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CBT, DBT, Psychodynamic Therapy For Depression - Oh My!

July 21, 2017
by Brian Baumal  |  Add Comment

If you are a "consumer" of psychotherapy, all the different types of treatments must be very confusing.  Let's sort them out.

Your mental health is extremely important.  When you buy a car and you have tons of options, you generally know what you're getting.  However, do you really undersatnd what kind of psychotherapy you are receiving when you meet a therapist for the first time?  There are lots of treatments that therapists practice to work with depression.  The following are some common ones for depression:

CBT
Cognitive Behavioural Therapy has become one of the primary standards for treatment of depression.  There is a slogan for CBT that says "Change your thoughts, change your life".  One of the underpinnings of depression is depressive thoughts about one's self and about one's situation, or life.  When those thoughts become overly negative, or so unconscious such that they are not even operating on an aware level, having CBT come in to address those thoughts can be very helpful.  One thing to note about CBT is that it can either be deployed as a series of standardized treatments (e.g. patients receive six treatments of CBT and showed marked improvement in their depression).  However, in one-on-one therapy, CBT is more long-term, where CBT techniques are not standardized but rather deployed situationally with each patient.

DBT
This stands for Dialectical Behaviour Therapy, and just becaue it looks similar to CBT in spelling, the are quite different.  Dialectics basically say that the mind tends to sort things into black and white issues - or that a person often feels like they have to choose between two opposed (dialectically different) things.  Depressed people are often keenly aware that they have to choose between two things (e.g. going out or staying in), but they tend to default to only one activity (usually the one that is a sign of depression).  Since depressed people can see the other side of things, DBT says "OK, there is another side - there is a duality here... what is going on in you that makes you choose one side?  What would happen if you chose the other side?  What would happen, or how would you feel if you were in the middle of the two sides?"  DBT is a very analytical approach that can often be engaging for depressed individuals.

Psychodynamic Therapy
This is a deeper exploration of one's inner world compared to DBT.  While DBT may look at two poles on a spectrum, psychodynamic therapy looks at many different spectra, and how you operate between them.  I am a present-centered therapist, which means I get curious about how those dynamics operate when we talk directly.

The Role Of The Therapeutic Relationship
Finally if we forget about technique, psychotherapy is a very personal experience.  Regardless of how good a technique is, the therapist must build a relationship that makes you feel trusted and secure.  As such the therapeutic relationship is as important, of not moreso, than any technique a therapist chooses to deploy.

 


Brian BaumalBrian Baumal is a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario.
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Living In The Grey Zone Is Better Than Depressive Black & White Thinking

July 19, 2017
by Brian Baumal  |  Add Comment

Bonus - Watch & Video And Play A Therapist For A Minute

I think the concept of the article, "Grey Zone" thinking, as opposed to Black & White thinking is one that many people understand as a pillar of imrpovement for those with depression.  Depressive people tend to see themselves and situations fairly negatively.  They get down on themselves and feel that situations in which they find themselves can be overwhelming and challenging.  The opposite, seeing things in "white" also sets people up for failure.  When EVERY day is not a good day, it is common for someone with depression to feel that all days will be bad, or that they are bad.  When EVERY project at work does not ALWAYS go as expected, depressed people can take it too personally.

As I said, I think there is a general sense that this is low-hanging fruit, something people realize they must address in order to relieve some of their depressive thinking.  They need to learn to live in the grey zone, where just having things change, or things not going according to plan does not mean that you are a bad person.

What I do think is more interesting is how extremely subtle, or almost unconscious this thinking could be.  That is to say, we know we must change it but we are unsure when this kind of thiking about ourselves and our outside world is operating.  Watch this 2-minute video (click here).  Watch it twice.  The first time, try to see if you can spot the subtle thinking that may have made this gentleman depressed.  If you can't find it, watch it again (click here), and pay attention to the portion from 2:05 to 2:18.  Can you spot it?  Now, move down the page to read my analysis...

