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Murrell Counseling Service, LLC

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Understanding our "Fight or Flight Response" of our Limbic System

Posted on March 9, 2013 at 9:36 AM Comments comments (26345)
Many of you have asked me to explain in more detail why we have anxiety issues and in furthering our understanding what are the basic strategies for controlling anxiety.  The most important element in controlling anxiety is to have a firm grasp of the physiology involved in the anxiety reaction that is often referred to in popular literature as "the fight or flight response".  I will give you a broad understanding of this important but very primitive reaction that we all possess by directing your attention to a specialized part of the brain known as the limbic system (it is the area colored in red in the illustration below).  The limbic system is a part of the brain that lies in the middle of our head a few inches behind our forehead.  It is composed of a number of smaller organs that together act as an alarm system that monitors anything outside our body that may pose a threat to us. 
 
Our five sense organs are highly attuned to anything that looks like, smells like, sounds like, tastes like, or tactilely feels threatening to us.  For that reason we involuntarily respond, even as infants, to loud noises or being suddenly dropped. The limbic system has a very powerful reaction our sense of being threatened.  If we feel that we are in danger, of any kind, the limbic system sounds the alarm and our body is immediately put on high alert.  It is the equivalent of a car alarm going off in a parking lot.  If someone tries to break into the car the alarm detects the attempted entry and sets off the car's lights and the horn starts beeping until the owner comes to investigate the situation.
Brain limbicsystem is important to undersand for clients if they are to be able to control their emotional reactions to stressful situations.We are physically prepared to "fight or flight" and we instantly have an enormous amount of energy available to us to either run away from danger, attack it head on, or if we don't know what to do to "freeze" and hope it goes away.  If you are familiar with the animal kingdom you see what happens when their respective limbic systems respond.  You may notice that predators (ie. lions, tigers, bears) all naturally go to the "fight" response.  Their prey on the other hand may go to the "flight" response (ie. deer) or "freeze" response (ie. rabbits). If you were to hook up the medical equipment to each of these animals you would find that all of them have the same kind of physiological activity that we experience as humans when we feel anxiety.  That is, our hearts begin to race, our breathing becomes shallow and rapid, our muscles all tense, we become easily startled and feel extremely tense to the point that all we can think about is how to resolve the perceived threat and find a safe place to calm down.
 
Our central nervous system goes on high alert (psychologists call this state "hypervigilance") and our endocrine system opens the flood gates of a number of powerful biochemicals, such as adrenaline and cortisol, that cause our hearts to race and muscles to suddenly tense. 
 
As we grow older our limbic system encounters other situations that it adds to the list of "dangerous or threatening" events.  This may include being punished for wrong doing by a swat on the bottom or being beaten up by the neighborhood bully on the playground at school.  Whatever the event may be, the limbic system adds that information to an emerging data base that remains in our unconscious mind for the rest of our lives.  As we continue to experience life we add new experiences, and new information, to the limbic data base of threatening situations.  This may include failures in taking an academic test or being rejected by our first attempts at romantic love.  Note here that the threat may not be a physical threat but rather a threat to our sense of well-being or our feeling that we are accepted and loved by others.
 
As we age we gather more and more data into the Limbic System information storage (which remains in our unconscious mind but instantly available).  The limbic system therefore begins to have a large number of situations that cause the "fight or flight" response.  This may include anxiety about taking tests, meeting new people, public speaking, taking elevators, being on high places, or spending time alone.  Notice that none of the list of situations listed above involve actual physical threat even though the limbic system response is a physiological one.  In other words, the limbic system is a "one trick pony".  Meaning that no matter what type of situation it is that we perceive to be threatening (meaning it may be a threat to us socially or psychologically) the limbic system always treats any perceived threat as if it were a potential physical threat to our very survival.  For this reason we over react to many things in our lives simply because this primitive part of our brain has encoded some aspect of the situation as being related to a past incident that caused us some level of emotional if not physical pain.
 
As a result we get a large number of "false positives" in our daily lives.  That is we react to things that may or may not be at all threatening as if they were in fact life threatening.  It like having a car alarm that goes off every time someone may bump the side of your car in a parking lot with their car door or a shopping cart.  The car alarm misinterprets this as if someone is trying to break into and steal your car.  In other words, it over reacts in much the same way our own limbic system does.  In both cases the car alarm and your limbic system are taking no chances; they will try to protect you even though they are over reacting in the extreme.
 
