Arizona Child Psychology, PLLC
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Table of Contents click below for more information

What is the Difference Between a Psychologist, a Psychometrist, a Licensed Professional Counselor (LPC) and a Psychiatrist?

What Specific Educational Training and Skills Do Psychologists Possess?

What Specific Educational Training and Skills Do LPCs Possess?

What is ADHD?

What is Autism?

What is Asperger's Syndrome?

What is a Childhood Anxiety Disorder?

What is Childhood Depression?

What is Enuresis?

What is Encopresis?

What is Academic Giftedness?

What is a Learning Disorder?

What is an Intellectual Disability?

What is Oppositional Defiant Disorder (ODD)?

What is Behavioral Therapy?

What is Cognitive Behavioral Therapy?

What is Eye Movement Desensitization & Reprocessing (EMDR) Therapy?

References

What is the Difference Between a Psychologist, a Psychometrist, a Licensed Professional Counselor, and a Psychiatrist?

Knowing the difference between different specialists and treatment approaches helps make one a knowledgeable consumer. While the professional work of mental health professionals often overlap, there are some important distinctions. One difference is that psychiatrists go to medical school for training, whereas doctoral level psychologists, psychometrists and Licensed Professional Counselors (LPCs) go to graduate school for training. LPCs earn master's degrees, psychometrists typically possess either a masters or doctoral degree, psychologists earn either Ph.D., Ed.D., or Psy.D. degrees, and psychiatrists earn either D.O. or M.D. degrees. As medical specialists, psychiatrists often prescribe medication for different types of problems, whereas psychologists, and LPCs typically do not prescribe medications in their treatment efforts, but rather focus on psychotherapy, counseling and educational approaches. Psychometrists specialize in the administration of psychological and educational tests, and they work in conjunction with licensed psychologists and do not operate independently. At Arizona Child Psychology, PLLC, we specialize in the utilization of psychological, counseling and educational approaches to the resolution of problems, and are a practice comprised exclusively of licensed psychologists, psychometrists and LPCs. However, we do value the contributions of professional psychiatry, and will sometimes make referrals to psychiatric providers if we believe our client might benefit from this type of treatment as well.

What Specific Educational Training and Skills Do Psychologists Possess?

In order to become a licensed psychologist a person must first complete their undergraduate college degree and then go on to graduate school to obtain a doctoral degree (Ph.D., Ed.D. or Psy.D.). Sometimes, an individual will also earn a master’s degree along the way to earning a doctorate. The American Psychological Association (APA) accredits three different types of doctoral programs in psychology: Counseling Psychology, School Psychology and Clinical Psychology. Graduate school training can last anywhere from 4 to 6 years and is followed by one or two years of internship or "residency" training, usually at a site away from the graduate university. After residency, most states require an additional 1 to 2 years of supervised work experience before becoming eligible for independent licensure, and some psychologists choose to complete this requirement through a formalized postdoctoral fellowship training program that allows them to further specialize in a particular area. Finally, becoming a licensed psychologist also requires an individual to successfully pass a national psychology licensing exam (the EPPP) before engaging in independent practice. Psychologists are also required to complete additional approved training / education every two-year licensure cycle in order to keep their knowledge base current and their license active.

The educational requirements for becoming a licensed psychologist are extensive, and provide an in-depth knowledge of psychological and emotional problems, personality and human development, integrated with specialized training in how to apply this knowledge to help people with emotional distress and other problems of living. The psychologist's training in research also allows him/her to evaluate the best ways to help people and to make "evidence-based" decisions regarding what helps and what doesn't help different individuals with different types of problems. Most psychologists (especially school psychologists) have specialized training and skills in psychometrics and psychological testing. Psychological tests are used in situations where there are questions about what a person's particular problem is. For example, a psychologist may use a battery of psychological tests in order to determine whether a child has Autism or an Attention Deficit Hyperactivity Disorder, or if the child's problems are being caused by some other reason. Psychological tests can include assessments of personality styles, tests of emotional well-being, intellectual (or "IQ") tests, tests of academic achievement, tests for possible brain damage, and tests for specific psychological disturbances and their severity. The use of psychological tests requires years of training that involves not only learning how to administer tests, but also how to integrate all the information derived from tests to correctly interpret their meaning. Psychologists are the only mental health professionals who are fully trained and qualified to administer and interpret psychological tests.

What Specific Educational Training & Skills Do LPCs Possess?

In order to become a licensed professional counselor (LPC), a person must first complete their undergraduate college degree and then go on to graduate school to obtain a masters degree (M.A., M.S., or M.C. degree). The Council for the Accreditation of Counseling and Related Educational Programs (CACREP) accredits different types of masters programs in counseling, including marital / couple / family counseling, community counseling, and mental health counseling. Graduate school training typically consists of 2-3 years of academic work, culminating in a 60 credit masters degree, including 600 hours of supervised internship or fieldwork. An individual must also complete an additional 3200 hours of supervised work experience (approximately 2 years) and successfully pass a national licensing exam (the NBCC) before being allowed to engage in independent practice as an LPC.

