian Medical Journal.
  • Kraft D (July 17 2011) Where families are prized, help is free. The New York Times.
  • Marchione M (Dec 2 2013) Fertility doctors aim to lower rate of twin births. The Washington Post.
  • http://myfertilitychoices.com/fertility-information/lgbt-options/
  • www.ncbi.nlm.nhi.gov/medlineplus/ency/article/001191.htm (Feb 2014)
  • http://www.nichd.nih.gov/news/resources/links/infographics/Pages/infertility.aspx (2013)
  • Pearson E (June 30, 2010) Depression and anxiety: do they impact infertility treatment? Infertility and Mental Health [www.womensmentalhealth.org]
  • Ramezanzadeh F, Noorbala A-A, Abedinia N, Forooshani A-R, Naghizadeh M-M (Jan-Mar 2011) Psychiatric intervention improved pregnancy rates in infertile couples. Malaysian Journal of Medical Sciences 18 (1) 16-24.
  • Schenker JG, Meirow D, Schenker E (Jun 1992) Stress and human reproduction. European Journal of Obstetrics and Gynecology and Reproductive Biology 45 (1) 1-8.
  • http://www.shadygrovefertility.com


wendy-iglehartWendy Iglehart, LCPC, is a Licensed Psychotherapist, Clinical Supervisor, and Collaborative Divorce Coach with over 19 years of experience and has her private practice in Cockeysville, Maryland. She has presented for the Licensed Clinical Professional Counselors of Maryland on the topic of infertility. The professional website, Pyschotherapy.com, published her article, “Infertility & Its Discontents: The Struggle & Transcendence from Both Sides of The Couch.” She has contributed various articles to divorce information websites about the Collaborative Divorce process. For her work as a Collaborative Divorce Coach, she has been featured in The Washington Post & Baltimore Child Magazine, as well as, an expert guest on the radio. In her private practice, she counsels adult individuals and couples through difficult transitions.

Build a Thriving Practice in 2016

Build a Thriving Practice in 2016

by Erica Goodstone, PhD, LMHC, LMFT

No matter how successful, or barely surviving, your therapeutic practice was during the past year, that year is now over.  Are you ready to begin anew, or are you carrying unresolved baggage from last year?  As therapists, we know the value of exploring our personal history – the events, actions, emotional responses, and both positive and negative results that have brought us to our current state.  Your practice has a life of its own, with a unique history of events, actions, successes, and disappointments.  You have worked with some loyal clients who have shown great appreciation for your help, some clients with whom you may not have been a good fit, and others who have disappeared without explanation.

At the start of this new year, we all have the opportunity to begin anew.  Now is the best time to assess the current state of your practice, whether or not the actions you have taken and the results you have achieved align with your dreams and goals.  Now is the time to decide what has worked well, what has slowed or blocked your success, and what aspects of your practice-building strategies could use some improvement.

Past and Current State of Your Practice

Be honest with yourself and answer these two questions:

  • Has my practice been thriving or just barely surviving?
  • What practice-building steps do I plan to continue because they have worked well for me, what activities do I plan to discontinue, and what additional strategies would I like to implement?

Putting Your Goals Into Practice

In college and graduate classes, we do not often receive adequate training on how to go about building a successful practice.  If we are lucky or proactive, then we can find a willing mentor to guide us to take positive practice-building steps as part of our daily activities.  Many therapists spend time joining insurance panels, networking, advertising, lecturing, and presenting workshops locally, building local referral sources.  Some therapists speak at national and international conferences, creating a referral source of professional colleagues.  These strategies remain the bedrock of building a strong practice.

However, far too many therapists seem to shy away from what is possibly the most efficient and effective way to establish credibility and authority in the minds of other therapists and potential clients.  The internet is not some passing fancy, some fly-by night scheme for unethical charlatans; it provides the platform to showcase the powerful work that therapists do.  Coaches already understand this, and they are thriving financially, leaving many therapists to wonder why.  Coaches often fearlessly post their simple success formulas, PDFs, videos, podcasts, e books, and digital programs at sometimes hefty fees.  They create webinars and virtual summits to rapidly build their opt-in lists and quickly become seen as experts without anywhere near the amount of training and credentials that most therapists have.

So, here are my questions for you as you begin this new year:

  • Are you ready to embrace the internet and all it has to offer, including creating your website, blog, articles, and videos, as well as promoting your practice on social media?
  • Are you willing to spend the time, and sometimes money, to learn for yourself the type of marketing skills required in this new and exciting virtual world?  Or would you rather pay someone else to do it for you for hefty fees and without guaranteeing the success you desire?

A recent article by Kyra Bobinet, MD, MPH, in Experience Life magazine provides a valuable technique to create desired behavior change.  She tells us to think like a designer because designers “tinker and experiment” to reach a solution.  Designers, according to Dr. Bobinet, focus “on the process of solving a problem and the joy that comes from figuring something out.”  I have adapted her “Putting It Into Practice” technique for you to focus on creating a more powerful internet presence this new year.

Here we go:

  • What is your unique area of expertise that sets you apart from your colleagues and that you would like to showcase online as an authority, expert, and brand?
  • I want to figure out how to ________ {the online image you want to portray}
    by trying _________ (web site, blog, podcast, video, webinar, digital product, etc.).
  • If I get stuck or the process makes me unhappy, I will also try _________ or _________ until I learn what works for me.
  • I will search for a solution and update my thinking whenever I see _________ (a negative emotion, like loss of joy or fear, or a relapse to my old ways).
  • I am the designer of my own practice and the image I present to the world.

Have a healthy, happy, forward-thinking and successful 2016.

Please feel free to send me your questions, comments, subjects you want to see covered, and topics that you, as an expert, would like to share here.  DrErica@DrEricaWellness.com

If you are ready to collaborate and share on social media, join the Marketing Our Practices Facebook group https://Facebook.com/groups/MarketingOurPractices

I look forward to working together with you to strengthen our professions in the coming months.


Erica Goodstone, PhD, LMHC, LMFT, LPC

Liver, Simply Amazing

Liver, Simply Amazing

Published May 19th, 2010 in Liver Health

By Tammera J. Karr, MSHN, CNC, BCIH, CNW, CNH

Most of us spend very little time thinking about our liver or any internal organs for that matter. In our pursuit for longevity, research talks about the brain and heart; and for good reason, but the livers vital role is as critical to health and longevity as the heart and the brain. Just where is the liver in relation to everything else, well if you’re an anatomy student you can probably lay your hand right on it, most of us can; the liver is located under the bottom ribs on the right side of your abdomen, only inches from your heart, kidneys and gut. The liver is the largest internal organ and the second largest next to the skin, it comprises 2.5% of body weight and is the only organ able to regenerate after injury or illness. The liver participates in functions associated with the cardiovascular, digestive, excretory systems and metabolism.