The net result can be that you become afraid of so many things that are encoded in your unconscious limbic system data base that you feel anxiety so much that you are afraid to live. The limbic system is so very sensitive that it only requires an image of something threatening to get a "fight or flight" response.  For example, if you are watching a movie and there is violence you may notice that your limbic system has misinterpreted the images on the screen to be categorized as a threat.  When you are deeply involved in a movie, novel, television, video game, radio program, or even a conversation your limbic system is busy examining the content of the thoughts and images presented for any indication of threat. It is not just the external images of something threatening but even our own thoughts that can be the triggers of the "fight or flight" response.  For this reason we can wake up with nightmares when our unconscious mind is replaying a scary movie or perhaps a scary event in our own life.
 
Producers of drama know exactly how to push the triggers of the limbic system so that we get the partial arousal of the "fight or flight" response so that we experience it as stimulation. Consider your favorite adventure movie and remember what you like the best. If it the chase scene?  Chase scenes alert our limbic systems when we identify with the person being pursued and we experience some heightened alertness as we feel ourselves tense up. We may have that same rush of adrenaline when we voluntarily participate in sports involving some risk.  I think one of my exciting experiences is when I get to go snow skiing at night in the Rockies.  I feel the adrenaline rush when I am zooming down slopes at high speed sensing the danger but loving the intense feeling of being alive in a beautiful mountain night.  It is deeply satisfying to experience the beauty of the mountain, the risk of skiing at high speed, the feeling of controlled falling, and the pleasure of accomplishing something of an adventure. The difference between excitement of skiing and the unpleasant feeling that comes with being stressed out or anxious is one important element: the feeling of being in control.  Scientists have studied what determines the difference between what is exciting or thrilling and what feels dangerous is the feeling of being in control of the situation.  This is most obvious when you interview someone who enjoys a particular sport (skiing in this case) and then interviewing someone who is scared to death to attempt such a sport.
 
On the one hand life involves risk.  However, choosing the risk and overcoming the challenges that it entails is one of the great satisfactions in a life well lived.  The truth is we need to challenge ourselves to feel life more deeply.  It is not unlike what occurs when you practice weight lifting.  Lifting weights actually makes microscopic tears in the muscle fibers.  However, the muscles quickly rebuild themselves and after a couple of days rest the body has repaired them so they are stronger than they were before you weight lifted.  The repaired, and stronger muscle, is then subjected to weight lifting again and the process is repeated so that after several months the muscles are much stronger than they were prior to the practice of regular weight training. In the same manner our mind is built to need a certain amount of challenge, or stress, in order to function at it's optimum.  To totally avoid the stress of triggering the "fight or flight" system would be to live a very safe but ultimately boring existence and to rob yourself of the satisfaction of overcoming your fears.
 
As Emerson once said, "Life is an experiment.  The more you experiment the more you learn. So the more experiments you do the fuller your life."   If you view each risk you take to try to overcome your fears as an experiment,  then journal about and analyze then your can disconnect the limbic system's natural response to try to overprotect you from death and danger.  Taken to an extreme, your limbic system can keep you from being fully alive.

Understanding Ego State Therapy

Posted on February 2, 2013 at 1:43 PM Comments comments (16430)
Ever wonder why you act differently when you are in different situations?  For example, let's suppose that you are at a party with close friends and there is allot of laughter; chances are you will feel free to laugh and tease each other much like you might have done as a child.  If you are in such a friendly nurturing atmosphere you might say, "I'm free to be myself today."  You might find yourself dancing around, making faces, telling jokes and in general having a good time. At the party you might think to yourself, "I feel really happy and excited to be with my friends."
 
Now contrast these emotions and behavior with what you would probably display at a funeral of a family member or close friend.  What is "proper behavior" at a funeral is very different than what would be appropriate normal behavior at a party wouldn't it?  At a funeral you would wear formal clothing, allow your sad feelings to be expressed in your emotional expression and behavior.  At the funeral you might be thinking, "I am so sorry that this happened; I hate that death has taken my friend that I already miss so much."
 