The educational requirements for becoming an LPC are extensive, and provide a depth of knowledge regarding human functioning in several core domains, including counseling theory, human growth and development, social / lifestyle issues, career development, multicultural foundations, and research / evaluation. An LPC's training and experience is usually practitioner focused, and is grounded in the application of knowledge and information derived from social science research to best alleviate problems of the human condition. LPCs may also establish specializations in different areas of practice (e.g., marriage / couples therapy, trauma work, at-risk youth ), and are required to complete additional approved training / education every two-year licensure cycle in order to keep their knowledge base current and their license active.

What is ADHD?

Attention Deficit-Hyperactivity Disorder (ADHD) is a condition that is based on the presence of a degree of inattention or hyperactivity / impulsivity that is so great that it interferes with a person’s ability to succeed at home, school, work or in relationships with others. ADHD is diagnosed based on the presence of symptoms that are listed in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (American Psychiatric Association, 2013). Symptoms must be present in two or more environmental contexts, and several symptoms must have been present prior to the age of 12. Conservative estimates suggest that approximately 3-5% of children nationwide are affected by ADHD (Hibbs & Jenson, 1996). Untreated ADHD can increase a person’s risk for failure at school, for involvement in substance abuse and criminal activities, and for the development of a variety of problems at work and in social relationships (National Institutes of Health, 1998; Monstrasa, 2005). Multiple avenues of treatment are available for ADHD, and commonly include psychological / educational / counseling interventions, and medication / pharmacologic interventions. Arizona Child Psychology, PLLC believes that the diagnosis of ADHD requires thorough assessment and evaluation, and that front-line approaches to treatment (psychological / educational / counseling) should typically precede other forms of treatment (e.g., medication therapy, neurofeedback, etc.). We also believe that psychological / educational / counseling approaches can complement pharmacologic (medication) treatment in those cases where medication is warranted. Arizona Child Psychology, PLLC believes that each child and family affected by ADHD deserves an individually tailored and comprehensive treatment plan to successfully treat and improve ADHD symptoms.

What is Autism?

Autism Spectrum Disorder (ASD) is a unique condition that includes deficits in social communication and social interaction across multiple contexts, and also involves restricted, repetitive patterns of behavior, interests or activities. ASD can also involve impairment in cognitive functioning, but ASD varies greatly across individuals. Some level of delay or abnormal functioning must have been present early in one's life to be diagnosed with ASD. In 2013 the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V) classified ASD as encompassing four previously separate disorders (autistic disorder, Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified). The incidence of Autism has been conservatively estimated at 6.6 to 13.6 per 10,000 individuals (American Psychiatric Association, 2000), with current estimates suggesting that approximately 1% of the population meets criteria for ASD (American Psychiatric Association, 2013). The Department of Health and Human Services Center for Disease Control and Prevention (CDC) released data in 2007 indicating that 1 in 150 eight-year old children have ASD in the United States (CDC, 2008). Also, the rate of Autism in boys is known to be approximately 4 to 5 times greater than that in girls (Hibbs & Jenson, 1996). Research has shown that early, intensive intervention can result in significant improvements for some children with Autism (Lovaas, 1987). As such, Arizona Child Psychology, PLLC believes strongly in the importance of early identification and treatment for children demonstrating possible signs and symptoms of this condition. “Identification” of ASD should involve a thorough and comprehensive psychological assessment based upon careful clinical observation and state-of-the-art assessment tools and techniques. Treatment of children with ASD should involve comprehensive efforts directed at the child, the parents and the child’s educational environment.

What is Asperger's Syndrome?

Asperger’s Syndrome falls along a continuum of what has been recently recognized as “Autism Spectrum Disorder” (ASD), and is now considered to be a form of autism. Children with Asperger’s Syndrome have definite delays in the social use of language (pragmatic language). Their greatest area of difficulty is often with social skills and interpersonal relationships. Another area of weakness is that they lack what is called “theory of mind,” also known as “mind blindness.” That is, an individual with Asperger’s Syndrome has difficulty considering and understanding other people’s thoughts and feelings. This can lead to a variety of problems in life such as the inability to predict the possible behaviors of others, lack of empathy, a lack of understanding of turn-taking, an inadequate understanding of “pretending,” a limited ability to detect or react to their audience’s level of interest, and other manifestations of social impairment. In 2013 the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V) reclassified Asperger's as a condition that falls along the autism spectrum, and involves deficits in social communication and a restricted range of interests, behaviors or activities. In contrast, Social (Pragmatic) Communication Disorder involves difficulties with verbal and nonverbal communication, but does not involve the restricted range of interests or activities. At Arizona Child Psychology, PLLC, we believe that the diagnosis of any neurodevelopmental or communication disorder involves a thorough assessment and evaluation so that the right and correct diagnosis can be made. Only when correct and accurate diagnoses are made can appropriate treatment interventions and strategies be selected.