The liver stores and filters the blood to remove infectious organisms, and processes approximately three pints of blood every minute.

Most blood arrives at the liver direct from the intestines via the portal vein carrying dietary nutrients and toxins – the remaining blood arrives at the liver via the hepatic artery. The liver is the primary organ for detoxification of toxic chemicals that enter the body through skin, respiration and ingestion; it is responsible for the metabolism of 90% of ingested alcohol, 25% of basal metabolism and for the conversion of stored glycogen into glucose for release into the bloodstream. So if your liver is bogged down with high fructose corn sweetener, medications and chemicals you are increasing your risk factors for type 2 diabetes, fatty liver disease, hormone disruption and obesity.

For those with thyroid disease, approximately 80% of Triiodothyronine (T3) is produced in the liver from the conversion of Thyroxine (T4) to T3 and T3 accounts for 20% of thyroid hormone production.  Triiodothyronine (T3) is approximately ten times more potent than Thyroxine (T4). That means having a healthy liver is central to hormone production and utilization, and not just of thyroid but of all hormones, insulin, testosterone, progesterone, estrogens (you have more than one), melatonin, DHEA…. Get the idea?

The liver stores several vitamins and minerals for the body to use; cobalt, 15% of the body’s copper,  manganese, ferritin (the endogenous form of iron), coenzyme Q10, biotin, folic acid, vitamins  A,C,D, E, K, and B1,B2, B5, B6, and B12  all concentrate in the liver. But that’s not all – endogenous phospholipids (healthy fats), and proteins are manufactured in the liver as well as cholesterol – vital for the protection of the brain, heart and hormones.

Liver malfunction may cause; Adult acne, Rosacea, Halitosis (bad breath), and Psoriasis.

Ailments that cause liver malfunction

Intestinal Permeability may be an underlying cause of liver malfunction.  This occurs from the additional workload placed on the liver in the detoxification of antigens that enter into the body as a result of poor gut health, this is especially important for children and adults with gluten sensitivity and autism. Systemic Lupus Erythematosus (SLE) a form of the serious autoimmune disease Lupus Erythematosus (LE) and Hepatitis A, B and C infections cause degeneration and death of the liver. Additionally impaired liver function may occur as a result of adrenal insufficiency and gluten sensitivity.

People with liver ailments should not consume; Carnitinesmart drugs– Adrafinil, Propranolol only with caution, Xanthinol Nicotinate, the herbs Coltsfoot Licorice, Valerian and high iron containing foods.

People with liver ailments should consume, Herbs like artichoke leaf, green tea, Jiaogulan, Korean ginseng, lycium, milk thistle, black Cherry (juice), Grape (juice), Lemon (juice drunk upon awakening in the morning), Pear (juice), Reishi Mushrooms. Many of these herbs and foods are found in high quality liver detox products and plans.

I encourage you to do a liver detox twice a year, and follow the footsteps of your ancestors; eat good grass fed, or organically raised liver one to four times a month, if you do not have Hepatitis C or elevated ferritin levels. Liver truly is natures multi vitamin, and eating liver helps your liver to be healthier – our ancestors new this, it’s time to go back to those old fashioned food values that kept all of us healthier.

To your good Health.

The Realities of a Global Epidemic: A Closer Look at Women’s Sexual Health

The Realities of a Global Epidemic: A Closer Look at Women’s Sexual Health

Robert Jesky, Dip.Ac, BHSc, MMed, BCIH



Women’s sexual health ranks as one of the most prevalent health issues of the 21st century.  Social norms founded on precepts dating back centuries have shaped current and degrading views of women, and this has led to exploitation so severe and embedded in the social fabric that it is tolerated and considered almost normal.  While, in certain societies, some changes have come in the way of gender role adjustment, the real nature of the issue is as pertinent as ever before, with more ingenious methods continually employed to maintain dominance over women and their bodies.  Women’s sexual health is interwoven into the sociocultural, sociopolitical, and socioeconomic environments, which means that devising methods to improve it requires examining how it is linked with these environments. As the incidence of sexual violence against women continues to escalate, we must expose and examine the environment of women’s sexual health and determine the stakeholders involved in order to determine a plan for policy change.  Currently, the situation is grave, with the mental, physical, and social well-being of hundreds of millions of women (young and old) at stake as they are subjected to sexual coercion, discrimination, and violence.  This epidemic has reached epic proportions and has strong causal associations with mass media and other sociocultural factors that arise from the milieu of modern existence.  The required courses of action include a large-scale social awareness campaign of acceptable and inappropriate conduct, a deconstruction of social norms, and new policies to regulate how women and girls are portrayed in the mass media.  This should first be conducted domestically (North America), with possible inclusion of other G8 members thereafter.  It is only through clarifying the environmental factors and cultural norms that perpetuate this issue that violence and sexual objectification of women can be rectified.

Keywords: Sexual violence, mass media, women’s health, sexual assault, sociocultural norms, sexualization, rape myths, gender equality



Imbalances in the social statuses of men and women have long been an issue dictating life events.  Many of these imbalances arise out of social norms that have been constructed around male-dominance.  Over the course of the last few centuries, the role of women in society has fluctuated little.  Women have been, and continue to be, the subject of exploitation.  What has changed, however, are the ingenious methods males use to continually exercise dominance over females.  With the professionalization of medicine came a new, unprecedented prestige that allowed for the phallocentricity of society to label natural, physiological functions of the female body as medical syndromes (i.e., menopause) or create new ones through disease mongering, predominately in the name of profit (Moynihan, 2003).  An example is the invention and promotion of female sexual dysfunction (FSD), a condition not based on scientific or medical evidence, but rather, a campaign popularized by the world’s pharmaceutical companies (Tiefer, 2006).  This “medicalization” of women’s bodies is a matter of public health, and it is one of many ways society exerts control over, and harms, women.  The issue has been under the microscope for some time, which has helped facilitate considerable discourse.  Yet aside from small changes in gender equality (like equal employment opportunity empowering some women in Western countries), there has been no significant change in society’s views of women, and things like objectification, discrimination, and physical and sexual assault are actually  worsening.