In a third setting, let's say that you are at work, you might find your emotions and behavior entirely different than at the two previously mentioned situations.  If you are at work then you are expected to do what?  Well get to work for one thing.  In other words, start using your mind to solve problems and provide a service to your employer.  If you are in a "white collar job" then you will likely be asked to sit in an office and solve problems for your employer.  If you are in a "blue collar job" then you may be asked to do more physical work.  In either case your work setting will expect a focused rational and disciplined effort on your part that engages a very different part of your personality than you would be expressing at a party or funeral. At work you may be thinking, "I've really got to stay focused on this task in order to make this deadline on time.  I'm feeling very anxious and tired but I've got to push myself to get this job done."   Notice how different your emotions and behaviors are in these three settings. 
 
What we have just discussed is that you are capable of acting in three completely different ways as you adapt to the various expectations of three different situations.  Had you been the patient of Freud he would have explained to you that you were engaging different sub-personalities or ego states.  The first ego state, at a party setting, would be expressing your very positive emotional needs for happiness and companionship. He referred to this ego state as the "Id". That is the part of your personality that is most concerned with expressing feelings openly and seeking pleasurable activities.
 
The second ego state, the one displayed when at a funeral, he would have labeled the "Super-Ego".  This is a part of your personality that you in effect downloaded in childhood from watching adults behavior in serious situations.  It is the sub-personality that contains all of your personal values and beliefs about what is ethical behavior.  It is the part of you most concerned with following the rules.
 
The ego state that you utilize in your work setting Freud called the "ego" or you might think of as your most rational self.  It is the part of you most concerned with making good choices and consequences in your thoughts as well as your behavior.  This is the part of your personality that you develop only after childhood.  You generally do have the developmental capacity to think logically until middle to late adolescence.  This means that until you reach the teen-age years, or perhaps even much later, you are not physically or psychologically developed well enough to make good decisions.
In therapy it is the "ego" sub-personality that the psychologist works with to gain better control of your emotions and behavior.
 
Most of you readers are familiar with the work of Dr. Sigmund Freud who was the founder of Psychoanalysis.  Although he died long ago, in 1939 at age 83, his influence was felt for many decades after he published his landmark book, "The Interpretation of Dreams" in 1899. He was a brilliant man born in what is now Czechoslavacia and later established his clinic in Vienna, Austria.  Freud's theories about how the mind worked changed the world of mental health treatment treatment. Prior to Freud the predominant psychological theories focused on the study of what was observed to be the ability of the human mind to learn and develop new habit.
 
What Freud described in his writings, and practiced in his therapy, was a novel approach to understanding the human mind.  His view was that all of your thinking was essentially an internal conversation between these three ego states or sub-personalities.  He viewed mental health problems as simply a lack of balance between these three parts: the Id, the Ego, and the Super-Ego.  He viewed the Ego in healthy personalities as being the most important of the three sub-personalities.  A lack of Ego strength in his view led to problems that were manifested in the patient's emotions and behavior.  If the Id was the most powerful of the three then the patient would be very impulsive and "act out" in order to satisfy their need for pleasure.  The Id does not have the rational capacity to understand or care about the consequences of your behavior.  Therefore it can be dangerous to let the Id be the dominant voice in your thoughts.  You may here yourself thinking, "I don't care about what happens later; I just want to do this right now!"  This can obviously lead to significant behavior problems.  When you have an overactive Id have problems with impulse control and often complain being of the negative consequences of their behavior.  When asked why you did something because your Id was in control you might find yourself thinking, or even saying out loud, "I just couldn't help myself."
 
Conversely if your Super-Ego is in control at the moment you will be focused on doing the right thing.  If you tend to be a perfectionist you know this experience well.  You will find it hard to accept anything less than perfection in your performance.  This may be manifested by workaholic behavior or simply the lack of balance between work and play.  If you were a client who are referred to me for anxiety issues you would probably have an overactive Super-Ego that doesn't allow you to ever enjoy relaxing.  You would be tired, depressed and anxious about your behavior if it fell short of your very best effort.  If you are a perfectionist you might hear yourself thinking, "I'm never doing enough. I will just stay at this task until it is perfect."  The problem is if you are a perfectionist you think this way about almost every task in your life.  Everything becomes a challenge that you feel driven to demonstrate and prove your worth by the high quality of your performance.  You would become, what psychologists often call, a "human doing" instead of a "human being."  Learning to just "Be in the Moment" and focus on what is happening in the present is very difficult for perfectionists.  Mindfulness meditation is a very good practice for perfectionists and you can find articles about this on the Internet.
 
