“You’ve Hired a Dog Trainer!”

Blake is furious. Yet, he’s remarkably composed at the same time.

“You’ve hired a dog trainer! I won’t take this anymore! What’s the therapist’s phone number?”

I give him the number and Blake calls the new therapist that the hubby and I have been seeing to help us work on getting Blake moving toward functioning. Our boy has been spending all day in bed and all night up doing who knows what. I see him for dinner and before I go to bed. He has few activities. He’s miserable.

Blake gets the therapist’s voice mail system. He leaves a message saying he doesn’t agree with what the therapist has his father and I doing. Blake suggests we all need to meet to talk this over.

Why Hasn’t He Called?

Nearly a week has passed and Blake has grown impatient. The therapist has not responded to his voice message.

“Why hasn’t he called back?” he wonders.

I have my suspicions. Blake rejected therapy when we brought him in to see this therapist. Now the hubby and I are the patient – in a manner of speaking. I imagine the therapist wants to talk to us first. We’ve been slowly implementing increasing demands on Blake. Each comes with an unpleasant consequence that targets his OCD if he does not participate. He’s gotten furious with each new step, but he’s been complying.

When the day of our appointment arrives, Blake demands to come with us.

“You’re welcome to come,” I tell him. “I’m sure the doctor will want to talk with Dad and I first. You might be invited in. You might not.”

“I’m willing to take that risk,” he says.

The Appointment

We arrive at the appointment and the therapist, the hubby, and I talk this over.

“Let’s see what he has to say,” the therapist says. “If he is willing to work with us, then we will have him stay. If he just wants to try to keep things the same, then we know he’s not ready to participate.”

He invites Blake in. Blake begins in a composed way, but he’s angry and he loses his temper. The therapist observes that our family spends a great deal of time going over what the problems are, but getting nowhere. He asks us to agree not to talk about the problems just until our next appointment. The hubby and I agree. Blake is having none of it.

“We have to talk about it! I can’t go a week without finishing this! I can’t! I won’t agree!”

And he storms out.

The hubby and I agree once more with the therapist that he and I will not talk about the problems or about what happened in the session. Blake is outside the building. He refuses to speak at all. He and I take off for home while the hubby goes back to work. Blake is silent for half the 45 minute ride home. Then, he apologizes.

“I’m sorry I exploded in there, Mom.”

“You were upset.”

“I know, but I really didn’t have a good reason to react the way I did. I agree. I’ll wait until next week to talk about things.”

“You’re coming back?”

“Yes. I’ll be there.”

So now Blake is in therapy with us. It’s not something he really wanted, but he wants more control than he’s had since the hubby and I have been going alone. That seems like a good place to start.

The First Step

Recently, after more than three years of Blake refusing treatment for his OCD, and for the depression that ensued later, the hubby and I made the decision to return to treatment. We didn’t give Blake a choice; we just told him we had an appointment with a specialist who might help us all find a way to do things in a better way. He entered the room on his own, but left in a rage after the therapist called us in to plan together (actually, he left when the hubby and I agreed to a plan the therapist had suggested). When Blake refused to return, the hubby and I became the patients, with the therapist directing us on how to shape our son’s behavior.

The first step was for the hubby and I to make a list of what Blake was not doing – where he was falling down in functioning (like sleeping all day and being up all night). We were also to list the things he was doing (for example, serving as a moderator for a special interest website) and, interestingly, what OCD behaviors we saw that he still had. That last part was odd to us. We hadn’t come to therapy to address OCD. We were more concerned that Blake was depressed and was barely carrying out the basic tasks of living. The therapist wasn’t as sure as we were that OCD wasn’t important.

When we showed up with our lists, he took time to review them.

“Let’s start with something Blake can be very successful at, like getting to the dinner table on time,” he suggested. “Now to chose what happens if he doesn’t make it on time. Hmmm… How bothered is he by the dogs?”

“Just a little,” we noted. “He always washes after he touches them, but it’s not like he runs to do it.”

“Okay, how about this? If he is late to the dinner table, you are going to rub a tissue on the dogs. Then you will break it into several pieces and place them on his bedroom floor.”

“What? How is this related to not getting out of bed?” the hubby wanted to know. “Why are we focusing on the dinner table and his dog contamination stuff when we want him to get out of bed?  And how does rubbing a tissue on the dog even relate logically to getting to the table on time?”