In North America, sexual violence has been considered a criminal offense for a relatively short period of time.  As a case in point, sexual assault has only been seen as a criminal offense since the 1980’s in Canada (SIECCAN, 2015).   All over the world, mass media objectifies women.  Commonly, women are portrayed as submissive and sexual objects, unequal to men (Wood, 2005).   This portrait is affecting girls and women of all ages.  It is thus not surprising to find that huge efforts are being made by researchers and advocacy groups to address the issue.  Nearly all research being conducted calls for further exploration of causal relationships, as well as offering potential strategies and intervention means, which require efforts from all levels of society.  However, while various suggestions have been made, and the number of studies investigating this issue continues to grow, there is a shortage of legislative action to increase protection and reduce incidences.  To address this epidemic, a twofold approach is required that calls for: (1) a metamorphic education campaign aimed primarily at the secondary level (including post-secondary education) and cultivating an accurate awareness of female sexuality, beauty, and inappropriate behavior that will help quell the current and age-old myths about gender; (2) the monitoring and regulation of mass media’s objectification of women, coupled with a corrective and more accurate depiction of women.


Since the early 70’s, academics have been critically analyzing concepts of health and the body.  Early definitions of health revolved around the body’s functionality and performance in the context of capitalism, especially an individual’s ability to effectively perform tasks for which s/he had been socialized (Parsons, 1964).   Such a characterization of health points to congruence with the work of social theorists (i.e., Michel Foucault) who directed their critique towards expanding the definition of the body as an instrument of materialistic exploitation and a means of production (Foucault, 1979).  This definition was initially inclusive, but over time, capitalist focus has shifted largely to the exploitation of women’s bodies for profit and the allowance of dominance.

Sexual health has to do with one’s psychological and physical health.  It is more than just having a positive and respectful sexual relationship.  According to the WHO (2012a), sexual health should encompass a state of physical, mental, and social well-being in conjunction with safe and pleasurable sexual experiences free of coercion, discrimination, and violence.  The pervasiveness of this health issue throughout much of the world constitutes a major issue of public health, as this issue affects women’s health in a multitude of ways.  These range from depreciating women’s self-worth, and being objects of marketing initiatives, to the development of eating disorders, as well as the effects of being sexualized.

Currently, the majority of the world’s population exists in developing nations.  Between 1950 and 2008, the number of people living in developing countries increased from 68% to more than 80% (Population Reference Bureau, 2008), and by 2050, that number is expected to exceed 8 billion people (Population Reference Bureau, 2012).  What this means is many women reside, and will continue to reside, in impoverished conditions.  Importantly, developed countries are not excluded from impoverished conditions.  As of 2014, around fifty million people were living below the poverty line in the US, where children and single mothers were at a greater disadvantage (Mattingly, 2015; Short, 2014).  Poverty, a significant determinant of health, tends to place a higher burden on women and girls by reducing their availability to a range of essential social, cultural, and economic opportunities, and predisposing them to additional sociocultural discrimination (WHO, 2012b).

Indeed, women’s sexual health can be linked to nearly every key determinant of health:notably, income and social status, education and literacy, social and physical environments, healthy childhood development, health services, gender, and culture (Public Health Agency of Canada, 2011).  This combination of issues suggests that there is not one single or easy solution.  We must start by changing male attitudes about women and girls, especially in regard to sexual behavior.

Exploration of the issue

A simple Google search on sexual violence against women, sexual violence, and sexual violence in media reveals the widespread nature of this issue with links to everything from news stories, to YouTube videos, to scholarly articles and organizations.  Refining that search by limiting results to news produces a closer look at current media stories that range from sexual assaults in United States military academies, to gang rape by British Navy sailors, to ongoing civil strife in India over sexual violence.  Taking the search a step further to include the terms news stories about sexual violence produces terabytes of information on sexual abuse, sexual assault, and sexual violence news stories.

Sexual violence is an issue that permeates every culture and exists within all social classes.  Within the news, the issue of sexual violence is mostly centered on victims and perpetrators.  What comes to light from the endless list of Google hits is that within developed countries, the issue of sexual violence is expanding, and to such an extent that teenage girls are starting to consider sexual harassment and assault a normal part of growing up (Hlavka, 2014). Although issues of gender inequality, unequal power, discrimination, and male dominance exist in developed countries, they are more pronounced in developing countries (i.e., India, Haiti).  Two germane examples are the prevalence of sexual violence against Haitian women and the absence of police protection in the aftermath of the devastating 2010 earthquake, and how within India’s rural areas, all-male village councils still dictate social hierarchy and control sociocultural norms.  In such male-dominated societies, women are viewed as unequal, which leads to a dangerously high incidence of sexual violation (Berton-Hunter, 2011; Majumder, 2012).

A variety of research has found that those who frequently enjoy pornography are likely to have attitudes supporting sexual violence against women (Malamuth, Hald, & Koss, 2012).  Hald, Malamuth and Yuen (2009) investigated links between pornography (media) and various scales of violence against women (i.e., sexual aggression, rape), and concluded that all pornography leads to changes in attitudes supporting violence against women. By objectifying women and furthering rape myth ideas, men may come to believe that women deserve and/or enjoy such treatment.  Similar studies have found that adolescents exposed to sexually explicit media tend to believe gender role myths and experience earlier sexual engagements, leading to higher risks of contracting STDs and less frequent use of contraception.  Among males, such exposure additionally increased the likelihood of perpetrating sexual harassment (Brown & L’Engle, 2009). Another harmful influence is video games, primarily mass exposure to violent video games.  Sexual objectification of, and violence against, female video game characters has been found to be associated with a higher tolerance of sexual harassment and a significant increase in the acceptance of rape myths (rape-supportive attitudes) for males, while for females such exposure leads to decreased tolerance of such behavior (Dill, Brown, & Collins, 2008; Beck, Boys, Rose, & Beck, 2012).  This shows that the male attitude toward sexual violence is altered upon exposure to, and consumption of, different forms of media, and that the media acts as a vehicle for the perpetuation of harmful ideas about women.  This is consistent with Huesmann’s (1986) theory of how media affects sexual behavior through the acquisition, activation, and application of cognitive scripts.