What is a Childhood Anxiety Disorder?

All children experience some unrealistic fears and apprehension from time to time, and most fears are developmentally appropriate and easily manageable (e.g., fear of the dark, fear of a parent not returning home, fear of new or novel situations, etc). However, sometimes anxieties and fears can become so intense that they become debilitating for both the child and their family. An “anxiety disorder” is an umbrella term used to describe several different clinical conditions all involving the common thread of excessive or debilitating “anxiety.” It is estimated that about 8 to 10% of the childhood population suffers from some form of anxiety (Hibbs & Jenson, 1996). Some of the most common anxiety disorders that affect children and adolescents include specific phobias, social phobias, obsessive-compulsive disorder, generalized anxiety disorder, and panic disorder. Each of these conditions is characterized by its own unique constellation of clinical signs and symptoms, but as a group anxiety disorders tend to respond well to cognitive-behavioral interventions. At Arizona Child Psychology, PLLC, we emphasize the use of cognitive-behavioral interventions and techniques in the treatment and resolution of childhood anxiety disorders. In some cases, referrals may also be made for medication based treatments if it is perceived as being necessary. As with other conditions, thorough assessment and evaluation is an important precondition to initiating treatment in order to ensure that treatment efforts are focused on the most relevant targets. At Arizona Child Psychology, PLLC, we believe that anxiety-related conditions are often among the most rewarding and fulfilling to treat because few things in life compare to helping a young person overcome and conquer his or her fears and anxieties.

What is Childhood Depression?

Like adult depression, childhood depression can involve feelings of sadness, hopelessness, lethargy, changes in sleep or eating habits, and other “classic” signs and symptoms. However, childhood depression can also manifest in very unique ways, and might show up as anger and irritability, somatic (bodily) complaints, and other symptoms not typically thought of as being associated with depression. Because childhood depression can sometimes be masked by other behavioral symptoms, making an accurate diagnosis of childhood depression can be challenging, and depressed children may “fall through the cracks” at home or at school because their symptoms are not easily recognized as being signs of depression. It is estimated that 0.4% to 5.9% of children suffer from some form of depression, and rates of depression may increase 2- or 3- fold during adolescence (Hibbs & Jenson, 1996). Careful evaluation and/or psychological testing and assessment can often help identify children and adolescents who suffer from clinical depression. Such depression can be triggered by any number of situational factors (e.g., parental divorce, death of a family member, the loss of a pet), or less commonly, by endogenous physiological factors involving a child’s unique body chemistry. At Arizona Child Psychology, PLLC, treatment of childhood depression typically involves careful assessment, cognitive-behavioral therapy, solution-oriented interventions and family-based counseling. In some cases of severe depression, referrals may also be made for medication based treatments if it is perceived as being necessary. Because Arizona Child Psychology, PLLC believes strongly that no child should suffer from clinical depression during his/her youth, and because good treatment options are most often available, FREE depression screenings are offered during the entire month of October for any current Arizona Child Psychology, PLLC client who requests it, in recognition of National Depression Screening Day and Mental Illness Awareness Week.

What is Enuresis?

“Enuresis” is the repeated voiding of urine into the bed or clothes. While there is a wide variability in age regarding when children first achieve bladder control, enuresis may be diagnosed in children who are older than 5 and who exhibit a frequency of wetting at least twice weekly for 3 consecutive months. When the wetting occurs during sleep hours at night, it is referred to as “nocturnal enuresis.” Although enuresis is frequently thought of as a childhood condition, it can also affect adolescents, and may become a source of shame, embarrassment and ridicule for older children and teenagers. Such is unfortunate because good treatment options typically exist for enuretic youth. Enuresis occurs in about 5-10% of 5-year-olds, 3-5% of 10 year olds, and around 1% of individuals 15 years and older (American Psychiatric Association, 2013). At Arizona Child Psychology, PLLC, enuresis is most often treated successfully through behavioral shaping methods and counseling approaches. In some rare cases, referrals may also be made for medication evaluations and adjunctive pharmacologic treatment.

What is Encopresis?

