Exposure Therapy

People say that the best way to overcome a fear or phobia is to bite the bullet and face it head on. Facing your fear is somehow supposed to make you less fearful.

Is this good advice?

Yes. Overcoming fears and phobias by facing them directly is the foundation of exposure therapy, a psychological intervention used when a person has a severe and debilitating reaction to a certain stimulus (object, animal, or context). Exposure requires the person to interact more and more closely with the feared stimulus until they’re no longer scared.

How does it work?

1) Exposure therapy is based on the tenet that fears and phobias are learned relationships. That is, the feared stimulus isn’t inherently scary, but is something that you learned was scary through a dramatic or traumatic experience. For example, I flew easily many times as a child, and wasn’t scared of flying until I was 15 and experienced severe turbulence on my very first plane trip alone. It only took five terrifying minutes of thinking I was about to die for me to learn a relationship between airplanes and danger, and for years subsequently, I cried in fear through every plane trip. Similarly, a 12-year-old with a dog phobia may have loved animals until she was ten and was bitten by a scary dog, requiring an ER visit and stitches. That one experience was enough for her to learn a relationship between dogs and danger, and now she feels automatic fear at the sight of any dog. Think similarly of someone who enjoyed driving, but became scared to drive following an accident.

Exposure therapy works by helping you unlearn the relationship between the feared stimulus and danger by repeatedly exposing you to the feared stimulus in the absence of danger. If the girl with the dog phobia interacts enough times with a dog without the dog doing anything menacing, the relationship between dog and fear will fade and will be replaced by an association between dog and neutral or maybe even dog and friendly. The person who had a car accident is encouraged to keep driving until he unlearns the association between driving and accidents. Sometimes exposure therapy happens naturally: In the past 15 years, I’ve taken many plane trips without incident. Through repeated exposure to flying in the absence of danger, I’ve largely unlearned the relationship (although whenever there’s turbulence, the old relationship is reinforced and I make strangers hold my hand).

2) Exposure therapy also rests on the principle of habituation. Habituation refers to the fact that it’s impossible to maintain an elevated level of anxiety for a prolonged period. That is, no matter how anxiety provoking the stimulus, your racing or pounding heart, sweaty palms, and dry mouth will always fade naturally if you wait long enough. For example: the girl who is scared of dogs sees a dog coming toward her on the sidewalk. Her heart races and she feels dizzy with fear so she crosses the street. Her symptoms abate, reinforcing her idea that the dog was dangerous. Through avoidance of the feared stimulus, she denied herself the opportunity to experience the physiological inevitable: that her heart rate, breathing, and blood pressure would have automatically returned to baseline even in the presence of the dog. Habituation to a feared stimulus decreases fear, whereas avoidance maintains it; exposure therapy forces habituation.

Final point: Exposure therapy is almost always gradual (e.g., looking at a picture of a dog, hearing the sound of a dog barking, being in the same room as a dog, approaching and petting the dog, letting the dog lick your hand). You may have heard of flooding, a type of non-graded exposure designed to stamp out your fear in one shot (e.g., a person with a snake phobia would be enclosed in a room with fifty slimy but benign snakes). Flooding is effective, but it can also be traumatic and there is a greater risk of spontaneous recovery of fears; graded exposure is appropriate for the large majority of phobias.

Resolutions Resolved

One month after New Year’s, a lot of us are assessing how we’re doing with our resolutions. If you’re happy with your progress, nice work. If not, two different psych concepts might help:

1)    Timing: A basic principle of behaviour change is that, to be effective, the reward or punishment for a given behaviour has to occur close in time to the behaviour. For example, giving the dog a treat an hour after it rolls over or sending your child to her room the day after she misbehaves is not effective. The timing principle explains why lifestyle-related behaviour changes like losing weight, getting fit, or quitting smoking can be hard. The delay between behaviours like skipping dessert or working out and the rewards of losing weight or seeing changes in your physique is too long. The same holds for punishment. Lung cancer 15 years from now is not an effective punishment; it would be much easier to quit if a cigarette this morning gave you cancer this afternoon.

What to do: close the distance between the behaviour and the reward or punishment by creating interim rewards or punishments. For example, decide that eating three healthy and balanced meals today means you can watch an extra episode of whatever show you’re hooked on before bed. Get your partner to agree to give you a half-hour massage on Saturday if you go to the gym three times this week and to hide your laptop (or crochet needles, chocolate, camera, other important item) for 24 hours if you smoke more than one cigarette per day.  Adjust the rewards and punishments until they work for you!