The difference between high functioning individuals and those who suffer from anxiety or depression is that the high functioning persons have a balance so that each of the ego states is given appropriate expression.  For this reason journaling or keeping a diary is a good coping skill.  It allows you to read what you are thinking and feeling.  This allows you to see what each of your ego states is contributing to your flow of thought.  I hope this gives you some useful information about understanding yourself.  For more information I recommend the book, Ego States by Drs. Jack & Helen Watkins published by W.W. Norton Books and copyrighted in 1997.  This is a growing field within clinical psychologists who practice E.M.D.R. and the two fields of study are often used simultaneously in psychotherapy.

FEAR: False Evidence Appearing Real

Posted on August 1, 2012 at 8:15 PM Comments comments (1863)
Much of the work with my clients is directed at their understanding of the importance of introspection and thought monitoring.  By this I don't mean that my clients are supposed to withdraw from the world and spend all their time sitting under a tree like Budda without interacting with other people.  But the sad fact is that many of my clients suffer from crippling levels of anxiety and fear about what may happen to them if they "get a life" and move from simply surviving to thriving.  In other words getting back into the stream of life and enjoying doing things that they might have been afraid to do.  Much of their fear and anxiety is based on their past experiences in which they suffered some trauma that they seemingly cannot forget.  This keeps them stuck in what I call an "emotional foxhole" in which they can't get hurt by anyone but they aren't really free to live and enjoy their life.  One of the acronyms that I find helpful is to remind them that much of what they fear may happen in the future is based on events that happened to them in the past that they are no longer in danger of letting happen again.  Many individuals who as children or adolescents suffered from bullying, abuse, or frequent rejection have unconsciously assumed that they will always be bullied, abused, or rejected whenever they move out of their "foxhole".  However the fact is that as adults they have many more skills and experience than they did as children and they don't have to stand for any more abuse.  It is not the reality of their present situation that they are focused on but rather the unreality of feeling that they are still helpless, unassertive, and unsupported that keep them in the "foxhole".  In short, it is their fear that keeps them stuck. However, when  remind them that they can now as adults, walk away, call 911, learn to be assertive or even aggressive if needs be, it may not be possible in the clients mind to overcome their fear.  If you think of the perceptions of childhood or adolescence when most abuse occurred it was at a time when most of us thought only with our emotions and had not developed our logical ability to see things objectively.  It was a time when a part of our brain, the limbic system, was recording all of the events around us that were associated with being threatened (either physically or socially threatened) and this recording stayed with us for life.  So as a result anything that looked like, sounded like, smelled like, tasted like, or felt to the touch like a threat our limbic system reacted to with either flight, fight, or freezing our bodies.  Yet as children we were prisoners of our emotional perceptions and often took things personally that had nothing whatever to do with us. It was much safer for us as children to believe that "there's something wrong with me" than to begin to ponder whether our parents were the real problem.  Even if our parents were alcoholics and incompetent as parents it was dangerous for us as children to question whether our parents knew what they were doing.  We needed to believe that our parents were competent to be parents and that they knew what to do to take care of us.  Unconsciously as children we knew that we weren't developed enough to be able to fully take care of ourselves and become independent.  So we unconsiously made the decision that we would blame ourselves rather than our parents if our family was dysfunctional. It was too scary to think that our parents were incompetent.  For our own peace of mind as children we had to believe that our parents were God-like figures who knew exactly what they were doing.  If we began to question their competence at too young an age we would simply feel more anxious when we then realized how much at risk we were to be in a family run by very abnormal people who masquaraded as competent reliable parents.  So our learned emotional behavior for many children and later as adults was to live in fear.  The sad truth is that many of Americans, clients or not, live in a constant state of fear and are not even aware of it's impact on their emotional as well as physical lives.  So the next time you find yourself afraid in a situation that you intellectually know is an irrational fear from the past just remember this blog and what FEAR really stands for.
 