Outlining the environments

At the micro-level, sexual violence threatens individuals in all age demographics and challenges schools, communities, and health services to increase awareness through educational programs, as well as to implement intervention strategies.  The micro-level is often referred to as the organizational level and has to do with the internal environment.  In the context of sexual violence, it is better understood as the immediate surroundings, such as family, schools, neighborhoods, and forces that affect the internal, more personal environment.  Without action taken at this level, women and girls will continue to be victimized in ever more serious ways.  Likewise, considering the fact that sexual violence is occurring even in primary and middle schools (Stein, 2007), such overwhelming prevalence will lead to unprecedented social degradation through a number of means (i.e., psychological harm, including detachment from society and suicide, learning and memory impairments, fear, distrust, etc.).  With increased exposure to violence, and victimization by perpetrators, the harmonious nature of a healthy society falls apart.  The meso-environment is what shapes the framework of an organization and can be considered infrastructure: policies, procedures, rules, and guidelines (Shaw, 2011).  Without proper acknowledgement of the issue at the micro-level (i.e., creating educational pamphlets and new sexual health syllabi, holding community awareness meetings, and drafting guidelines for protection/intervention), the awareness needed to effect change at the macro-level could fail.  The macro-environment, broadest of the three, is tied to changes in the social, technological, economic, environmental, and political (STEEP) sector (Morrison, 1992). Such an environment should promote female equality.  A failure to offer financial security through rights, freedoms, and equality in society leaves females highly susceptible to illness by lacking essential control of key determinants of health, most notably control over sexual and psychological well-being.

Creating a policy

A large-scale social awareness campaign is a first, and essential, step.  Men of all ages should be educated on what is inappropriate and illegal sexual conduct, on how to appreciate female sexuality, and on the equal rights and freedoms women have.  Women of all ages should receive this education as well, but with an emphasis on the fact that the responsibility to uphold a positive and equal view of women falls to both women and men, especially potential male perpetrators of sexual assault.  This would help reduce any shame, guilt, and blame that women may feel in regard to being objectified, discriminated against, or assaulted.  Next, within the macro-environment, policies could be established to regulate how women and girls are portrayed in mass and social media, in conjunction with a ban on advertising aimed at children and involving anything even remotely explicit.  If children are exposed to positive messages regarding women early in life, then those positive messages will stay with them throughout adolescence, and, ideally, into adulthood.  Prevention, therefore, is key to tackling this issue.  In order to facilitate this change, parents, schools, communities, organizations, social institutions, and governments need to be involved in carrying out the necessary changes.

What’s at stake?

Many individuals and groups are involved in women’s health and equality: females of all ages; governments and agencies, like the United States Department of Health and Human Services (HHS), Health Canada, UN, and WHO; healthcare organizations like Medicaid; schools and education systems; law enforcement; social welfare programs; women’s health advocates; NGO’s; human rights groups; the medical profession and its associated professionals (i.e., physicians, and healthcare providers), the pharmaceutical companies; and mass media. With so many entities involved, it can be hard to tell who is responsible for managing this global health crisis.  What is primarily at stake is women’s health and well-being, which encompasses a myriad of things: menstruation, reproduction, STD’s, sexual abuse, violence, eating disorders, mental illness, etc.  At the same time, we must consider the commercial interests of media conglomerates (i.e., corporate advertising), the fashion industry, pharmaceutical companies, and their associative large pecuniary rewards.  Surely, for corporations and pharmaceutical companies like Pfizer, who partake in the medicalization of women’s sexual health, the likelihood of large pecuniary losses is high.  Likewise, media conglomerates would potentially face sizable losses due to the paucity of remuneration for ad placement and display of such pharmaceuticals.

Dispelling myths

With top brands investing hundreds of millions of dollars in advertising (Taube, 2014)., some may say that implementing policies aimed at prohibiting the sexualization of females creates too great a risk of large pecuniary losses in advertising, and is thus not feasible.  Such concerns would certainly be warranted, but any monetary gains and losses are speculative, at best.  Ad campaigns don’t have to decrease, but rather, modify their messages.  Companies can find new ways to reach their target audiences to avoid financial losses and continue to promote their products.  Indeed, any antithetic arguments about financial losses for mass media are simply, to borrow a phrase from Theodore Levitt, a form of marketing myopia.  Various aspects of mass media can be considered art, whether they be fashion design, the modeling industry, glamour magazines, photography, or the conceptualization and creation of advertisements and video games.  For artists, brands, and corporations to remain successful, they have to continually recreate themselves.  Such a practice is not only pertinent to remain competitive, but also requisite for continuance.  Mass media is capable of painting a new portrait of women, and in fact, is obligated to do so.  It is important to note that perceptions of women’s bodies are always evolving and malleable – in the 17th through 19th centuries, men tended to seek women with pale complexions, plumpness, and beautiful minds.  These are in contrast to the twentieth century’s view of the slender figure as the ideal of beauty and the foundation of a new standard (Stearns, 2002).   Mention of these points holds credence to the powerful role mass media plays in establishing fads – hence the significant impetus behind the fashion/modeling industry – which correlates to a high degree with the construct of an acceptable appearance.

In a parallel manner, although there are countless studies already demonstrating a causal relationship between mass media and violence towards women, any arguments about mass media’s inculpability can be additionally addressed as follows. If we entertain the idea that violence towards women is the product of epigenetic algorithms,  then we must ask: how could violence against women be related to a greater chance of survival and reproductive success today?  The answer may be found in behavioral epigenetics.  Research in epigenetics and behavior offers evidence of how signals from the environment trigger molecular changes that lead to short- and long-term effects on neurobiology, physiology, and behavior (Powledge, 2011).  Studies demonstrate that one’s environment largely affects one’s social behaviors.  The degree of influence can be strong enough to alter regulatory factors of genes to such an extent that the individual’s physiology (i.e., metabolic activity in brain nuclei) and behavior (i.e., reproductive, agonistic, and emotional) changes (Crews, 2010).   Similarly, epidemiological research has shown that genotypes play an influential role in a person’s sensitivity to environmental insults (Caspi et al., 2012). In short, early social and developmental experiences can trigger neurobiochemical changes that ultimately influence both behavior and health throughout life (Jašarević, Geary, & Rosenfeld, 2012; Miller, 2010).  These studies highlight how the interplay between genes and the environment is critical within the process of development and individual behavior.

Technological advancement has amplified mass media’s environmental presence and furthered its influence on one’s upbringing.  Thus, its long-term effects on people’s attitudes and behaviors cannot be overlooked.  A disturbing example is Nazi Germany’s propaganda machine that used every medium possible to manipulate people, from the most obscene articles or the latest hit song, to the radio scripts of the wireless commentators (Sington & Weidenfeld, 1943).   Since at least WWI, well-crafted propaganda messages have been disseminated through news stories, films, photograph records, speeches, books, sermons, posters, flyers, rumors, and billboard advertisements to the general public (Garth, O’Donnell, & O’Donnell, 1992).  Notably, application of the propaganda toolkit awards the power to (re)educate, modify opinions, adapt persons to a particular society, and create disbelief (Ellul, 1973).  The medium that ultimately maintains this power is the media.  A more current illustration of how mass media is tied to government propaganda comes by way of the US government’s recent contracting of Sony pictures to produce anti-Russian sentiments (Sputnik, 2015). In Wikileak’s release of Sony emails, there is evidence of leading figures in the LA/NY film, TV, media, digital, and theater communities scheming to influence world affairs through said mediums (Wikileaks, 2015).