   

2)    Values: Why do you want to quit smoking, lose weight, or spend more time with friends this year? Values describe what’s meaningful to you, what you stand for, and how you want to relate to and interact with other people and with the world. Values provide direction and motivation; connecting with them can help you commit to behaviour change and give you the sense that your hard work is worth the effort (in fact, there exists an entire school of therapy based on mindfulness and commitment to taking action guided by values).  For example, remembering that I value my physical health will help me exercise and eat well even when I don’t feel like it; connecting with my value of close family ties will help me keep my resolution to spend more time with my family, even when it’s inconvenient or requires expensive travel.

Let me know if this helps!

Update

To date, no meetings have taken place between representatives of Quebec psychologists and representatives of the provincial Ministry of Health and Social Services.

Other things are happening, though.

1)   Even if the Ministry isn’t paying attention, the press is. In the past two weeks, articles about the issue have appeared in the Montreal Gazette and in La Presse. Rose-Marie Charest, president of the Ordre des Psychologues du Québec, and Marcel Courtemanche, president of the comité des chefs de service en psychologie en milieu hospitalier du Québec, were interviewed on Radio-Canada; both commented on the impact of the shortage of public sector psychologists on public accessibility to services, and on the roles of poor working conditions and of the disparity between educational requirements and compensation in perpetuating the shortage. 

2)   Students waiting for news about internships for next year were advised to expect letters from the sites we applied to, confirming receipt of our applications and advising us that they are keeping our unopened applications on file and will let us know when things change. Here’s the rub, though: not all internship sites are participating in the pressure tactic; even within hospitals that have announced their solidarity with the tactic, some clinics are offering applicants interviews as usual. This means that students who have applied to participating and non-participating sites may be in the awkward position of having to accept or reject an offer from one site before sites in which they are equally interested even review their application. To say nothing of the potential awkwardness of starting an internship as scheduled in September while your fellow students are forced to make other plans.

What to do? Although students are not obliged to support the Quebec psychologists’ position, those who plan to work in Quebec after graduation certainly have an interest in improved salary and working conditions.

Professional respect and decent pay are important. Supporting your future colleagues is important. But so is continuing your training and finishing your degree in a timely fashion.

I’ll keep you posted.

Winter of Discontent

In a pressure tactic designed to get the attention of the provincial Ministry of Health and Social Services, Quebec public sector psychologists announced in December 2010 that they are refusing to accept psychology interns for the 2011/2012 school year. Their problem: poor working conditions and lack of respect for their work, as demonstrated by remuneration not commensurate with the demands and the training requirements of the profession.

Yearly salary for a full-time psychologist in the public sector in Quebec is between $37,219 and $70,759 and comparisons with the salaries of psychologists in the rest of Canada ($57,000 to $130,000) and with other health care professionals in Quebec reveal significant discrepancies. For example, although Quebec social workers, nurses, and physiotherapists are eligible to practice as professionals after completing their undergraduate training and psychologists have to complete a PhD (i.e., a minimum of five more years of school, creating a corresponding five more years worth of student loans, and a five-year delay before starting to earn), the former professionals earn salaries that are equal to or higher than that of Quebec psychologists.

In response to the lack of respect and recognition, Quebec psychologists are leaving the public system en masse to work in private practice, where they can earn between $85 and $150 per one-hour session. The holes in the mental health care system mean that full-time psychologists are stretched extremely thin between clinical work (e.g., evaluation, psychometric testing, treatment, crisis management, consultation with other professionals), research, administrative tasks, and teaching and supervision, and that Quebeckers who can’t afford private services face long waiting lists for mental health care.

Refusing to train interns effectively stalls the education of new psychologists in the province, threatening to even further increase the number of vacant psychologist positions in the public system. For Quebec citizens, it means even less accessibility to services. For me, it means that my internship applications for next fall, mailed before Christmas, are being received but not opened, and that my degree—already long—risks being delayed by one year.

However, in the past few days, the Ministry acknowledged the pressure tactic, and a preliminary meeting between Ministry representatives and representatives of Quebec psychologists is in the works. Stay tuned.

Now This Is Happening

Mindfulness—a state of conscious awareness in the present moment—is a centuries-old Buddhist practice and one of the biggest trends in mental health right now. Mindfulness means full attention and presence in the now, on purpose and without judgment. It means being in tune with one’s self, and noticing and embracing the experience of each moment, good or bad. Mindfulness doesn’t necessarily imply formal meditation; it can simply mean a conscious effort to be present and aware during every moment. 