“It doesn’t.”

“Then why are we doing it? Shouldn’t the consequence be logically tied to the behavior?”

“Natural and logical consequences haven’t worked with Blake,” he reminded us. “We can’t try the same old thing.”

The hubby wasn’t convinced, but he was willing to give it a try. I was intrigued and kind of confused, but I understood that Blake had been unmoved by the natural consequences that had been coming to him, or any consequences that the hubby and I had employed that were logically connected to his behavior. The therapist wrote the plan down. All that was left was to inform Blake of the plan.

Blake Explodes

Blake was infuriated by this new plan. He didn’t even make it to dinner that night. He went upstairs to his room. He slammed his door and his shutters, and he threw things everywhere. Then he came back downstairs like nothing had happened.

The hubby and I carried out the consequence as directed. We didn’t make a big deal out of it to Blake. We simply quietly wiped a tissue on both our dogs’ fur, then cut it apart into several pieces. Then I went upstairs and placed those pieces on his floor. Blake responded by pouring Nature’s Miracle all over his carpet.

The next night, he showed up to dinner on time. And the next. And the next. And our dinners were actually pleasant. The hubby was still confused about the plan and wrote to our therapist.

Why again are we using Blake’s OCD as part of getting him to come to dinner? It just doesn’t make sense to me.”

Remember, Blake hasn’t been functioning and he hasn’t responded to regular consequences. We are trying to prevent you from having a 35-year-old who hasn’t launched.”

The rest of the week continued without incident. We felt just the littlest bit hopeful. It was a baby step. It wasn’t the big goal we wanted. We could only hope Blake would respond well to what came next.

Lifting the Fog

My Own Depression

In my last post, a little over a month ago, I shared that I was dealing with my own major depressive episode. The reason I haven’t posted is that, frankly, I haven’t felt able to write until today. Depression is one weird state of being. I’ve been here, but haven’t felt here. I’ve been going through the motions, doing the things I’m supposed to do (well, most of them) when one is depressed. I’ve been keeping my engagements, eating as well as I can, getting out for walks, trying to get enough sleep.

The thing is, no matter where I’ve been, or who I’ve been with, I haven’t felt present. I’ve laughed, but I didn’t feel the humor; I went to dinner with friends and talked, but I slowly disappeared from the conversation as I found it more and more difficult to interact. I slept, but I constantly felt as though I could fall right back to sleep.

Therapy. I went to therapy, too. Twice. The therapist was nice enough, but I don’t think that she understood the depths of my despair. My office mate, a seasoned child psychologist, says that she believes we psychologists make difficult patients. We know how to avoid, we are critical in the consulting room of what we are experiencing, and we are thinking ahead of the therapist we are seeing. Maybe that’s all true. So I’m looking for someone who can really call me on my stuff – someone who is more experienced as a therapist and parent than I am.

A Little Light

At the same time, just yesterday I experienced a little lifting of my mood. Even the hubby noticed it. The reason, I’m pretty certain, is that I found something that’s given me just the tiniest bit of hope, and the belief that there is something we can do to begin to make changes with what’s been going on with Blake. I feel just a little bit empowered.

A few weeks ago, while I was at a professional conference on anxiety, I met a very experience therapist at dinner one night. As we got to know one another and shared about our respective children, I shared a bit about what we are experiencing with Blake – days where he doesn’t get out of bed, his despair about life, his frequent missing events that would have been important to him.

“I’m not letting you go through this alone,” she said, reaching out to me, as she shared a bit of her own personal story. “This isn’t going to continue. We are going to get him help and I’m going to stay with you through the process.”

That evening, we plotted and planned. We agreed on who I should call. And I promised to stay in touch and follow through. Within a week, the hubby and I had an appointment with Blake with a longtime expert on kids and young adults who, like Blake, have a mixture of depression on top of OCD. What’s more, he’s had lots of experience with treatment refusers. We went with hope that, this time, Blake would agree to getting help.

Blake Rejects Treatment

Blake rejected treatment – no surprise there. On the way out the door he claimed to understand how “desperate” his dad and I are. He promised he would change things, but offered no concrete example of how he would do so. And then he fell asleep at 7 pm that very evening, missing dinner and sleeping until 3 pm the next day, forgetting he had a lunch date with his grandparents who were in town. And then he did the same thing the next day, missing his beloved grandparents once again.