Understanding the Power of Thought

Posted on October 16, 2011 at 11:00 AM Comments comments (18835)
Dr. Michael Murrell in his offices at 1358 E. Kingsley, ste. B, Springfield, MO 65804.Ever ask yourself the question, "What am I thinking and how does it effect me?"   If you haven't asked yourself that question then I would invite you to do so right now.  The reason for my suggestion to begin this self observation is that your thoughts are very powerful and have a great impact on the quality of your life.  As a psychologist I have come to believe that your thoughts play a very large part in not only what you think but also what you feel.   Consider the possibility that every thought you entertain in your mind has an emotion attached to it.  That is pretty obvious when you consider that for example looking at a photo of a loved one will often bring a smile to your face because you experience some form of a positive emotion (ie. joy, happiness, calm, euphoria).  
 
Have you ever played with dominoes as a child?  Did you ever set them up on their ends in rows and topple the first domino just to watch the one next to it fall and cause a chain reaction in a line up of dominoes?  If so then you can imagine that your thoughts are the first domino in a line of dominoes, set up vertically, in a row.  The domino next to thought would be your emotion; so in many cases what you are feeling emotionally is the result of what you are thinking about.
 
The next domino in the chain would be your behavior.  In other words, behavior is an outward expression of your thoughts that trigger a feeling or emotions, that is the source of your movement or behavior.
 
The next and final domino in the chain would be your physiology or bodily functions.  That is to say the way your body feels (tense or calm) and the way it functions (pleasantly or in pain).
 
In effect then your thoughts are the prime controller of your emotions which, taken together, control your behavior, and ultimately effect your health.
 
If I have a client who comes to therapy complaining of anxiety or depression one of the first topics we will discuss after their assessment is the subject of their thought life.  Often clients are unaware of what they have been thinking about and how strongly it effects them.  If, for example, they are thinking about how inadequate or unattractive they are then they will find themselves emotionally responding to these thoughts will very negative emotions of anxiety and/or depression.  Many clients have a very negative view of themselves and have done so for years without ever being aware of how toxic such a habit is their their emotional and physical well-being.
 
To demonstrate this to yourself you may wish to try a small experiment.  I am going to invite you to make a list of your four best moments in your life.  Take your time and think about that subject.  You may list the day you got married, or the day your had your first child, or the day you achieved something that you worked very hard to accomplish.  After you have made your list find a comfortable and quiet time to just look over your list and think about one of these events.  Close your eyes and really let yourself go back in time and remember all the details of the event.  What did you see?  What did you hear?  What did you smell or touch or taste that made this moment so memorable?  Also remember what you were thinking  and feeling about yourself at that moment.  Were you thinking, "This is great! I am so proud of myself for accomplishing this!"  Perhaps you were thinking, "I am so lucky to be here and to be alive."   Whatever your thoughts are notice how strongly they trigger your emotions.
 
You can do this experiment on a regular basis to practice controlling your thoughts, calming your emotions with positive feelings, and giving yourself a brief mental vacation when you want to reboot your attitude. Your attitude is really a combination of your thoughts and feelings.
 
I'd like to share a message from Rev. Charles Stanley about attitudes.  He stated in one of his famous sermons, "The longer I live, the more I realize the impact of attitude on life. Attitude, to me, is more important than facts.  It is more important than the past, than education, than money, than circumstances, than failures, than successes, than what other people think or say or do.  It is more important than appearance, giftedness, or skill.  It will make or break a company...a church...a home.  The remarkable thing is we have choice every day regarding the attitude we will embrace for that day.  We cannot change our past...we cannot change the fact that people will act in a certain way.  We cannot change the inevitable.  The only thing we can do is play on the one string we have, and that is our attitude....I am convinced that life is 10% what happens to me and 90% how I react to it. And so it is with you.  We are in charge of our attitudes."
 
 

Desensitization for Anxiety

Posted on August 21, 2011 at 11:17 AM Comments comments (7891)
Research has shown that one of the most effective ways to treat anxiety is what is called desensitization or exposure therapy.  Simply stated this simply means that you overcome your fear by first of all clarifying what you are afraid of and then design a program with your psychologist to do establish a list of steps to overcome your fear.  For example, let's suppose that you were in a severe car wreck and as a result have a great deal of fear about driving.  This is not an uncommon response.  There is a part of everyone's brain (the limbic system)
 
that acts as a self-protective device that remembers everything associated with a traumatic experience.  In other words, anything that looks like, sounds like, smells like, tastes like, or feels like it was associated with the traumatic experience causes anxiety.  The limbic brain is saying in effect, "Watch out! Remember the last time you experienced these sensations you experienced severe pain."   This self-protection device can keep us from danger but it can also significantly interfere with the rest of our lives if we allow it to overcome our reason.  In our example the person in a car accident may rationally want to return to driving, which makes their life infinitely more convenient, but the limbic brain keeps sounding the alarm so they feel overwhelming anxiety at the thought of getting in a car and driving by themselves.
 