 

 

 

 

 

He says "I look forward to the next day, not every day, but generally I do"
He also says "I enjoy meeting people - again not every day"

Notice as he says "not every day" it is like he's adding that phrase onto what he is saying - like it's an extra or new thought that helps temper his looking forward to and enjoying meeting people.  What we can probably gather is that this gentleman thought that every interaction he should have with people should be positive and enjoyable, and when it wasn't, he somehow blamed himself.  Now that he has the new awareness that things will not be enjoyable every day, he can begin to let up on himself and his expectations - and slowly, his mood will begin to rise.

As a therapist watching this video, I view it as an artist may view a painting - I can see where the artist had made a real effort and impression on the canvas, and I hope you can too.  This is what the art of psychotherpy for depression is all about - working with patients to realize their unconscious processes and making them subtly aware of the thoughts that may make them depressed.  It can be interesting work, especially when you realize how buried some of the depressive mechanisms are within our psyche.

 


Brian BaumalBrian Baumal is a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario.
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Humour And Humanity In Treating Depression

July 17, 2017
by Brian Baumal  |  Add Comment

I've seen many websites in Toronto from therapists that say they are using the most advanced treatments, the latest research on brain scans and structuring their therapy on whiz-bang studies in the treatment of depression.  For all of that, they seem to be forgetting one thing - humor and humanity in the treatment of depression!

Psychotherapy for depression - most obviously - includes addressing the unconscious thoughts that people have about themselves, their relationships and their views of the world.  The question becomes "What is that voice, and how do we address it?"  Fortunately, we don't have to look at whiz-bang studies to understand that the inner-world of the depressed person likely has thoughts that include "You can't do it", "You're not worthy" and "You're the only one who is this bad."  I also heard a well-known psychiatrist say "Never argue with a depressed person, you'll always lose."  For clinicans what that means is that it is very difficult for us to be directive with depressed people, and give them a roadmap to wellness, or activities they should do to lift their depression, because deep down they will find ways to avoid do it.

So how do we address this issue?  Well, it's one of the reasons why I like working with depressed individuals - we use humour and humanity to break through that unconscious world. and when we can incorporate these aspects into therapy, it makes for a better session all around.  For example, depressed individuals have overly negative views of the world around them.  Even what seems to be positive can be viewed negatively.  Ask a depressed person about watching a beautiful set of fireworks, and they may say "They were too far up in the sky, I had to crane my neck and it hurt."  As a therapist, I may say "Great, you've just come up with a business idea - $5.00 neck massages for people watching fireworks.  I bet someone could make some good money with that."  

Now the goal is not to get the depressed person to laugh (which could simply be a nice by-product of the intervention).  Rather the goal is to circumvent the overly harsh critical and isolationist voices in a way that doesn't trigger them into action in the therapy session, or doesn't get me into a "no win" argument situation.  The intervention is my way of saying "look, there were probably lots of people there who had similar neck issues.  The best anyone can do is manage the issue and enjoy the fireworks as best they can."  This opens the door to having the patient explore what makes him so different than others around him watching the fireworks - and that more directly addresses some of the isolationst voices and ideas in the head of the depressed person.  These isolationist views are certainly more fundamental issues in mechanics of depression, but it is much better to approach them with humour and humanity to start - factors that anyone - depressed or not can appreciate.  

 


Brian BaumalBrian Baumal is a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario.
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The World Is Divided Into Two Groups...

July 16, 2017
by Brian Baumal  |  Add Comment

Those Who Understand Depression & Those Who Have No Clue

Sometimes people ask me depression actually exists.  They feel that if it's all in your mind, then it cannot exist and then they go on to explain how they just simply "get willpower to do stuff and do it."  They say to me "when I feel blue, I just get out and meet people and it goes away - why can't others do that?"  This has lead me to the conclusion that there are two types of people in the world, those who understand that depression is real and those who by their own experience have never experienced the kinds of thoughts and feelings depressed people have.

When I encounter those "just do'ers", I often explain the concept of "Depressive Reality", or even what can be called "Analysis Paralysis" (a term with which most people are more familiar).  I ask them when they are at their work or jobs, if there is someone there who is a really great planner - someone who can see everything that could go right or wrong with a project, initiative or task.  They often tell me that they know of such people, and I say "Those people can be really valuable because they will point-out all the landmines that you may have to avoid in order to do things."  The people I talk to say "Yeah, that's true."  And then I say "And how many times do you look at that person at work and also think 'stop complaining?'"  I often get nodding heads and knowing grins.