Meanwhile, the hubby and I haven’t given up. Yesterday, we saw that expert on our own. He is prepping us to gradually work to increase the likelihood that Blake will enter treatment willingly and ready to work. We don’t know if it will actually work, only that we have several assignments to do ourselves over this next week. We also know that this will be itty bitty steps. Yet, I left the office yesterday feeling just the tiniest bit better. I have something to do, a direction to go in.

I noted to the therapist yesterday that the saddest part of the last two years is that we’ve been repeatedly told that there is nothing to do if Blake doesn’t want treatment. He shared with us his belief that the population of depressed/anxious young adults (and teens) whose lives are spiraling rapidly downward has long been neglected. For now, the hubby and I will be the catalysts for possible change. I understand that it is going to be a difficult road – but I’d rather be moving toward something than sinking deeper into the the muck that I’ve been in.

Exposure and Response Prevention (ERP) Comes to Our Home (Re-Post)

This post originally appeared on this blog in August of 2013.  It has remained one of my most viewed posts.  The photos of Blake’s hands are probably the most clicked on photos in this blog, and appear at the top of Google’s Images when you search for anything related to OCD and hand washing (and they appear to be the first “real” image of what can happen to a person’s hands when contamination OCD leads to hand washing). I thought it was worth re-posting.

* Advisory:  This post has some photos of hands damaged from over-washing.  They may be difficult for some people to look at.

This is a nearly empty bottle of liquid soap.

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It looks pretty normal sitting on the bathroom counter until you take a closer look.  That brown ring around the bottom of the bottle is dirt from our backyard.

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The bottle of soap caught my eye several days ago and I snapped a few photos of it to remind myself of where we’ve been.  This bottle, with its dirt that is settled all around the bottom has been with us this entire summer – since before I even began this blog.  It is a remnant of one of Blake’s last OCD treatment sessions before we made the  heavy-hearted decision to stop therapy.  I am sharing it with you today, as a way to share what Exposure and Response Prevention (ERP) can look like.

What is ERP?

ERP is “the most important therapy in CBT for OCD,” according to the International OCD Foundation.  In a nutshell, ERP involves a conscious choice for a person with OCD to confront the items (thoughts, situations, etc.) that create discomfort and then not do the compulsions or rituals that would normally be provoked.   The idea is for the OCD sufferer to allow his or her anxiety and discomfort to abate naturally, without using rituals to cope and thereby creating healthier ways of coping.  This is commonly done with the help of a mental health therapist who is trained to do Cognitive Behavior Therapy (CBT) with OCD (for more information, Click Here.  Janet at OCDtalk has also written a thorough post on ERP.).

In our situation, Blake was really struggling with hand-washing compulsions (in addition to many others).  It was particularly bad at the time and he ran to the sink to wash anytime he felt the slightest bit “dirty.”  No amount of salves or special creams could heal the damage he was doing to his poor hands.  Below are some photos of how his hands looked around the time.  A reminder, these are 14-year-old hands.  They are painful for me to look at.  Anyone who pokes fun at compulsive hand-washing or thinks it is a joke has never lived with a family member who is suffering because of it.  The pain is real, intense and it interferes with day-to-day activities.

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While Blake’s treatment team had done ERP work with him on the hand-washing at the office (they would touch “dirty” things and then he would not wash), we were seeing little impact of the exposures.  We all agreed at the time that Blake was “white knuckling” it through the exposure and avoiding truly immersing himself in it by reminding himself that he could wash as soon as he got home.  He never gave himself the opportunity to allow his anxiety to come down to a manageable level.  So, it was decided that one of his therapists would make the trip to our home.  The plan was for Blake and the therapist to “contaminate” our entire house so that Blake would not have a place of safety to run to in order to avoid his discomfort.

The Day Arrives…

Blake was in agreement with the plan, until the actual day arrived.  He was tired of painful hands and was hopeful that this exposure would finally put his hand-washing to rest.  He greeted his therapist, happily, at the door.  As they began to prepare for the actual exposure, he began to change his tune.

