Dichotomous reasoning involves viewing situations as binary rather than continuous. Dichotomous sometimes called “black or white” thinking, ignores shades of gray. A dichotomous thinker only acknowledges right-wrong, ignoring dilemmas with no right choice and non-normative information; or success-failure, ignoring effort and where success moved to failure; or perfect-incompetent, ignoring learning and practice gains; and big-small, ignoring medium and all sizes in between.


The problem with this type of cognitive distortion is that most of life happens in the grey are between black-white ends, which limits the options for dichotomous thinkers by shrinking their world to extremes. This also makes it hard to make positive meaning out of ordinary experiences, which is an important brain function. To help expand the mind away from extremes and give more meaning to life’s smaller events, try this exercise:

Let’s say you have one or more of these beliefs:

  • You can marry for love or money.
  • You can’t trust rich people.
  • Rich people are shallow.

Now you have won the lottery, you might then think something like this:

  • I can either be rich or be loved.
  • I can either have tremendous wealth or be kind and trustworthy.
  • I can either have money or have a deep, meaningful life.

Now your options are limited to keep the money and be superficial, or give up the money and have depth. To get more options, try rewriting those same thoughts with and instead of or.

  • I intend to be wealthy and live a life filled with love by paying attention to the feelings of my self and others.
  • I intend to be rich and trustworthy and kind by staying in touch with my values.
  • I intend to have both a wealthy and deeply fulfilling life by giving to others who are less fortunate.

Now you have at least 3 options, and possibly many more. To help support your new thinking, find examples (called ‘exceptions’) of people in the world who represent the and-statement.

  • Paul Newman had wealth, and love in his life, staying married to Joanne Woodward from 1958-2008.
  • Oprah is very rich and also stays in touch with her values, people trust her, and see her as kind.
  • Bill Gates is super rich and also has a meaningful life through his many foundations.

Meaningful life     ————————–   Meaning and Matter     —————————–   Material Life

(Depth, love, poverty)              (Authentic, relationships, generosity)               (Shallow, alone, wealthy)

To extend the positive benefits of the exercise and alter negative behaviors in your own life, take a personally held set of dichotomous beliefs and rewrite them as a continuum, filling in the middle with and types of statements.

Source:     Jackie Gartman


skype therapy

Online therapy is a growing area of the mental health field and early research shows that it can be just as effective as   therapy for many populations. Online therapy, also known as e-therapy, e-counseling, tele-therapy or cyber-counseling, can occur through e-mail, video conferencing, online chat, or Internet phone.

Skype, and encrypted digital software through third-party sites, have made online private practice accessible for a broader swath of patients, including those who have difficulty with office treatment. Some examples of these types of clients are parents with kids with disabilities, those with physical or psychological limitations (e.g., agoraphobia, nerve pain, etc.), people who work more than 40 hours a week, and the list goes on. Convenience also is a factor; remote capability addresses some pragmatic barriers, such as transportation difficulties, lower overhead and fees for services, and one may no longer need to cancel appointments due to minor or even some major inconveniences, like broken legs, being out of town, etc.

broken leg

There are some issues with online treatment; eye contact, erratic Internet connections, exploitation, privacy, and reimbursement are all issues that must be addressed by the therapist and client prior to beginning online treatment. 

Therapists should have an informed consent for online treatment that address confidentiality, privacy, and Internet policy related to technology use. Since the client and therapist typically look at each other’s faces on a computer screen, gazes can be off-kilter. “So patients can think you’re not looking them in the eye,” said Lynn Bufka, a staff psychologist with the American Psychological Association. “You need to acknowledge that upfront to the patient…” In addition, “You have to prepare vulnerable people for the possibility that just when they are saying something that’s difficult, the screen can go blank,” said DeeAnna Merz Nagel, a psychotherapist licensed in New Jersey and New York. “So I always say, ‘I will never disconnect from you online on purpose.’ You make arrangements ahead of time to call each other if that happens.” For a copy of my consent form, click  here: LJN_phone:online consent


Clients should verify therapist credentials in the first session by asking to see the license or have a facsimile emailed. Clients may also want to inquire as to the privacy precautions they can take on their end that might further protect information being shared across the web during session. Some examples are always making sure to fully exit all other programs, carefully ending session by signing out and closing  whatever application was used for treatment, and using a private location for the session.