I then ask the "jus do'ers" to put themselves in the head of that person.  I ask them to understand that people like that see every option and have difficulty choosing one.  Moreover, as they sit and do not take-on activity, a voice inside their own head may tell them to stop complaining, and that voice makes things worse because it makes their mindset somewhat negative.  Usually, the "just do'ers" begin to understand the seeds of depressive thoughts, and that even though there are benefits to a lot of analysis, depressed individuals may take it a bit too far.

Now here's the rub.  In my own personal thinking, I tend to lean much more towards "depressive thinking" than "just doing".  However, I have lost a lot of weight and kept it off for five years.  I exercise and eat well every day, and often when I find myself listening to people who have trouble doing so in the back of my mind I am thinking "It's so simple, just get out and do it!"  Then I catch myself - I've just thought the way people who don't understand depression think!!!

When I treat people with depression, the goal is NOT - I repeat is NOT - to move everyone over to "just do'ers".  I eat well and exercise often when it is difficult for me to do so.  It is sometimes a burden for me, and sometimes I am sad about having to do it (though I always feel good afterwards).  So, I've been fortunate enough to be a "depressive do'er" in my life.  When I work with depressed patients, I often focus on "logically pursuing goals" and the best actions that people can do make those goals happen.  Depressed people are good at answering that question - but what I am really interested in is the anxiety that they feel in telling me about their plans. Underneath the doing for them often lies the anxiety of taking action and it is that anxiety that tends to hold people back.  When we are able to begin to address the anxiety of actually doing, and moving beyond planning and analysis, movement can begin for the depressed person.

 


Brian BaumalBrian Baumal is a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario.
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When Do You Know It's Time To Seek Therapy?

July 7, 2017
by Brian Baumal  |  Add Comment

Chances are, if you are at this website, the answer to when you need to see a therapist is somewhat self-evident.  However, for those who are still on the sidelines, or perhaps those of you who are friends or family to someone that may need to see a therapist, this post may be helpful to you.  Making a decision to see a psychotherapist or get help for either a mental health condition or other issue that may be significantly affecting you is a serious matter and decision.  Here is a list to help you determine if you need to see a therapist:

Have Your Emotions or Moods Changed?
Many of us, when we have physicial symptoms, know when things seem different.  For example, we may have had a cold that has gone on longer than normal, or a cough that seems different.  Perhaps your existing back pain has changed and is now in your chest.  You know when you are not right physically.  The same thing occurs emotionally.  We generally know how sad, happy, outgoing, anxious, withdrawn or even depressed we normally are or when our reactions are in-line with our circumstances.  When those emotions and moods change in either intensity or duration, it may be time to seek professional help.  For example, it is completely normal to be sad, withdrawn or even depressed if a family member passes away - but if that feeling lasts for longer than you expect, or if it is accompanied by other symptoms such as anxiety, regret, undirected anger or a change in your relationships with people close to you, it may be time to get some assistance.

Are Your Behaviours or Activities Changing - And If So, To What Degree?
One of the fundamental things a mental health professional will look at are how some of your basic routines have changed or been impacted.  Are you showing-up to work two hours late, or are you becoming a workaholic?  Has your diet or sleep changed?  Has your weight gone up or down regardless of diet?  Have your relationships changed in any significant way?  Are you engaging in addictive or destructive behaviour such as drinking to excess, eating much more than normal, or spending money irresponsibly?  A normal shift in mood or change in circumstance may cause any one of these factors to be impacted, but a significant or sustained change in any one of these may be a sign that it is time to see someone.

Have Your Thoughts Changed?
Are you noticing that your thoughts, such as your hope for the future, your thoughts about your job, family or finances have changed?  Do you feel either helpless, or perhaps have sudden bursts of energy or thoughts that you did not have previously?  Have you given thought to suicide, even if it is just a passing thought?  Are you thinking about taking a somewhat drastic action like quitting work, or leaving a relationship without significant reason for doing so?  These changes in your thoughts may be a sign that it is time to see someone?