“I don’t remember actually agreeing to do this,” he told the therapist.  His anxiety was already on the rise, and he was trying to thwart the exposure from going any further.  His therapist and I reminded him of his desire to get better and advised him how important a step this was toward breaking free from the grip OCD had on his life.

Begrudgingly, he followed his therapist into the backyard where both dug into the dirt and began to put handfuls of it into a squirt bottle.  Then they returned to the house where they filled the bottle with tap water and shook it vigorously.  It looked like a muddy mess.  I silently gulped when I saw it.

Are you really going to spray that mess all over my house?

This was not going to be easy – and I really have no problems with dirt.  I can sit in it, get it under my nails, whatever…  But this – even I wasn’t relishing the idea of my house being sprayed with a bottle of dirty water.  The thing is, that was just the point.  Yes, it is uncomfortable to have dirt sprayed in your house.  It’s even kind of over the top.  BUT, it’s not going to kill anyone.  It is survivable – you can even thrive with dirt on your belongings.  The point for the OCD sufferer is to stick with the discomfort long enough to recognize that it abates and that they can have a good life without having to give in to their compulsions.

Reticent as I felt, Blake’s anxiety was rising through the roof.  He now wanted no part of this exposure.

“I changed my mind.  I don’t want to do it,” he stated.

His therapist reminded him that this exercise, as uncomfortable as it felt right now, was going to help put his OCD in its place.  She asked me to bring her all the bottles of liquid soap that were in the house.  I complied and sought them out.  Within a few minutes, I was back.  Blake was not in a good place.

The Battle Begins

While I’d been on my mission, Blake’s therapist had opened my bottle of dish soap (which Blake uses all the time to wash his hands) and poured a good amount of that muddy water right into it.  Blake was going to have none of that and before anybody could convince him otherwise, he’d dumped the entire contents of the bottle down the drain and placed the empty container in the recycle bin.

“Blake,” she reminded him, “we need to contaminate all the things you use to relieve your anxiety.  You remember; we talked about this.”

“No,” he said firmly.  “I don’t want to do it.”

She continued with her task and began to pour muddy water into the liquid soap bottles I had brought to her.  Blake’s face grew red.

“I said, ‘No’,” he stated.  “LEAVE.”

The therapist continued.  She was finished contaminating his sources of washing.  She took a rag and sprayed it with the dirty water.

“Come on, Blake.  Help me.  Let’s contaminate the house together. It’s better if you’re a part of this.”

NO! LEAVE!”  His voice was powerful.  Anxiety was making way for fury.

“Remember?  You wanted to get better.  I’m not going to stop because I care about you.  I care about your hands and I don’t want you to have to keep living with OCD bossing you around and controlling your life,” she told him.

THERE’S NOTHING WRONG WITH ME!!!!  I’M TIRED OF THIS!!! I’M TIRED OF BEING TOLD THAT I’M SICK!!!  SICK! SICK! SICK! LEAVE!!! GET OUT OF MY HOUSE!!!!”

Blake was absolutely getting out of control at this point.  He’d never said an angry word to his therapist before.  Now, he was screaming at the top of his voice and looking like a maniac. My heart was breaking for him.  I didn’t know whether to cry or burst out into giggles at the sheer anxiety the whole thing was creating in me.

His therapist continued with her quest.  She carefully wiped the dirty cloth over all the furniture, the walls and our personal belongings.  Our entire family was going to be in on this exposure.  But was Blake going to buy into it?

Blake Hits His Breaking Point

“I TOLD YOU TO LEAVE!!!  I CAN’T TAKE THIS ANYMORE!!  I’M JUST GONNA…”

Blake lunged for the pencil cup on top of the cabinet near him.  In one swift move, he pulled out the sharpest pair of fabric shears in the house and raised it up over his head, as if he were about to plunge it into someone.  But it wasn’t clear to me if he was going for his therapist or himself.

“Put it down, Blake!” I commanded, but my words weren’t necessary.  Blake’s hand hesitated in the air and his expression turned to horror and he began to tremble.

“What am I doing?  What am I doing?”

He ran down the hallway to the living room where he started sobbing.

“I’m sorry.  I’m sorry.  I’m sorry,” he repeated.

The therapist stepped outside to call her supervisor.  Blake looked at me through his tear-filled eyes.