In spite of these obstacles, online therapy is proving to be efficacious.  A study published by the journal Psychiatric Services, patients receiving mental health treatment through video conferencing reported “high levels of satisfaction” (Frueh, C., et. al., 2000.) One article in Newsweek (2006) reported that recovering addicts might benefit from online therapy, especially for those who feel uncomfortable attending traditional face-to-face support groups. Researchers from the University of Bristol compared the effectiveness of 10 online sessions with a therapist to treatment by a general practitioner. 42% of the participants treated through online therapy recovered from depression versus 26% with in-person care. What seems to matter most is the match between the client and the modality “The success of therapy depends a lot upon how willing and engaged the client is,” said Tina Tessina, who has a doctorate in psychology and has been practicing in southern California for 25 years. “So if that person responds better to online than to in-person, or is more willing to disclose in the online therapy, because if feels more anonymous, it can definitely be beneficial.”

online therapy

I currently offer online therapy services in the form of Skype videotherapy and teletherapy over the phone. If you are interested in my services, please contact me! Note: In keeping with my licensing requirements,  I only work with clients currently within the Texas borders.

Lavelda Naylor, MA, LMFTA

4230 Gardendale
Suite 502
San Antonio, TX 78229
Phone: (210) 460-0442
Fax. 210.593.9714

References for Post

Frueh BC, Deitsch SE, Santos AB, et al. (2000) Procedural and methodological issues in telepsychiatry research and program development. Psychiatric Services, 51:1522-1527.

Ehrenfeld, Temma. (2006) Virtual TherapyNewsweek


Video games are a good tool to extend play therapy into adolescence (Ceranoglu, 2010) since this medium is the preferred form of play for this age group; 97% of American teens ages 12-17 report gaming (Lenhart et al., 2008). In addition to being in the language most preferred by teens, it is well-known that teens are notoriously apathetic to talk therapy. Playing games allows for a kind of parallel activity that can help them open up about deeply personal issues they may not otherwise discuss.

Here are some other aspects of gaming therapy that may be interesting to you:

1. Gaming can impact development in positive ways;

  • Action games that require fast response are causally related to increases in many faucets of spatial cognition (Spence & Feng, 2010), such as:
  • contrast sensitivity
  • spatial resolution
  • attentional visual field
  • enumeration
  • multiple object tracking
  • visuomotor coordination
  • speed
  • mental rotation
  • affect regulation
  • reaction time
  • inhibitory control
  • Prosocial games have been found to improve social cognition (Greitemeyer, Osswald, & Brauer, 2010). 

xbox layout

2. Different types of games elicit different types of play (Hamlen, 2011):

• Active play= high cognitive load and fast paced (Call of Duty, Left For Dead, Halo)

• Strategic play= manipulation of game resources (Civilization 2, Star Wars Lego Games)

• Creative play= can modify the game environment (Animal Crossing, SIMS)

• Explorative play= discover new things and solve problems in the gaming field (Legend of Zelda)

• Boys favor Active and Strategic play while girls favor Creative and Explorative play

kids gaming

3. Games can be used in therapy to understand many psychological aspects of kids (Ceranoglu, 2010; Spence and Fang, 2010):

• Explore weaknesses/strengths

• Temperament

• Exercise moral judgment

Role play

Build self-esteem

• Establish rapport with therapist

• Increase social cognition

• Engage in playful fighting behaviour

• Regulate affect

• Explore autonomy and decision-making

Down's and Gaming


4. Research has found video Games to be an effective therapy tool for these special populations (Goh, Ang, & Tan, 2008):

• ADHD (Tahiroglu et al., 2010)

• Anxiety disorders (Jordan, 2009)

• Autism spectrum (Parsons, Mitchell, & Leonard, 2004)

• Depression (Ferguson & Rueda, 2010)

Neuropsychological rehabilitation (González-Fernández, Gil-Gómez, Alcañiz, Noé, & Colomer, 2010)

• Down’s (Wuang, Chiang, Su, & Wang, 2011)



Ceranoglu, T. A. (2010). Star Wars in psychotherapy: Video games in the office. Academic Psychiatry, 34(3), 233-236.