Are You Having Difficulty Coping With A Situation Yourself, Or Do You Find Yourself Stuck?
Unfortunate circustmances happen to people all the time.  Job loss, marital strife, sudden illness or even the death of someone close unfortunately occur.  Sometimes, we may just find ourselves stuck and are not able to move forward.  In situations like this, even if you are coping well, or have a good support mechanism, it may be time to talk to someone about your thoughts or feelings, especially if you feel that you have difficulty moving forward from the circumstances in which you find yourself.

Are You Sick And Tired Of A Certain Behaviour Or Trait?
Sometimes we may finally realize that a certain behaviour or trait that we have is not serving us well and we wish to change it.  This kind of reason to see a therapist falls more under the rubric of general self-improvement, but it is an area that many therapists specialize in.  So even if little is wrong psychologically or behaviourally, if you have an engrained habit or thought that you want to change, and you feel that it is really time to change it, it may be worthwhile to see someone.

Do Others Notice A Change In Your Behaviour?
Sometimes you may be experiencing any of the above traits or symptoms, but you may not notice it at all.  Or rather, you may not notice the impact the above is having on you.  For example, people may notice that you are more tired, irritable or withdrawn.  In some cases, your relationships with people may change altogether.  In situations like this, it may be worthwhile to speak to someone who can help you understand why your relationships have changed.

 


Brian BaumalBrian Baumal is a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario.
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The Limits Of Friends & Family

July 7, 2017
by Brian Baumal  |  Add Comment

Many of us are fortunate to have friends or family members that help us and care for us and therapists will often encourage patients to seek support from friends and family.  However, there are a number of limits to getting self-help, or even mental health advice or input from friends and family.  As you read the list below, realize that it is written as a way of protecting the caring relationship between you and the friends and family with which you seek help.  Your friends and family are a valuable resource and should be used to help you get through a situation, but consider these factors:

Friends and family may not have enough time
Many people see a therapist on a weekly basis, or twice a month in order to discuss what is going on in their lives.  If a situation gets detailed or requires a lot of working through, friends or family may not have the time needed to assist in the matter fully.  It is possible that seeking too much help or time could put a strain on the relationship.  Therapists are skilled at setting boundaries in the relationship so that patients do not become reliant on the therapeutic process in their lives. However, friends and family may not know how to negotiate these boundaries up-front, and both you and they could be in a situation where you need more time than they have available to give.

There are situations which you may not want to discuss
Money, sex, the deep issues with a marriage, previous trauma, illness, thoughts of suidice, serious addictions, infidelity, illegal activity and other secrets may be difficult to discuss with a family member or a friend.  It is possible that you may find yourself seeking help from a friend or family member, but leave out a few key pieces of information that may be at the root of your problem.

They may break confidentiality
There are really three aspects to this.  The first two involve gossip.  There is the standard gossip, where a friend or family member may discuss details of your conversations with others when there is no good reason to do so.  The second issue is gossip related, but the person in whom you confide may themselves feel the need to discuss something with another family member or friend, either for their own self support, or they may take matters into their own hands and intervene on your behalf without you knowing it.  This could have very negative consequences.  The third issue involves a friend or family member disclosing your thoughts or behaviour to authorities or medical practitioners because they are worried about what you are saying to them.  There may be nothing wrong with this, per se, but if the parameters are not set-out in advance, then such disclosure, even if it does help you, may leave you feeling betrayed.  Moreover, there are certain situations by law where a friend or family member must report certain aspects of a conversation.  These primarily involve any sort of harm at any time (past, present or future) to children and utterances of doing harm to other people.  Therapists are trained to set-out these parameters at the start of the relationship and know when to report, and how to tell a patient that they have to report.

It may put a strain on the relationship
The above three factors and a few others indicate that supportive relationships between you and friends and family members has the potential to put a strain on the relationship.

Friends and family members are not self-help experts
How much drinking is too much?  Is someone experiening a serious episode of mania or depression?  Is someone experiencing distorted thinking, or even a psychotic break?  When does depression become dangerous?  Is it possible that your spouse has a mental illness that is affecting you?  Do all mentions or thoughts of suicide need to be "cracked-down" on?  Is someone (especially in their late teens or early 20's) showing signs of develpoing a serious psychiatric condition? Are changes in behaviour a result of medication?  In many cases, these issues are rare and managable - but it is also like asking a friend's opinion on a persistent cough that does not go away.  There are certain things that therapists look for to help determine if more serious interventions are needed.