Western governments know all too well how powerful the mass media is in swaying the opinion and mood of the populace.  They use the media in every political campaign to launch attack ads against opponents, to present aggrandized representations of themselves, and worse.  More directly, mass media plays a paramount role in transmitting information to large audiences, which, for many, is the sole source of information for political decision-making (Fog, 1999).

Taken together, this shows that mass media has an irrefutable impact on the existence and formation of views within the sociocultural sphere. Attempts to absolve the mass media’s influence on the perceptions of women and girls that have contributed to the sexual violence epidemic is surely spurious, and an effort to obfuscate the truth.

Capitalizing on resources

What is needed is a paradigm shift, perhaps similar to that of the Victorian era, where the beauty of one’s mind is held in the highest esteem.  By reverting attention away from curves and cleavage, society may be better able to appreciate the intelligence and talents of women. Abolishing parochial views that undermine females will help unleash their massive potential. In doing so a wealth of new resources will come to light and society may be better positioned to tackle some of today’s most challenging issues.


The prevalence of sexual violence against women and girls is increasing worldwide, and can be considered an epidemic. Studies have demonstrated that sexual violence is largely precipitated by misleading sociocultural norms/attitudes about gender and sexuality. Mass media plays a highly influential s role in popular culture, and causal relationships have been found between attitudes towards females, sex, violence, and the sexualization of women in the entertainment and sex industries. Yet, its existence as a principal element of gender inequality goes unchallenged. In light of the fact that individuals are greatly affected during sensitive life stages such as adolescence and puberty to novel experiences, which markedly influences how the individual responds to social and sexual cues later in adulthood (Crews, 2011; Romeo, Tang, & Sullivan, 2010), appropriate intervention during juvenility is pertinent to ameliorating behavioral dysfunctionality; notably sexual violence directed towards females. Mass media could and should therefore revolutionize how it depicts girls and women, and with its far reaching educational capabilities work together with public health bodies and educational institutions to help transform the views of boys and men.

In a parallel manner, to combat the growing prevalence of sexual violence worldwide  the federal government should initiate a nationwide prevention strategy involving the removal of sexualized portrayals of women in media.  In conjunction, a nationwide re-education program should be put in place to correct misleading sociocultural norms, promote gender equality, and explain legal, safe, and healthy sexual practices.  Such a policy would contribute to the protection of hundreds of millions of females around the globe by setting the precedent whereby other nations could follow.  This policy would also help re-balance the power dynamic between men and women, decrease discrimination in educational and employment settings, and help prevent violence.



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About the Author:

Robert Jesky’s academic background includes a diploma of acupuncture (Dip.Ac), a Bachelor’s of Health Science (BHSc), and Master’s of Medicine (MMed) in Integrative Traditional Chinese and Western Medicine from Dalian Medical University, Dalian, China.  Outside of these academic accomplishments, he is recognized as an Acupuncture Detoxification Specialist; a designation granted by the National Acupuncture Detoxification Association.  The use of such techniques aids in the effective treatment of persons with drug addiction and its associative effects. Arguably, this is something that is important in helping address one of modern society’s biggest afflictions.

Aside from engaging in ongoing studies, he is currently a Professor at Huizhou University in Guangdong, China.  As a faculty member of the Life Sciences department, he develops and instructs courses in Biology and Health Science.  As a Professor, he aims to provide evidence-based lessons to enhance students’ abilities to make educated decisions as they pertain to healthy lifestyles and academic advancement.  While his interests are in a range of scientific fields and academic disciplines, he is most passionate about neuroscience.  Broadly speaking, his interests revolve around neurogenesis and regeneration (i.e., oligodendrogenesis and neuritogenesis), cognition, and the cellular and molecular pathways that comprise the biological systems responsible for learning, memory, and neurodegeneration.

Silence is a Counseling Skill

Silence is a Counseling Skill

Jolene Oppawsky


Graduate Faculty and Clinical Supervisor

Social Sciences

University of Phoenix

Tucson, Arizona Campus


Listening is an active process, and an important technique in counseling.  This article evaluates the role of listening in counseling sessions and discusses common reasons for silences.  Theoretical views of silence as resistance, research on silence in the session, and the values of silences in sessions, as well as how counselors deal with silence, will be explored.

Keywords: silence, resistance, therapeutic silence, listening



The idea behind therapeutic silence in counseling sessions is it allows clients to think after an expression, which allows them to come up with more profound awareness.  It allows the clients to dig deeply into their feelings, to struggle for alternatives for action, and to weigh decisions.  Listening to silence also has a calming effect on clients, as well as counselors.  It prevents them all from racing ahead.  It prevents counselors from pushing too hard, or at the wrong time, and it is a capping mechanism for clients’ emotions that are out of control.

Listening is a process that elicits non-speaking verbalizations and body language, as well as words, from the person being heard.  In most models and theories of counseling, theorists and counseling professionals agree that listening skills play a paramount role (Cihangin-Cankaya, 2012; Knapp, 2008; Landary, Hill, Thompson, & Obrien, 2004; Duba, 2004; Levitt, 2001), although listening is often not included on the list of counselor skills.  In fact, seasoned counselor professionals agree that this skill is one of the most difficult.  Lane, Koetting, and Bishop (2002) think that if the counselor does not use silence with skill and sensitivity, then clients may feel that the therapist is disengaged, which places the therapeutic alliance in jeopardy.  A plethora of blogs and a number of peer-reviewed articles stress the meaning and understanding of silence used by both clients and counselors (Cihangir-Cankaya, 2012; Haque, 2012; Thomason, 2012).

Evaluating listening

Wise people say, “anyone can listen,” yet our society promotes social conversation and discourages silence.  People in our society learn to be uncomfortable with long pauses, while other cultures support silence.  Smaby and Maddux (2010) write that: “continuous verbal tracking may be perceived as impolite by Asian Americans.”  Novice and seasoned counselors alike feel they are not doing enough for their clients unless they are talking and telling; however, multicultural examples support a different view.  LeBeauf, Smaby, and Maddux (2009) said – in a paper presented at the American Counseling Association’s Annual Conference on adopting counselor skills for multicultural and diverse clients – that Christian Methodists may use silence for reflection, while Southern Baptists use silence to express dissatisfaction with what is being said or to disconnect with the session.  Inner stillness is a feature of spiritual enlightenment in Buddhism and a measure of inner growth in Hinduism.  Many models of mental health delivery services are based on medical models, which function by orders, prescriptions, and diagnoses.  One of the most difficult tasks for counselors is finding the right mixture of listening and response.