Ferguson, C. J., & Rueda, S. M. (2010). The Hitman study: Violent video game exposure effects on aggressive behavior, hostile feelings, and depression. European Psychologist, 15(2), 99-108. Goh,

D. H., Ang, R. P., & Tan, H. C. (2008). Strategies for designing effective psychotherapeutic gaming interventions for children and adolescents. Computers in Human Behavior, 24(5), 2217-2235.

González-Fernández, M., Gil-Gómez, J.-A., Alcañiz, M., Noé, E., & Colomer, C. (2010). eBa ViR, easy balance virtual rehabilitation system: A study with patients. Annual Review of CyberTherapy and Telemedicine, 8, 49-53.

Greitemeyer, T., Osswald, S., & Brauer, M. (2010). Playing prosocial video games increases empathy and decreases schadenfreude. Emotion, 10(6), 796-802.

Hamlen, K. R. (2011). Children’s choices and strategies in video games. Computers in Human Behavior, 27(1), 532-539. doi: 10.1016/j.chb.2010.10.001

Jordan, N. A. (2009). This is why we play the game: A quantitative study of attachment style and social anxiety’s impact on participation in online gaming relationships. Syracuse University Ph.D. Retrieved from ProQuest Dissertations & Theses (PQDT) database.

Lenhart, A., Kahne, J., Middaugh, E., Macgill, A. R., Evans, C., & Vitak, J. (2008). Teens, video games, and civics Retrieved from Pew Internet & American Life Project. Retrieved from doi:

Parsons, S., Mitchell, P., & Leonard, A. (2004). The Use and Understanding of Virtual Environments by Adolescents with Autistic Spectrum Disorders. Journal of Autism and Developmental Disorders, 34(4), 449-466.

Spence, I., & Feng, J. (2010). Video games and spatial cognition. Review of General Psychology, 14(2), 92-104.

Tahiroglu, A. Y., Celik, G. G., Avci, A., Seydaoglu, G., Uzel, M., & Altunbas, H. (2010). Short-Term Effects of Playing Computer Games on Attention. Journal of Attention Disorders, 13(6), 668-676. doi: 10.1177/1087054709347205

Wuang, Y.-P., Chiang, C.-S., Su, C.-Y., & Wang, C.-C. (2011). Effectiveness of virtual reality using Wii gaming technology in children with Down syndrome. Research in Developmental Disabilities, 32(1), 312-321.



I will begin seeing clients Feb 1, 2012. If you would like an appointment, email or phone me and we will discuss your needs.

Lavelda J Naylor, MA, LMFTA
The Key Counseling Services of SA
4230 Gardendale
Suite 502
San Antonio, Tx 78229


Approach to Therapy
As a marriage and family therapist, I enjoy working with the Satir Model (Satir, 1983; 1988; 1991), which is an experiential systems approach that suggests quality relationships are more likely when we effectively communicate from the Self. To do this, we must know the self, take personal responsibility for the self, and be willing to share the self with others. Good communication skills are also needed. When these qualities are present, there is an overall sense of well being that allows for creative and flexible problem solving. When absent or diminshed, things get stuck. If you feel stuck and want to get moving again, call me.

What is therapy like?

In our first session, we will do a brief assessment of the issues, set some joint goals, and make a plan that will identify where we want to go and how we might get there. In subsequent sessions, we will work towards your goals by examining the issues from different perspectives, identify conflict and  communication patterns, and seek for a “transformative idea” in your own experiences–The Key–that will continue to promote growth in the system long after our journey together ends. While each journey is unique and the length of therapy depends on client need, we are sure to know when you have arrived at the destination.

But does it work? 

The Satir Model has been applied successfully to children (Haber, 2011; Smith, 2010), individuals (Morrison & Ferris, 2002; Yang Li & Vivian, 2010), couples (Lee, 2009; Morrison & Ferris, 2002), families (Haber, 2011; Seligman, 1981), and groups (Root, 1989) to address a variety of concerns, such as depression (Caston, 2009; Srikosai, 2008), pathological gambling (Lee, 2009), suicidality (Smith, 2010), and alcohol dependence (Srikosai, 2008). The Satir Model integrates well with Emotion Focused Therapy (Brubacher, 2006), Social Construction Theory (Cheung, 1997), and cognitive-behavioral/mindfulness therapies (Claessens, 2009). The wide applicability and flexible nature of the model makes it a good fit for most cultures, including collectivist cultures (Yang, 2012; Bermudez, 2007; Cheung & Chan, 2002) and GLTB community (Carlock, 2008).