How is mindfulness related to mental health? 

1)   Proponents of mindfulness believe that much of what ails us stems from our habits of acting unconsciously and automatically, and of ignoring the present moment in favour of focusing on the past or the future. Lack of attention to the present leads to a poor understanding of our selves, our actions, and our perceptions, and promotes automatic reactions driven by insecurity or fear. Advocates suggest that practicing mindfulness improves mental health by increasing insight and understanding, and by helping us slow down and respond rather than react.

2)   Mindfulness implies not only observation and awareness of the present, but acceptance, too. I like to sum up the concepts of acceptance and mindfulness with the phrase “Now this is happening,” adopted from a funny scene with Jack Black in the non-mindfulness-related movie Anchorman. “Now this is happening” reminds me that what’s happening is indeed happening--whether or not I like it, approve of it, or am prepared for it--and that refusing to accept it won’t make it stop happening. The acceptance inherent to mindfulness is not an attitude of passivity, but rather a realization that the faster and the greater grace with which you accept that you are, for example, locked out of your house, not getting the job you wanted, or rejected romantically, the sooner you have a strong position from which to start dealing with it.

The mindfulness movement is everywhere right now in clinical and popular psychology. Psychology conferences are replete with symposia such as “Eat, Drink, and Be Mindful: Mindfulness Interventions for Binge Eating,” bookstore self-help sections boast titles like “Mind Your Manners: Teaching Children Respect Through Mindfulness,” and there doesn’t seem to be a single mental health problem that some clinician or researcher, somewhere, isn’t trying to treat through mindfulness.

For mental health professionals who don’t like it, don’t believe in it, or aren’t prepared for it: Now this is happening.

Multiple Personalities

Dissociative Identity Disorder (DID) is pretty much the most fascinating DSM diagnosis of all. Formerly called Multiple Personality Disorder, DID is a rare disorder diagnosed when a client presents more than one discrete identity or personality state that recurrently takes control of his or her behaviour. Each identity has a distinct and enduring way of behaving, perceiving, and interacting. Correspondingly, in addition to significant memory lapses and time unaccounted for, symptoms of DID include things like being told that one behaved extremely uncharacteristically, not responding to one's name, and being frequently accused of lying.

DID is associated with early traumatic experiences, particularly childhood physical or sexual abuse, often by a parent or other trusted caregiver. The hypothesis is that dissociation is an extreme response to severe trauma: the mind splits off the memory and awareness of the abuse; the memories go into the subconscious and eventually emerge in another personality, meanwhile allowing the original identity to exist as though untraumatized. 

Without forgetting the anguish and suffering inherent to DID, I can't help but be impressed by the brain's capacity to protect individuals from their own terrible experiences by creating a separate personality to whom the terrible experiences happened. Some research has even found evidence for differences between identities in handwriting, and in physiological variables like heart rate and blood pressure! 

Clinical psychology doesn't get more amazing than that. 

The Pursuit of Happiness

Psychologists and therapists have traditionally focused on alleviating misery–-making anxious people less anxious, angry people less angry, and psychotic people less psychotic–-and assumed that happiness was a byproduct. Researchers in a relatively new subfield of psychology believe that reducing suffering is not enough and that increasing happiness should be a separate and equally important objective.

Positive psychology is the study of positive emotion and human strengths, with the goal of identifying and building strengths, nurturing talent, and improving quality of life in relatively untroubled people. Positive psychology researchers study the traits and habits of happy people and, based on their findings, design interventions to increase happiness.

So what makes us happy?

·     Strong interpersonal relationships make us happy. The people in the highest percentiles of happiness are extremely social, have rich and meaningful friendships, are in a romantic relationship, and don’t spend a lot of time alone.

·     Knowing and using our personal strengths makes us happy. Positive psychology therapy clients complete questionnaires that identify their strengths and are assigned to, for example, use their key strengths in new ways three times per week. If your two greatest strengths are patience and teaching, things like helping your niece learn to read and showing your dad how to use HTML increase happiness. Likewise, couples in therapy with a positive psychologist are assigned to go on a “strengths date,” i.e., a date during which both partners get to use their strengths.

·     Meaning (using your strengths in the service of a greater good or to belong to a larger community) and engagement (the ability to get lost in what you’re doing, whether it’s stock trading, parenting, or making music) make us happy. Pleasure (the experience of positive emotion), on the other hand, is less relevant to happiness. 