The occurrence of silence in the counseling session and whether it is initiated by the client or the counselor are important elements when evaluating the significance of silence in a session.  A long period of silence initiated by the client at the beginning of the therapy session can mean something different than one initiated by the client later.  Initial silence by the client may reflect embarrassment or resistance, whereas later silence can be a communication medium for emotional expression.  Duba (2004) says that silence encourages self-reflection.  Later silence, from the counselor’s perspective, is usually a medium for the therapeutic support of the client.  There are several resources available to aid novice and seasoned therapists in assessing their listening skills.  A printable listening skills test is available at healthcareworkforce.net.

Any article on silence in the counseling session should emphasize that natural pauses and periods of silence are common in all interactions.  Therefore, counselors should avoid the tendency to categorize each pause, interpret each period of silence, or over-think silent periods.   Generally speaking, silence has four inferences.  They are negative or positive inferences, or rejecting or accepting inferences.  Societal pressures and expectations can discourage silence by fostering social conversation.  This can cause people to link silence to rejection, defiance, or condemnations.  Phrases such as “the cold shoulder” or “the silent treatment” or a child’s remark, “mommy, Billy isn’t speaking to me anymore” come to mind.  These silences say coldly that the other person is not worth talking to or worth one’s time.  Due to the stereotyping of silence, it is all too easy for the client, as well as the therapist, to interpret pauses and silences in initial sessions as negative, rejecting, or as resistance.  Negative interpretation flares when clients are afraid of what the counselor is thinking or when clients try to impress the counselor.  Likewise, novice counselors, and some experienced counselors, may have not yet learned to deal with silence or resistance.

Common reasons for silence in the session

Silence in the counseling session often means, simply, that the client or the counselor is wondering what to say next.  Wondering what to say next can come about after an initial period of “chitchat” that is formally known as establishing and maintaining a therapeutic alliance.  It is hard to bridge the silence that occurs between the preliminary greetings and getting down to work.  Another process is one where the client or the counselor is confused on an issue or temporarily loses the train of thought.  Another common type of client silence occurs when the client is thinking over what he or she just said.  Here, an interruption by the counselor can disrupt the client’s train of thought, and he or she loses track of the main theme.  The most common cause of pauses or silence in a session, as well as in other verbal communication, is that of “thought collecting” (Tindall & Robinson, 1947).  In their old but still valuable empirical study on the use of silence as a technique in counseling, thought collecting – also called “contemplative silence” in the study – accounted for 50% of the pauses in a counseling session.  There is a serious dearth of old and recent empirical studies on silence in counseling, but the information in recent blogs and articles supports the findings in this old study.

Brammer (1979) wrote on “hostility-motivated resistance” or “anxiety-motivated embarrassment.”  The first occurs when clients do not come to therapy of their accord, but are sent to therapy.  He reports that this type of silence is an effective manipulative tool for the client.  Brammer’s old findings are echoed in recent articles and studies on clients who are sentenced to diversion programs.  Berg and Shafer (2015) stated in an article that “mandated clients often describe treatment as ‘doing time.’”  Brodsky (2011, 2013) says poorly motivated clients feel that therapy is intrusive when therapists use the questioning approach in therapy.  Another aspect of “hostility-motivated resistance” is called “anticipatory (expectancy) silence” in a study done by Tindall and Robinson (1947).  In expectancy silence, clients just sit back and wait for the counselor to say something.  Those clients may associate counseling with a medical model and expect cures and treatments for the high hourly rate.  They may have expectations such as, “let’s see if he or she can cure me” or “let them earn their money” (personal communication, Shirley DiCenso, August 7, 2014).

“Anxiety-motivated embarrassment” results from a client’s embarrassment at telling someone his or her problems.  A multicultural contributor to “anxiety-motivated embarrassment” may be when family members do not embrace mental health counseling (McGoldrick, Giordano, and Garcia-Preto, 2005).  A sensitive and productive silence is one in which a client is experiencing painful feelings he or she cannot verbalize, but is searching for a way to express, and the counselor does not interrupt this process by speaking.  Another type of healthy silence occurs when a counselor waits for a client to recover from the fatigue of expressing a difficult emotion.  An appropriate remark for the counselor to make could be, “it’s alright if you want to wait awhile to speak.”

Silence as resistance

Silence can be a manifestation of resistance (Beutler, Moleiro, & Talebi, 2002).   Counselors agree that refusal to communicate in a session is an extreme form of resistance that arises when clients perceive a situation, topic, or counselor as threatening.  Resistant behaviors can be classified as external or internal.  Internal resistance comes from how the client’s personality responds to perceived threat.  External resistance relates to the setting of the session, the impact of the counselor’s technique or skill, or counter-transference (Messer, 2002).  Historically, resistance has been one of the widely accepted phenomena of counseling and is considered by some to be a defensive form of transference.  The term “resistance” was introduced by Freud to indicate unconscious opposition toward bringing material into consciousness, and to aid in the mobilization of repressive and protective functions of the ego (Freud, 1959).  Transactional Analysis theorists interpret resistance as a “game” with “payoffs” (O’Reilly-Knapp & Erskine, 2003).

The existentialist view of resistance is interpreted as self-sabotage that denies and stymies a client’s potential to embrace life (May, Angel, & Ellenberger, 1958).  Perls’ (1992) viewpoint when writing about Gestalt theory says that all resistance represents clients’ refusal to be self-supportive.  Conversely, Rogers (1957) places the cause of resistance on the counselor.  Other professionals, like Arnold Lazarus, consider resistance to be a form of denial and illusion to cope with stress (Multi-model therapy video uploaded on August 31, 2014).  Denial and illusion are useful for clients who feel threatened.  Denial and illusion used as resistance help clients recover from severe emotional distress, and can be seen as useful homeostatic functions, which means that silence can be a coping mechanism.  Denial and illusion may be temporary until these clients can mobilize a better coping strategy.

Recent authors, such as Haque (2012), stress a culturally sensitive approach when doing therapy with Arabs and Muslims that includes reflective listening but also stresses the need to ask clarifying statements that seem unclear or ambiguous.  Thomason (2012) advocates for best practices in counseling Native Americans, although his cited research based on Internet survey questions does not directly address listening as a counselor skill.