“I wouldn’t have hurt myself,” he said.  “I just wanted her to stop.  I can’t believe how far I went to protect my OCD.”  He cried quietly for a few minutes until his therapist stepped back into the room.

“Do you want to talk?” she asked him.

“I’m so sorry,” he said.  “I wouldn’t have done anything.  I know what I need to do now.”

He walked down the hallway with a half-smile on his face and picked up the abandoned squirt bottle.

“May I?” he asked.

“Of course,” she answered.

He began to make his way through the house, squirting that dirty water on the walls and the countertops.  He covered his game consoles in it and his favorite sitting areas.  Tears streamed down his face, but now they were tears of relief.  He knew this was what he needed to be doing.  Then, he directed the therapist to his room.

“We need to do my room,” he told her and he contaminated his entire room with that water, making sure he didn’t miss a thing.

The Aftermath

Blake adjusted relatively quickly to his contaminated surroundings (although I did put away all sharp objects, just in case).  He didn’t care that there were pieces of dirt in the soap bottles.  He relished it when I reminded him that our entire home was contaminated.  He’d won another battle in the war on his OCD.  His hands healed.

But the other areas his OCD affected were untouchable.  He wouldn’t budge on them; held onto them like a badge of courage and battled us to keep them.  Of course, this lead to us ultimately discontinuing treatment and to being in the limbo that we are in.

Today I still find remnants of that exposure, though it is about 3 months in the past.  There are still places that are too high for me to reach where he aimed that squirt bottle – and I kind of like the bits of dirt that remain anyway because they remind me that we still live with contamination to some extent.  They also remind me how far Blake was willing to up the ante to protect his OCD, how powerful the disorder can be in asserting itself.  And I wonder when Blake will grow in his own power and desire to take it on.  We can only wait and see.

He’s Home!

Image courtesy rawich @ freedigitalphotos.net

Image courtesy rawich @ freedigitalphotos.net

Blake is home!  After nearly three weeks, our boy is back!  He is exhausted. He seems older and more mature in some ways.  He is struggling with re-entry, and he is still basking in the bliss that camp apparently was.  The stories are just beginning to come out, and I am sure we will learn the details of his time away over the next days and weeks.

I had noted that he never wrote, but he insisted, as we drove home, that he did write us one time.  Sure enough, a letter from him was waiting in the mailbox when we arrived at the house!  Leave it to Blake to conserve space.  Three letters (one for each of us) were written on one, postcard-sized notecard:

“For the sake of convenience,” it began, “I have divided this letter into three sections – one for each of you on the back.”

He continued, “I found out that writing letters is like showering at camp (one of those things you keep telling yourself you’ll do and then never do).”

Have I mentioned before that Blake is a character?  Needless to say, he had a wonderful time.  We did discover one reason why we almost never saw him in photos.  Apparently the camp was very generous in taking his group off-grounds for camp outs and activities. One trip was to an amusement park within five minutes of our home!  It was on this trip that Blake once again found that his Exposure and Response Prevention (ERP) treatment experiences for his OCD came in handy.

Image courtesy of anat_tikker at FreeDigitalPhotos.net

Image courtesy of anat_tikker at FreeDigitalPhotos.net

“It was really cool,” he told me.  “There were kids in my group that were terrified of roller coasters.  I got to be a helper.”

“How did you do that?” I asked.

“I talked to them in line about facing their fears.  I let them know what to expect.  Then, as we got close, I told them that the choice was theirs and that this was a real opportunity for them.  And then, they always got on the ride!”

“And they ended up being glad that they did?”

“They did!” he said.  “It’s funny. I think I got to feel what it was like for you and Dad coaching me on facing my fears.  I got to do what you did.”

It sometimes amazes me that Blake still holds on to what he learned in treatment.  He recognizes the importance of standing up to a fear and not giving in to discomfort.  These are some of the basic tenets of OCD treatment, and he has no problem implementing them with others.  Then he basks in watching their success.  I wonder to myself what this is about.  Is he practicing with others so that he can keep himself sharp?  Will he actually start using these tools that he has with his own OCD one day?  I don’t know the answer; only time will tell.  Still, I’m happy what he learned in treatment helped him to get closer to others, and that, maybe it made their lives just a bit better for knowing him.

Welcome home Blake!!