The implications of positive psychology findings are considerable. People seeking happiness through pleasure can consider pursuing engagement and meaning instead. The known relationship between happiness and outcomes like better health and longer life can have a significant positive impact on larger systems such as health care and the economy. Finally, positive psychology is an exciting and validating option for future mental health professionals (ahem) who are less interested in severe mental illness and very interested in helping well people improve their quality of life.  

Personality Disorders

DSM personality disorders are fascinating and controversial because they suggest that a person’s personality--by nature multifaceted, unique, and shaped by experience--can be maladaptive and inappropriate to the point that it constitutes a disorder. According to the DSM, a personality disorder is an enduring, inflexible, and pervasive pattern of experience and behaviour that deviates markedly from the expectations of the person’s culture; is manifested in terms of cognition, emotion, interpersonal functioning, and impulse control and leads to significant distress or impairment. The ten DSM personality disorders are divided into three clusters.

Odd or Eccentric: A person with a schizoid personality is a loner, detached or aloof, with a restricted range of emotions. A person with a paranoid personality is distrustful and suspicious, and frequently and unjustifiably perceives others as deceitful or disloyal. A person with antisocial personality disorder is popularly known as a psychopath or sociopath: manipulative and lacking in empathy or conscience. A person with a schizotypal personality is odd or eccentric, with unusual or peculiar beliefs or behaviour.

Dramatic, Emotional, or Erratic:  Borderline personality disorder is characterized by emotional instability, poor self-image, dramatic shifts in mood, fear of abandonment, and tumultuous interpersonal relationships. A person with a narcissistic personality is grandiose, selfish, entitled, and intolerant, with a strong need for admiration. A person with a histrionic personality is theatrical, flashy, emotional, and uncomfortable when not the centre of attention.

Fearful or Avoidant: A person with an avoidant personality fears criticism, avoids social interaction, and is risk-adverse and sensitive to rejection. A person with a dependent personality is needy and submissive, very sensitive to criticism or disapproval, and needs a lot of reassurance and help making decisions. A person with an obsessive-compulsive personality is focused on efficiency and productivity, and may be considered a perfectionist or a workaholic.

Each personality disorder is described by 7 to 9 traits, most of which are not independently pathological. Lots of people people are, for example, impulsive and fail to plan ahead, or show restraint within intimate relationships out of fear of shame or ridicule, without having an antisocial or avoidant personality disorder, respectively. Further, a personality disorder is not necessarily immediately obvious. You could be dating someone for three months before you realize that he is intolerant of your opinions, expects special treatment from waiters and customer service representatives, and frequently and tangentially mentions his Harvard PhD in conversation with strangers–-helping explain why he has a hard time sustaining a relationship.

Therapists can use a strong or otherwise unusual personal reaction to a given client as a clue to the possibility of a personality disorder, and can convert the reaction into a therapeutic intervention by telling the client about it (e.g., “I feel personally responsible for your well-being to an unusual extent” or “I feel like nothing I could do would allow me to gain your trust”). If the client says it’s not the first time he or she has received that particular feedback, the therapist can ask something like, “What do you think it’s like for others to feel so much responsibility for you?” or “How has your difficulty with trust affected your marriage?” to help the client gain insight about how his or her personality impacts his or her relationships.

Personality disorders don’t come out of nowhere, and can constitute a valid response to a maladaptive early environment. If you were consistently misled and betrayed as a child, paranoia is a reasonable response. If you were an adored and overprotected child who was never criticized and who never faced a tough decision or problem on her own, dependence is to be expected. The emotional instability and fear of abandonment common among individuals with borderline personality disorder are the natural outcomes of alternating abuse, invalidation, and neglect. This developmental perspective on personality disorders can be validating for clients and helpful in maintaining patience and empathy in therapists who work with people with personality disorders. The therapist’s job is then to guide the client to an understanding of the impact of the behaviour pattern on the client’s current relationships and to help the client replace dysfunctional patterns with more adaptive and appropriate behaviour.

Activity Scheduling

When you’re sad, bored, lonely, or otherwise unhappy, people often suggest that you get out of the house, join a group, do something nice for yourself, or some variation on that theme. It’s intuitive that engaging outwardly or doing something that you enjoy feels good, but this type of activity has been found to be so effective in improving mood that psychologists working with depressed clients implement mandatory participation in rewarding and pleasurable activities or in activities that increase feelings of mastery. An empirically validated treatment for depression, activity scheduling was developed thirty years ago after research demonstrated that depressed people find fewer activities pleasant and engage in pleasant activities less frequently than do non-depressed people. 