Research on silence in the counseling session

Quantitative and qualitative analyses of aspects of silence in counseling are needed.  An old study on client-counselor talk by Carnes and Robinson (1948) concluded that a high client-to-counselor talk ratio is not an indicator of a good client-counselor relationship, just as client talk is not an indicator of awareness.  This finding seems supported in the qualitative literature that discusses effective training times and counselors’ social skills in sessions (Rautalionko, Lisper, & Ekehammer, 2007).  The increase in the use of a professional assessment rating scale to rate interpersonal communication skills can be helpful in obtaining empirical data (Cihangir-Cankaya, 2012).

There are many old qualitative professional articles on silence (Duba, 2004; Knapp, 2007; Ladany, Hill, Thompson, & O’Brien, 2004); Levitt, 2001).  All the above-cited professionals agree that silence is important in the counseling sessions and is part of the therapeutic alliance.  They also say that counselors should be able to deal with silence comfortably and need to learn how to deal with both uncomfortable and comfortable aspects of silence.

This writer found the suggestions extrapolated from the sparse quantitative research and the qualitative contributions on how counselors deal with silence to be technique-oriented.  Techniques such as disregarding, interpreting, or manipulating silences are not always helpful.   Dealing with silence should not come from an automatic technique, but should stem from the counselor’s self-examination of ego, personal involvement, and the perception of threat in a given session, and how these things affect the client.

Exploration of how a counselor deals with silence

For the counselor, a minute of silence can seem like an hour.  Silence is often an embarrassment.  Both professionals and students have reported to this writer that when it comes to silence, negative thoughts have a tendency to creep in, such as: “if I don’t say something, don’t respond, the clients will think I don’t know what I am doing.”  Clients will think they are hopeless cases or that they have said something that is unacceptable, making them undesirable as clients, and people.  Counselors who are effusive find it hard to be silent when the client wants to talk because silence is not a personal characteristic outside the counseling situation.  When it comes to silence, some counselors find it challenging to behave differently in a session than they do outside of a session.

Counselors exploring silence during sessions have tough, on-the-spot decisions to make: should they interrupt the silence, or listen to the silence and wait for the client to proceed?  The question becomes whether or not to let the client assume responsibility for speaking once he or she has initiated the silence.  However, counselors must be sensitive to situations where a client needs support.  The counselors’ minds are busy thinking about what is going on and what the silence means.  Clients should not be pushed by silence into facing their problems and feelings before they are ready.  Astute counselors recognize this dilemma and can help the clients over the rough places by listening to silence.

Values of silence in the counseling session

A counselor’s silence forces a client to talk, helps the client focus on his or her problems, and helps place responsibility for therapy on the clients.  Another value that this writer sees is that it gives the introverted, less articulate client a better chance to succeed in therapy.  Rorschach tests indicate that introverted clients may be very creative individuals with rich inner lives, but the stereotypical introvert can be seen as inferior to the more socially valued and therapy-valued extroverted client (Anastasi, 1976).  A counselor’s silence can also reveal the counselor’s sensitivity to cross-cultural approaches to silence (Hague, 2012; LaBeouf, Smaby, & Madux, 2009; Thomason 2012).  Further, depending on whether it is ignored or utilized, silence as resistance can indicate the course of therapy.  Silence can also be a clue to a client’s defense structure.  For example, a client may become silent when values or morals are brought up in a session.  Again, silence can also be a protective mechanism for clients to keep acute anxiety under control.

Listening to children in-session

The bulk of literature on children and listening focuses on improving the listening skills of children and not on counselors’ listening skills.  O’Quigley (2000) reviewed the literature, and the scant findings on listening to children, when writing about children of divorce.  The dynamics of counselor listening and the common reasons for silence in the session were similar to those of adults; however, counselors have to use children’s play and other activities to hear and understand children.  This writer believes that silence as resistance cannot be interpreted as stated above with adults.  Silence by children in therapy is not unconscious opposition, but rather an embarrassment or a learned process from the family (for example, “we don’t talk about family problems in front of people”).  Theories and models that are talk therapy-based are not appropriate in sessions with children and can lead to long silences by children, and serial questioning by therapists.  Play therapy and art therapy is the talk of children and elicits rich information without intrusive and ill-received questioning, which is often seen as too pushy, and can take place at the wrong time.  Novice and seasoned therapists alike do not tend to feel they are not doing enough if children are unresponsive to verbal interventions.

Excerpts of a vignette

A therapy group made up of eight-year-old boys, who were all from different cultural backgrounds but had all been sexually abused, was excited about making shields to express their special qualities and powers needed to overcome their traumas.  Shields are common toys used by children in mythical play.  The boys’ excitement was welcomed after an initially bumpy start in group therapy, in which verbal sharing was hard for the children, and their silences and reluctance to participate were trapping the therapist into serial questioning.  Joe Crow drew himself on his shield to show his physique and indicate that he could protect himself and say no to being re-victimized.  Kim Chow portrayed himself teaching little children, because he wanted to be a teacher.  Geraldo drew an older man with a mustache and wanted to know how to spell “wise.”  Mike drew a redbird and a fox.  He said, “if you see a redbird, it brings luck,” and “a fox is sly and crafty and can protect themselves.”  All the boys wanted to wear their shields in-session and were excited to be photographed wearing them.  Drawing shields in therapy broke the clients’ silence and prevented the therapist’s continuous verbal tracking, as time and time again, the boys brought up their strengths and powers and referred to their shields (Oppawsky, 2011).

Conclusion and needs assessment

There is a dearth of current quantitative and qualitative research on silence in the counseling session.  New quantitative and qualitative research on silence is needed, especially clinical research on specific aspects of counselor silence.  It is not good enough to blog on silence, as this provides only superficial information and can create a false sense of security for therapists who proclaim, “I’ve read up on aspects of silence in the session.”  Research on silence and listening in sessions with children focuses almost solely on how to help children listen.  Empirical studies are needed to further the research on silence as a counseling skill for professionals working with children.  Given today’s dilemmas regarding immigration and refugees, there is also a dire need for research on culturally-specific dynamics of listening as a counselor skill in sessions with clients of diverse cultures.



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Beutler, L. E., Moleiro, C., & Talibi, H. (2002). Resistance in psychotherapy: What conclusions  are supported by research. Journal of Clinical Psychology, 58 (2), 207-217.

Brammer, L. M. (1979). The helping relationship: Process and skills. New Jersey: Prentice Hall.

Brodsky, S. L. (2013). Therapy with coerced and reluctant clients. Journal of Marriage and Family Therapy, 39(4), 539-540.

Brodsky, S. L. (2011). Therapy with coerced and reluctant clients. Washington, DC: American Psychological Association.

Carnes, E. F. & Robinson, F. D. (1948). The role of client talk in the counseling interview.  Educational Psychology Measurements, 8, 635-644.