Working with a skilled psychologist can be very helpful with anxiety problems.  In the above case the client was able to drive after about five months of therapy by approaching the problem systematically in small steps.  They first of all simply learned how to relax themselves using deep breathing, biofeedback, and guided imagery. They started by imagining themselves sitting in their car and feeling their anxiety heighten.  Then they used the techniques listed above to reduce their anxiety to a manageable level.  They next moved to actually sitting in their car and again used the techniques to reduce their anxiety to a manageable level.
 
Eventually they step by step overcame their anxiety as their experiences moved them closer and closer to actually driving alone.  It was the slow but deliberate process of exposing themselves to situations that initially frightened them and then learning to relax themselves that was the key to their returning to full functioning as a driver who had the freedom of the road and actually enjoyed taking road trips!
 
This same technique has been proven to be successful for any number of clients who have overcome their fears that resulted from a past trauma (ie. domestic violence, a painful loss, a childhood or adult history of abuse, or a combat related loss).  The basic tenant is that the limbic brain, in trying to prevent a reoccurance of a trauma, can become an impediment that needs to be treated in order to restore the reduction of anxiety as well as the freedom to experience life to the fullest with only a normal level of manageable anxiety.

What to expect if you are a New Client for Counseling

Posted on February 9, 2011 at 3:49 PM Comments comments (5027)
If you are a new client who has never been to see a mental health professional, the first time that you come to our waiting room it is quite normal to feel a little nervous.  For that reason our office manager, Brenda, takes extra care to make our new clients feel welcome.
 
Brenda has been a mental health professional for more than nine years and she will in all likelihood be the first person that you will meet when you come to the front desk.  She will first of all ask you if you would like a beverage (ie. coffee, soda, or water) while you are filling out your paperwork.  You will need to bring your insurance card if you are going to use health insurance and a drivers license or other form of identification.
 
You will be asked to fill out a basic information form, a short written outline of what to expect in therapy, and a short form that asks you about which of the 90 possible symptoms you are experiencing.  This will take only a few minutes but we ask that you come 15 minutes before your scheduled visit to be sure that you have ample time to fill out these forms. 
 
I will come out to the waiting room to greet you and take you back to my office.  It is a large "sage green" room with comfortable chairs, large floor to ceiling windows that overlook our parking lot.  The first meeting is really a "getting to know you" session in which you get a chance to ask me questions and I will ask you some as well.  I always encourage clients to speak whatever is on their minds and know that whatever their feelings, thoughts or opinions are they are welcome to speak freely in my office.  Psychologists are bound by law to practice strict confidentiality and cannot divulge anything directly to another person without the permission of their client.  This frees up the client to be quite open about whatever is the therapeutic issue that needs to be addressed.
 
The first session or two will be an opportunity for the client to decide if they feel comfortable with the psychologist (if my clients don't feel comfortable I will gladly refer them to another psychologist) and for the psychologist to develop a diagnosis as well as a treatment plan.  Just a physician must make an accurate diagnosis in order to precisely treat a physical disease, so a psychologist has to ask many questions and perhaps do some evaluations in order to diagnose and treat emotional issues as well.  Insurance companies require diagnosis in order for them to pay the psychologist so it is important work that must be done in the first few sessions.
 
Many clients state that after a few sessions they "feel very safe" coming to counseling, also called psychotherapy, and look forward to the opportunity to unload thoughts and feelings that they may not be comfortable sharing anywhere else.  Last week I had one client who stated that she "immediately felt better just walking into our offices" after she had a very stressful day knowing that she could look forward to 50 minutes of time to talk about anything that was bothering her.
 
It may take only a few sessions to achieve the client's goals in counseling or it may be months or even years before they are satisfied with the changes that have taken place in their lives.  In many cases E.A.P. (Employee Assistance Plans) will pay for five or six free visits and that may be all that is required to meet the behavioral changes that are the goals of the client.
 
If you have any questions about counseling or psychotherapy please call the office at 881-1580.
 

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