Clients are provided with a blank weekly calendar and are asked to pencil in, for example, 15 minutes of rewarding or pleasurable activity twice per day. The activity has to be realistic: a severely depressed client is unlikely to suddenly join a sports team or redecorate the kitchen. A realistic pleasurable activity might be 15 minutes of reading a magazine and sipping a hot drink. An activity that promotes mastery might be as simple as watering the plants, completing a small errand, or merely showering and shaving. For a depressed client whose life is very busy (with unpleasant or unrewarding activities), a pleasurable activity might be an afternoon coffee break during which the client stops working and listens to his or her favourite music for 15 minutes. Clients are asked to monitor their mood on a graph so that they can observe the mood shifts that correspond with activity.

The non-depressed-person version of activity scheduling is personal projects. A personal project is a hobby, venture, or activity that makes you feel happy, fulfilled, or accomplished–-things like learning to knit, joining a pub ‘trivia night’ team, building a bookshelf, writing a blog, training for an athletic event, learning to play an instrument, designing a software program, and volunteering. The parallel between activity scheduling for depressed people and personal projects for well people is obvious, and provides an intriguing perspective on the role of personal projects in quality of life. Psychology research supports the prescription of enjoyable and rewarding activities as an anti-depressant for depressed clients; it doesn’t seem far-fetched to bet that personal projects increase fulfillment and improve quality of life in well people. 

Intermittent Reinforcement

Some people (ahem) check their personal email an absurd number of times per day. Sitting in front of a computer all day, it’s hard to resist checking for new messages, even if you just checked five minutes ago. In fact, it’s almost impossible. Why?

I think I know, and I think I learned it in Intro to Psych in 1999.

In the 1950s, behavioural psychologists experimented with learning by rewarding caged rats with a food pellet every time the rats pressed a lever. Although the rats initially only pressed the lever randomly or by mistake, they quickly learned the relationship between behaviour and reward and responded with frantic lever-pressing. In psych terms, the food reinforced the lever-pressing behaviour, that is, made it more likely to be repeated. Real-life examples of this kind of conditioning include rewarding your child with a new toy when he makes his bed or your company rewarding every two years of service with a pay increase. Toys and pay raises increase bed-making and company loyalty, respectively.

What does this have to do with email checking? Well, once the rats had clearly learned the relationship between lever-pressing and food, researchers started experimenting with the timing and probability of the reward. They wanted to know what would happen if they gave a rat a food pellet every third time it pressed the lever rather than every single time. Or if they provided food every 60 seconds no matter how many times the rat pressed the lever in the past minute. Or if the reward was completely random, that is, independent of timing and frequency of the behaviour. These variations are called reinforcement schedules. To their surprise, the researchers found that the most successful reinforcement schedule was intermittent reinforcement, that is, random and inconsistent reinforcement. This finding has since been widely replicated, in animals and humans, across situations and types of reward. 

Let’s go back to email checking now. You arrive at work in the morning and check your personal email first thing. You have a bunch of new messages. When you check again 15 minutes later, you have two more new messages. The next three times you check, there’s nothing. After lunch, still nothing. But an hour later, in mid-afternoon, you sign in again and bingo–you’re rewarded with 3 new messages! Yessss!! You feel pleased and validated because all your hard email-checking work paid off. You read your messages, respond or delete, and return to work. But 15 minutes later you have the urge to check your email again. You're in the clutches of email's inherently intermittent reinforcement!

Question: Is it disturbing or reassuring to realize that your personal behaviour is governed by basic principles of learning theory that apply to all people? And, um, all rats.

Twilight Zone

Seasonal Affective Disorder (SAD) is a mood disorder in which people whose mental health is stable for most of the year experience depressive symptoms during the winter months. But what about the short-term anxiety, disorientation, or melancholy that you feel in the winter around 4pm when the light starts to change? At first I thought it was just me, but the fleeting depressive state that occurs at dusk is a legitimate phenomenon (although not included in the DSM) and it has a name. It's called Hesperian depression, after the moment when the Greek God Hesperus, the evening star, rises in the sky. 

I've discovered that the best way to combat Hesperian depression is to be doing something at that time other than staring out the window at the darkening sky. For me, the best thing is to go for a run, but a phone call to a friend, a coffee break, or some other quick and pleasant distraction will also do the trick. By the time you're done, darkness will have fallen completely, Hesperus' rise will be complete, and that uncomfortable twilight period will be over.