Finding a Therapist

Image courtesy David Castillo Dominici at freedigitalphotos.net

Image courtesy David Castillo Dominici at freedigitalphotos.net

A little while back, one of my wonderful readers asked if I would write a post about finding a therapist who treats Obsessive-Compulsive Disorder.  I thought that was a wonderful idea.  I know how confusing it can be to find a therapist to treat yourself or a loved one.  It’s tough for me – and I AM a psychologist with plenty of connections in the mental health community.  It can be that much more confusing when you don’t know the lingo or what to even look for.

What I am sharing here is a combination of my personal experience in obtaining treatment for Blake, as well as suggestions from wonderful resources such as the International OCD Foundation (http://ocfoundation.org), the Anxiety and Depression Association of America (http://www.adaa.org), and the Association for Behavioral and Cognitive Therapies (http://www.abct.org). Please take it as just that, not as a perfect guide for finding a therapist.  Ultimately, it is best for you to make a carefully thought out decision that you determine fits you or your loved one best, perhaps with input from a medical or mental health professional who you trust.  That said, here are some thoughts I have:

Ask Professionals You Trust:

Many times, our own doctors or friends we know who are mental health professionals know people who treat OCD.  If there is a professional in your life who you trust, ask them.  When I reached out for help for Blake, I called another therapist friend who had noticed Blake’s OCD symptoms.  She had mentioned to me that she knew a child psychiatrist who specialized in OCD.  I am personally asked by friends and acquaintances all the time for referrals to therapists for different types of issues.  And I am very happy to assist if I am able.

Contact Professional Organizations:

Mental Health professionals who are dedicated to treating Obsessive-Compulsive Disorder and anxiety disorders often belong to specialized organizations, such as the International OCD Foundation, the Anxiety and Depression Association of America, and/or the Association for Behavioral and Cognitive Therapies.  If you live in a country besides the United States or Canada, search for organizations in your country that are for therapists who specialize in treating OCD, anxiety, or in Cognitive Behavior Therapy.  Many of these have a part of their website where you can actually search for a therapist who specializes in treating OCD in your area – or nearby.  Or you can call the organization directly and they will help you locate a therapist.

Interview Therapists on the Phone:

Most therapists are happy to speak with you on the phone before you decide to make an appointment.  Choosing a therapist is a very personal decision and no one therapist fits all. If it is possible, speak to more than one therapist who treats OCD.  Ask questions about the therapist’s approach to treating OCD, as well as their training and background.  Specifically, are they trained in Cognitive Behavior Therapy – Exposure and Response Prevention?  Find out how loved ones are included (or not) in treatment.  How much of their practice is devoted to treating OCD, or anxiety disorders?  What is their attitude about medication (experts will generally say that it is best if the therapist is open to it as a potentially beneficial part of treatment)?

When I made that first call to the psychiatrist, he personally phoned me back and took time to assess the situation.  Based on what I shared, he believed that Blake could begin with a psychologist (which would also be more cost effective) and he referred me to one.  That therapist also personally returned my call and spoke with me about the situation before we decided to proceed with treatment.

Assess Your Own Level of Comfort:

When you’ve interviewed a therapist, ask yourself how comfortable or confident you feel about the therapist.  This is important.  This is someone you, or your child, will be sharing personal information with and who will be asking you (or them) to do things that make you feel uncomfortable.  It is essential that you feel comfortable and confident in order to create a strong working relationship.

I recall having felt so heard on the telephone, both by the psychologist, who we ultimately saw, and by the psychiatrist we spoke to first.  The psychologist even spent time educating me about OCD during our conversation and referred me to a helpful website and to books that I could order that would help me to help Blake.  Before we ever met, I was confident that both individuals could help my son and our family.

Educate Yourself:

This is not so much about finding a therapist, but it will certainly help.  One of the best recommendations I received when we realized that Blake had OCD was to read about OCD from reputable sources, like the International OCD Foundation, and to obtain books on treating OCD in children.  Learning about the disorder yourself helps you to know what to expect from treatment and to understand what is happening in therapy and why.

These are just a few thoughts I have about finding a therapist.  I hope that they are helpful.  Here are a couple links to more information on finding a therapist to treat OCD:

– International OCD Foundation:  How to Find the Right Therapist

– Anxiety and Depression Association of America:  Choosing a Therapist