Evaluating Treatment Results

In my own practice I have found clients to become quickly engaged and to be willing to stay the course to get the desired results a majority of the time. To evaluate progress I run a brief spot check Session Rating Scale) over the course of treatment that assesses four domains of client-therapist-treatment interaction. Occasionally, we will evaluate outcomes using the ORS (Outcome Rating Scale) that briefly assesses four domains of functioning. These results are used to refine the process and enhance the journey. In addition, I use the treatment plan to help track positive and negative change as related to goals. Markers for termination are 1) client has reached all or some of the identified goals, 2) client/therapist feels the client is ready to take over, 3) there is no progress in treatment (referrals are discussed), and/or 4) other unique indicators are processed as keys for termination.

It is my goal that you get more of the life you want and my mission is to empower you to do just that!

Here is a link to my latest publication. Many thanks to David and Glenn.

For Therapy Services: The Key Counseling of SA

For many people the holidays are a stressful time. For those who have lost a loved one, the holidays can be especially difficult. Here are some tips from James E. Miller that might be helpful during this time of year.

1. Accept the likelihood of your pain.
• Chances are it will be a painful time.
• Your pain is a sign that you have been blessed to have close relationships.
• There will be difficult moments, but the holidays don’t have to be
• Sometimes the anticipation is worse than the actual experience.

2. Feel whatever it is you feel.
• You will have emotional reactions to the impact of the holidays.
• You are human.
• No one else will feel exactly the way you do, when you do, with the same

3. Some feelings you may experience:
Depression. Fear. Anger. Guilt. Apathy.

4. Express your emotions.
• You must find a release for what is going on inside of you.
• Express yourself in a way that works for you. Possibilities are limitless.
Cry. Talk. Journal. Listen to music.

5. Plan ahead.
• Identify what will be the more difficult parts of the holidays.
• Ask for help in thinking about what you will do and carrying out tasks.
• Give thought to the various choices you have in spending the holidays.
• Divide your tasks into smaller, more manageable units
• Give yourself the freedom to change your plans.

6. Take charge where you can.
• Identify what aspects of the holidays are meaningful to you and which ones you can forego.
• Decide if there are traditions that can be modified to fit the new circumstances of the loss.
• Try not to make drastic changes, but some changes can be healthy and important.
• Eat healthfully and drink wisely, maintain an exercise program, get some sleep, and practice those things that give you energy.

7.Turn to others for support.
• You may have to let people know how they can help, be straightforward about what you think will help and what will not
• Seek out those who will let you talk or cry or do whatever you need to do.
• Contact local bereavement support programs for counseling or join a grief

8. Be gentle with yourself.
• Give yourself time to rest and be forgiving of yourself.
• Don’t over commit yourself and allow yourself to cancel plans if you need to.
• Give yourself permission to ease holiday demands and set easy-to-attain goals.

9. Remember to remember.
• Find an object that you can carry, wear, use, or place in easy sight that will link you with the one who died.
• Create a small remembrance area in your home.
• Honor your loved one with a ritual of remembrance.
• Don’t force yourself to remember if you don’t feel up to it – you’ll know when the time is right.

10.Search out and count your blessings.
• Remain as open as you can to what you appreciate.
• Stay present in the moment and accept the warmth that is yours to receive,
however fleeting.

11. Do something for others.
• Find moments to place your attention outside of yourself.
• It can be something that takes an hour or days – see what is right for you.
• Volunteer, help a neighbor, or assist a stranger. The possibilities are limitless.

12.Give voice to your”soul”.
• An inner part of yourself is involved in the grief, separate from your body, mind, or feelings.
• Honor the questions that you may find yourself asking that affect your spiritual beliefs.
• Consider making room in your days for the expression of your soul (prayer, meditation, reading, etc.).

13. Harbor hope.
• Stay open to the demands of this experience. There is hope for your healing and growth.

Source : link


For Therapy Services: The Key Counseling of SA

A Personality Disorder is an enduring, stable, pervasive, and inflexible pattern
of internal experiencing. They often manifest in adolescence or early adulthood and include behaviors that deviates significantly from cultural norms. In addition, symptoms cause significant leading distress and impairment in personal and social functioning. Journal of Clinical Psychiatry (2004): “14.8% of Americans (30.8M adults) meet diagnostic criteria for at least one personality disorder.”  