Overall, I do believe there is a strong place for friends and family members to provide support.  However, I was brought-up with a saying "you get what you pay for".  Over reliance on support from friends and family, and the occurrence of any of these situations has the potential to do more harm than good - both in the supportive and personal relationship you have with your friends and family.  As such, these are important factors to consider if you are thinking of seeking help from a therapist.

 

 


Brian BaumalBrian Baumal is a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario.
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Really, Really Tough Questions About Therapy

July 7, 2017
by Brian Baumal  |  Add Comment

A) I don't get how therapy works - explain it to me
B) In therapy I will blame my parents
C) Maybe I should just take a vacation instead
D) There is a stigma attached to therapy
E) How can working on my past help me now?
F) What's the difference between therapy and coaching?
G) Is it true I may get worse before I get better?
H) I might feel foolish
I) Why can't my friends and family help me?
J) I feel weak if I have to ask for help
K) Will a therapist put some weird ideas in my head?
L) Why should I pay money just to talk to someone
M) Why do some people call it "cycle-therapy"?  Will I stay in therapy forever?
N) Do Therapists Have Flaws?
O) Can Therapists Read Minds

A) I Don't Get How Therapy Works - Explain It To Me: There are two parts to therapy - The Therapeutic Relationship & The Therapy Technique.  Every form of therapy requires a good relationship, one where you can feel free to talk about anything or nothing, one that is emotionally responsive and one where you don't feel judged.  Consider the relationship like the therapist's "bedside manner".  The Therapy Technique is like procedure that the therapist uses - there is CBT, DBT, Present-Centered, Existential, Gestalt, Adlerian, Rogerian, Psychoanalytic and the list goes on.  When you talk about yourself in this kind of environment, and when you examine parts of you in a different light than before therapy begins to work.  Within a few sessions you will know whether talking to the therapist is going to produce results.

B) In Therapy I Will Blame My Parents - No you will not.  It is should be obvious that parents do play an important part in your life, so that means we will discuss them, but it does not mean we will blame them, nor will I force you to  "over discss them" or draw conclusions about you that don't make sense.  Your relationship with your parents is treated with the importance and care.

C) Maybe I Should Just Take A Vacation Instead - I am all for vacations helping mental health.  In fact I remember one medical doctor, specializing in treating certain chronic conditions saying to me "I wish all my patients would take a vacation" for their mental health.  I then asked "Well, does the vacation cure them of their condition, and if not so, why are you in business?"  Of course, he got the joke that vacations are helpful but not curative.  Basically, one needs to do everything they can for their mental health.  Vacations, yoga, spas, new-age techniques and therapy all work together to give you a fighting chance for a life you want.

D) There Is A Stigma Attached To Therapy - You bet your life there is, and brave souls need only apply.  On a more serious level, taking a step towards any change is difficult, and at the same time it is a great act of courage.  I can guarantee that the people who will make an issue out of you being in therapy do not have the courage to do it themselves.  You have my permission to look down your nose at them knowing you are the better person ;)  Note too that therapy is not just for mentally ill people.  In the 100 years since therapy has been around, it has evolved to help people in all walks of life.  As a therapist I am amazed at the number of well-adjusted  people I meet and talk to who say to me "Hey I was in therapy for a while."

E) How Can Working On My Past Help Me Now?  It is a huge misconception that therapists "work in the past".  We talk about the past but work in the present.  The misconception comes from two areas.  First, everyone thinks that therapists are like Sigmund Freud and his ability to say something like "your mother didn't breast feed you when you were young, and this is why you cannot hold on to money, you're cured."  Though Freud's shadow does still loom large over psychotherapy, much has changed.  It's just like you would never expect to ride on a commercial jet liner that was 100 years old either.  The second truth about therapy and one's past is that therapy talks about the past, but it works in the present.  For example, you may be talking about an issue that happened in childhood, and I may say "looking back at that experience, what do you wish you had then that you have now?"  The goal is to simply mobilize some of stronger, more adult parts of you that are resources to you in the present (e.g. bravery, intelligence, humour) to help put the past into some context.  In this way, you actually give your present resources a renewed sense of strength. 