The DSM

First published in 1952, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the diagnostic reference manual used by psychologists, psychiatrists, and other mental health clinicians in North America. The manual lists all the different depressive disorders, anxiety disorders, substance-related disorders, psychotic disorders, eating disorders, impulse control disorders, sexual and gender identity disorders, and personality disorders, among others. Each disorder is described by a set of diagnostic criteria.

What’s good and bad about the DSM?

Let's start with the good. First, the manual creates a common language for professionals. If I tell my client’s GP that the client has panic disorder, the doctor knows what I’m talking about. Second, a DSM diagnosis provides validation for clients; if you think you’re going crazy, it can be a relief to hear that your problem is a documented phenomenon. Third, DSM criteria are helpful in recruiting participants for psychiatric research. When you read an ad for individuals who experience recurrent and persistent intrusive thoughts or impulses and repetitive behaviours that they perform in response to an obsession, you’re reading the DSM criteria for obsessive-compulsive disorder.

What are the problems with the DSM? One of the biggest criticisms is that a DSM diagnosis is stigmatizing--a valid point. For example, if you have a major depressive episode documented in your medical file, your insurance carrier might consider you a suicide risk and raise your life insurance rate. If your file says that you have a personality disorder, some therapists may hesitate to accept you as a client. For this reason, as psychology interns, we are taught to be very careful what we write in client files.

A second criticism of the DSM is that it’s categorical and the diagnostic thresholds are arbitrary. I’ll use the diagnostic criteria for post-traumatic stress disorder (PTSD) as an example. You might have experienced a traumatic event and responded with intense fear, helplessness, or horror (criterion A). You may re-experience the event through flashbacks, nightmares, or memories (criterion B) and avoid people or places associated with the trauma (criterion C). But if you don’t experience arousal symptoms such as angry outbursts and sleep disturbances (criterion D), according to the DSM, you don't have PTSD. Without a DSM diagnosis, you may be denied access to specialized treatment, and your insurance company may decline to reimburse your therapy fees.

A final point to consider about the DSM is that the inclusion of a given condition constitutes an indicator of how that condition is viewed by society. Infamously, homosexuality was included in the DSM up until the 1980s. Today, there is heated debate about whether or not Gender Identity Disorder (the feeling that your physical gender does not match your true gender) is a real disorder and if so, whether or not the DSM should change the name to the less pejorative “Gender Incongruence.”

The edition in current use is DSM-IV-TR (text revision), published in 2000, but DSM-V is to be published in 2012. In preparation, working groups at the American Psychiatric Association are making decisions about such proposed additions as binge eating disorder, Internet addiction, and premenstrual dysphoric disorder.

Stay tuned.

What's the difference?

What's the difference between a psychologist and a psychiatrist?

A psychiatrist is a person who went to medical school and chose to specialize in psychiatry rather than pediatrics, oncology, or another medical specialization. Psychiatrists are doctors and they can prescribe drugs. In contrast, a psychologist is a person who completed a PhD in psychology (although in Quebec prior to 2006, a psychologist could be granted a license with a master's degree).

The reason it's confusing is that both professionals do mental health research, see patients in clinic or hospital settings, and teach in universities. And, although therapy is usually the province of psychologists, some psychiatrists conduct therapy as well. 

What's a psychotherapist, then? Enter further complication. Until recently, the title “psychotherapist” was not protected in Quebec and no regulations governed its practice. Any psychologist, psychiatrist, doctor, nurse, social worker, sexologist—or for that matter, any software developer, construction worker, or event planner—could advertise himself or herself as a therapist. However, the term "psychotherapist" became regulated in 2012, and the right to practice psychotherapy and the use of the title psychotherapist is now restricted to psychologists and members of certain other professional orders. This legislation is good news for the public because it prevents individuals who are not adequately trained from providing psychotherapy.

Sometimes when I tell people I'm a psychologist, they say "Oh wow, I bet you're reading my mind right now!" This is a whole other level of confusion wherein psychologists are mistaken for psychics.

In sum, psychiatrists are doctors; psychologists are PhDs; psychotherapists (in Quebec) are psychoeducators, nurses, guidance counsellors, social workers, and occupational therapists, among others; and no one can read your mind. Now go forth and impress mental health professionals with your advanced understanding of the differences between professions!