Cihangir-Cankaya, Z. (2012). Reconsideration of the Listening Skill Scale: Comparison of the listening skills of the students of psychological counseling and guidance in accordance with various variables. Educational Science: Theory and Practice, 12 (4), 2370-2376.

Duba, J. D. (2004). Using silence: Silence is not always golden. In L. Tyson, R. Peruse, J. Whitledge, J., Duba, P.Newfeld & J. DeVoss (Eds.), Critical incidents in group counseling. Alexandria, VA: American Counseling Association.

Freud, S. (1959). Inhibitions, symptoms, and anxiety. In E. Jones (Ed.) & J. Riviere (Trans.) Collected Papers 1, 287-359. New York: Basic Books.

Haque, A. (2007). A review of: “Counseling and psychotherapy with Arabs and Muslims: A sensitive approach by Marvan Dwairy available at http://dx.doi.org/10.1080/1556490070123884.

Knapp, H, (2007). Therapeutic communication: Developing professional skills. Los Angeles: Sage Publications.

Landany, N., Hill, C. E., Thompson, B. J. & O’Brien, K. M. (2004). Therapist perspectives on using silence in therapy: A qualitative study. Counseling and Psychotherapy Research: Linking Research with practice, 4 (1), 80-89.

Lane, R. C., Koetting, M. G., & Bishop J. (2002). Silence as communication in psychodynamic  Psychotherapy. Clinical Psychology Review, 22 (7), 1091-104.

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LeBeouf, I, Smaby, M, &  Maddux, C. (2009). Adopting counselor skills for multicultural diverse  clients. Paper presented at the 2009 American Counseling Association Annual Conference March 19-23, 2009, Charlotte, N. C.

Levitt, D. H. (2001). Active listening and counselor self-efficacy: Emphasis on one microskill in   beginning counselor training. Clinical Supervisor 20 (2), 101-115.

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McGoldrick, M., Giordano, J. & Garcia-Preto, N. (2005). (Eds.). Ethnicity and Family Therapy. NY: Guilford Publications.

Messer, S. B. (2002). A psychodynamic perspective on resistance in psychotherapy: Vive la Resistance. Journal of Clinical Psychology, 58 (2), 157-163.

Oppawsky, J. (2011). Sexual abuse: Therapy for children and adolescents .NJ: Xlibris.

O’Quigley, A. (2000). Listening to children’s view: The findings and recommendations for recent research. York, England: Joseph Rowntree Foundation.

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Perls, F. S. (1992). Gestalt therapy verbatim. Gouldsboro, ME.: Gestalt Journal Press.

Rautalionko, E., Lisper, H., & Ekehammer, B. (2007). Reflective listening in counseling: Effects of training time and evaluator social skills. American Journal of Psychotherapy, 61(2), 191-209.

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Smaby, M.H., & Maddux, C. D. (2009). Counseling skills: Assessing mastery, transfer, and client outcome. Pacific, CA: Brooks Cole.

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Thomason, T. (2012). Full circle: Returning native research to the people.  Journal of Indigenous Research, 1(2), 1-10.  Also available at http://digitalcommons.usu.edu/ricjir/vol1/iss2/4.


OppawskyDr. Oppawsky is an advising faculty member at the University of Phoenix, Tucson, Arizona.  She teaches a full array of counseling courses in the graduate program and selected courses in the undergraduate program in Human Services. She also teaches graduate and undergraduate courses in Psychology at the University of Phoenix. She formerly taught counseling for Boston University in the overseas program and has taught psychology courses at the University of Warsaw, Poland and at the University of Lithuania.

Dr, Oppawsky has her PhD in Clinical Psychology from the Elite University of Munich, Germany and a Master’s degree in Counseling and a Master’s degree in Human Services from Boston University. She is a licensed Clinical Psychologist and a licensed Psychotherapist in Germany. In the USA she is a licensed professional counselor in Arizona (LPC), an approved clinical supervisor (ACS), a Human Services Board Certified Practitioner (HS-BCP), AZ RN, and a Diplomate member of the American Psychotherapy Association.

Dr. Oppawsky has years of clinical experience and human service experience abroad and in Tucson with diverse populations. She has several professional publications to her credit. 


Promoting our Professional Colleagues and Their Practices

Promoting our Professional Colleagues and Their Practices

Dr. Erica Goodstone

Marketers do it.  Coaches do it.  Therapists, however, usually don’t promote and market each other’s books, events, and practices.

As therapists, I believe we do a disservice to our clients and potential clients when we fail to adequately market and cross-promote one another’s wonderful healing work.  Many therapists, especially those who are more knowledgeable and experienced, tend to shy away from the internet.  Many are reluctant to get involved in social media and don’t want to spend their time blogging, connecting, and sharing.

I have noticed a distinct pattern in the ways therapists interact online.  It feels like an every-man-for-himself mentality.  There is a sense that there is not enough work to go around, that if I share about the work and events of another therapist, my potential clients will not come to me.  This attitude, I believe, is rooted in a feeling of competition, lack of abundance, and fear.

When we avoid marketing and promotion because of fear, regardless of the actual fear, we prevent people from finding us, people who may desperately need our services.  But it is worse than that.  When licensed, supervised, educated, and skilled therapists do not make themselves known and do not assist their professional colleagues in becoming known, then those clients who most need our professional help will seek it elsewhere.  If therapists are not out there, online, on social media, in the news, authoring and promoting their books, and sharing the good news about each other’s work, then potential clients desperately seeking help will become easy prey for those who do promote well.

Anyone can claim to be a life coach, a relationship coach, a healing coach, a career coach, an addictions coach, etc.  Some coaches have good training; many others do not.  Many coaches come from a business background and understand the value of self-promotion and cross-promotion.  They eagerly support each other, knowing that cooperation builds credibility and authority.  And many coaches do not have to follow strict ethical guidelines or other requirements for licensure.

Maybe it’s our therapeutic education with a distinct lack of marketing training.  Maybe it’s the sense that our licenses clearly restrict self-promotion.  Or maybe it’s a personal belief held by most therapists that promoting therapeutic practices is unethical and could in some way harm our clients.  But it is time to realize that the internet has changed our world, and we need to embrace that change.

The next time you see an interesting post online by a licensed professional, take a moment to not only read the post and “like” it but actually leave a meaningful comment.  And then go and share that post with your own social media followers.  Imagine if all of us did that for each other!  It’s time to break the habit of participating in groups only to promote your own articles and events.  Instead, become a go-giver.  Give support, leave a comment, and share and build a network of colleagues whose work you acknowledge and appreciate.

Apply to join the Marketing Our Practices Facebook group at:https://Facebook.com/groups/MarketingOurPractices