TYPES and PREVALENCE (% of general population)

Antisocial – (3.6%) marked with disregard for and violation of the rights of others (often starts as Conduct Disorder in childhood)

Avoidant – (2.4%) characterized by social inhibition, feelings of inadequacy, and hypersensitivity to criticism

Borderline – (2%) high in impulsivity and interpersonal relationships, self image, and affect are unstable

Dependent – (0.5%) submissive and clinging behavior in response to a need to be taken care of

Histrionic – (1.8%) excessive emotionality and attention seeking

Narcissistic – (6%) grandiosity, need for admiration, and lack of empathy

Obsessive-Compulsive – (7.9%) preoccupation with orderliness, perfectionism, and

Paranoid – (4.4%) distrust and suspiciousness that others’ motives are malevolent

Schizoid – (3.1%) detachment from social relationships

Schizotypal – acute discomfort in close relationships plus cognitive or perceptual distortions and   eccentric behavior

Personality disorders generally require psychotropic medication and psychotherapy treatment due to the prolonged and severe nature of symptomology and level of impaired functioning. Unfortunately, treatment may be difficult to initiate or maintain due to barriers, such as patient denial, medication attrition, expense, and duration of treatment. Despite these obstacles, therapy is warranted as most of the types have severe consequences not only for the patient but for his/her family and social networks.

Psychotherapy for personality disorders is often focused on improving perceptions of and responses to social and environmental stressors, as well as social skills training. Some treatment options include but are not limited to…

  • Psychodynamic psychotherapy: assumes perceptions are shaped by early life experiences. Thus the focus of treatment is aims to identify perceptual distortions and their historical sources.  Goals may include the development of more adaptive modes of perception and response. Treatment is long term; usually extended over a course of several years at a frequency from several times a week to once a month. 
  • Cognitive therapy (also called cognitive behavior therapy [CBT]): assumes cognitive errors based on long-standing beliefs influence the meaning attached to interpersonal events. Focus of treatment is how people think about and perceive heir world. Goals may include reformulating perceptions and behaviors. This therapy is typically limited: duration of 6-20 weeks (still more than the national average), once weekly; however, in the case of personality disorders, episodes of therapy are repeated often over the course of years. Mindfulness therapy may be useful in treating PDs.
  • Group psychotherapy allows interpersonal psychopathology to display itself among peer patients, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication, and behavior. Sessions are usually once weekly over a course that may range from several months to years. Ease of access and duration of services, as well as the interpersonal nature of groups can make them a good option for those with PDs.
  • Dialectical behavior therapy (DBT): This is a skills-based therapy (developed by Marsha Linehan, PhD) that can be used in both individual and group formats. Assumes maladaptive coping and focuses on development of coping skills to improve affective stability and impulse control and on reducing self-harmful behavior. Tested for BPD, weekly one-on-one counselor and group training sessions on skills such as distress tolerance, interpersonal effectiveness, emotion regulation and mindfulness skills can be helpful. More research is needed on other PDs.
  • Systemic Therapy (e.g., family therapy) are about contextualizing issues and examining
    relationship patterns in human systems (Jenkins and Asen, 1992). Family therapy is usually suggested when either PD symptoms are negatively impacting the functioning of the family, or when problems in the family may be making the PD symptoms worse. Sometimes these two problems interact — the BPD symptoms impair family functioning, and poor family functioning makes the BPD symptoms worse.
  • Integrative Relational Psychotherapy (IRP): Combining a rigorous biopsychosocial model of personality with a relational framework for patient assessment and treatment planning, IRP is designed to produce rapid and sustained systemic change in patients suffering from virtually all DSM-identified personality disorders.


Linehan, M.M. (2000). The empirical basis of dialectical behavior therapy: Development of new treatments versus evaluation of existing treatments. Clinical Psychology: Science and Practice,(1), 113-119.

Verheul, R., Van Den Bosch L.M., Koeter, M.W., De Ridder, M.A., Stijnen, T., Van Den Brink, W. (2003). Dialectical behavior therapy for women with borderline personality disorder: 12-month, randomized clinical trial in The Netherlands. British Journal of Psychiatry, 182, 135-40.

For Therapy Services: The Key Counseling of SA

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