F) What Is The Difference Between Coaching And Therapy?  Psychotherapists in Ontario are regulated and have to meet certain standards of education and conduct or face discipline.  Beyond this coaching helps people reach certain goals - along the way, they may find out stuff about themselves.  Therapy works in the opposite way - people find out stuff about themselves and then reach goals.  It's a much more open-ended exploration.  I have found that patients can chose the form of self-help that best suits them.  However, those with serious psychological conditions should consult a therapist, or even their family doctor for self-improvement issues.

G) Is It True That I May Get Worse Before I Get Better? Sometimes the therapeutic process can be new and seem unknown for the frst few sessions.  The best thing you can do is talk to your therapist about these as they happen - in fact within the first few sessions you should feel that you could talk to the therapist about anything, including ambivilent feelings and know that the therapist will be able to address your concerns.  In fact the therapist can often use them to propel your growth and change.

H) I might feel foolish - It is really difficult to really open-up to a stranger.  In fact, one quickly realizes in therapy how different it is to open up to a therapist than it is talking to a friend or family member.  You have probably never opened-up like this before.  At the same time, as a result of taking that risk you will learn more about yourself and will eventually become more comfortable with revealing your feelings. When you have achieved that degree of trust, you will have unlocked your potential for growth, self-discovery.

I) Why Can't Friends And Family Help Me? Friends and family definitely can help you, and they should.  What you may tend to notice about friends and family is that you get to a limit with them.  You may not be able to discuss certain topics (money, sex, illness, other family/friends), and they may not be able to provide the help you need.  Sometimes a friend or family member just may not have the time you need in order to be helped.  In many cases, people may avoid discussing real issues, or seeking too much help from friends and family for fear of straining the relationship.

J) I Feel Weak If I Have To Ask For Help. There was a commercial a long time ago for a dandruff shampoo, where someone says to a person using the shampoo "Hey, I didn't know you had dandruff" and the shampoo user says "Exactly."  However, the shampoo user may have had difficulty using it, or lifting it off the shelf - but the benefits are clear.  It is difficult to ask for help, especially when we feel we have so many other ways to try to cope with our problems.  Therapy is but one way of dealing with the issues we have, and there is nothing wrong asking for help.

K) Will A Therapist Put Some Weird Ideas Into My Head?  I certainly will not, and neither should any other well-trained psychotherapist who practices a recognized form of psychotherapy.

L) Why Should I Pay Money Just To Talk To Someone? I would wittily argue that you're not paying money to talk to someone but that you're paying someone to listen - and that should largely answer the question.  However, the person to whom you are paying the money is trained to move you forward - so you should be getting good value for your investment.

M) Why Do Some People Call It "Cycle-Therapy" And Will I Stay In It Forever?  The length of time you stay in therapy is dependant on a number of factors, but I can assure you that my goal is to get you out of therapy so that you can tell others that I've done a good job ;)  On a more serious note, there's the standard answer that therapy will uncover other issues that need to be worked-on and the process thus goes on-and-on.  This is sometimes, but very rarely true.  If you have come-in for a specific goal and feel you have reached it, you can and should consider terminating, even if there are other issues you wish to work on - you may find other ways of dealing with them.  Also, certainly the severity of the condition will dictate the length of time involved.  What I will say though is that my goal is to resolve the issue you came in with quickly and efficiently - and on average this takes about six months.

N) Do Therapists Have Flaws - You bet we do.  Two points on that.  First, woud you rather speak with someone who has experienced and understands the issues you are going through, or would you rather have someone who's had the life of Brad Pitt for example?  Second, the reason we don't talk about our flaws is that the session is YOURS, not OURS.  If we open-up too much, we run a number of risks including taking time away from your issues and making you feel less comfortable talking about certain aspects of your life.

O)  Can Therapists Read Minds - Alas, we once could.  However, now it seems that every time we try, we are now prompted for a password and the name of your favourite pet in school.

 


Brian BaumalBrian Baumal is a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario.
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