“Encopresis” is a bowel control problem that involves the involuntary soiling in inappropriate places (such as underwear) in children older than 4. Even though a diagnosis of encopresis is reserved for children 4 and older, children under 4 may also have difficulty achieving bowel control, and may require special interventions to help them achieve developmentally appropriate control of their bowel movements. In most cases, soiling occurs rarely at night, and is more common during traditional waking hours and especially after school (Christophersen & Mortweet, 2003; Levine, 1976). If left unmanaged, encopresis and chronic soiling can lead to an array of problems and difficulties for children, not the least of which can be isolation from peers and/or adults. Specialized toilet training is the cornerstone of treating soiling problems, and the treatment of encopresis also requires extra efforts to manage a child’s constipation (withholding) behavior. Because some conditions can mimic encopresis (e.g., Hirschsprung disease), careful history taking and evaluation is important. While specific statistics are unavailable regarding the number of children under 4 who require extra effort to achieve developmentally appropriate bowel control, the prevalence of encopresis has been estimated at 1-2% in children over 4. Moreover, encopresis is know to affect boys three to six times more often than girls (Bellman, 1966; Christophersen & Mortweet, 2003). At Arizona Child Psychology, PLLC, we believe that there is often no greater gift parents can receive other than helping their child achieve control over bowel and soiling problems.

What is Academic Giftedness?

There are many different interpretations of the term “gifted.” Most include advanced development in the following areas: intellectual ability, creativity, memory, motivation, physical dexterity, leadership, and sensitivity to the arts. With respect to educational services for the gifted in the State of Arizona, the definition of giftedness is limited to academic giftedness, or a student's potential for future success in school. Gifted education is mandated in Arizona for students in K–12. According to the State statute, a “gifted pupil” is a child who is of lawful school age and who demonstrates superior intellect or advanced learning ability or both (ARS 15-779.02). This is typically determined by scores at or above the 97th percentile on nationally normed ability or intelligence tests in one or more of three areas - verbal, quantitative, or nonverbal reasoning. An ability or intelligence test is different from an achievement test such as the AIMS, in that achievement tests measure what a student has learned with respect to their grade level standards, while ability or intellectual tests measure more innate or natural problem solving skills. Most school districts provide ability testing for children who are suspected of being gifted. However, the measures used are typically a timed paper and pencil test in a group setting, and are administered by a teacher who specializes in gifted instruction. Because not all children respond well to this type of testing scenario, an individual test of intelligence (IQ test) given by a psychologist or psychometrist trained in intellectual assessment might provide a more fair indicator of a child's true intellectual functioning. At Arizona Child Psychology, PLLC, we offer individualized intellectual / gifted evaluations that can be used by a child’s school in determining appropriate academic placement.

What is a Learning Disorder?

A Learning Disorder is a problem acquiring academic knowledge and information within a particular content area, and most frequently involves skills related to reading, mathematics or written expression. A Learning Disorder may be present when an individual’s achievement on an individually administered, standardized test is significantly below that expected for the individual’s age, level of intelligence and academic background. Additionally, in order to be diagnosed with a Learning Disorder, the learning problems must significantly interfere with an individual’s academic achievement or activities of daily living. While there are several different theoretical approaches to assessing and diagnosing Learning Disorders (e.g., the discrepancy model, Response to Intervention [RTI], CHC cross battery assessment), comparisons between intellectual ability and academic achievement has served as a primary criterion for determining special education eligibility since the enactment of the Individuals with Disabilities Act (Wechsler, 2003). Approximately 5-15% of students in public school settings in the United States are identified as having a Specific Learning Disorder (American Psychiatric Association, 2013). Additionally, Learning Disorders are most commonly diagnosed in elementary school aged children (often in the 3rd or 4th grade) when academic rigors increase, although Learning Disorders can be identified at other ages as well. If a Learning Disorder exists, it is important to accurately identify it as early as possible since demoralization and low self-esteem can become associated with continued academic failure. Additionally, the school drop-out rate for children or adolescents with Learning Disorders has been reported at nearly 40% (American Psychiatric Association, 2000), underscoring the importance of early identification, intervention and academic support. Arizona Child Psychology, PLLC strongly believes that children who are identified with a Learning Disorder should receive academic accommodation and/or intervention since all children do not necessarily learn in the same way, and that “cookie cutters” belong in the kitchen – not in the classroom.

What is Intellectual Disability?

Intellectual Disability (ID), previously referred to as mental retardation, is a condition that involves significantly below average intellectual functioning, and also involves significant impairment in adaptive functioning, such as the ability to care for oneself, impaired social / interpersonal skills, or lack of self-direction. ID is usually diagnosed during childhood or adolescence, and symptoms must be present during an individual's developmental period. ID can be mild, moderate, severe, or profound, and each level of severity has its own unique diagnostic features, limitations, and prognosis. If ID is suspected, it is extremely important to accurately assess and diagnose this condition as early as possible since many educational and support services are available to children and adolescents who receive a formal diagnosis. Support services are also frequently available to families who are affected by the challenges of caring for a child with intellectual disability. A thorough diagnostic psychoeducational evaluation is often the first step in helping individuals affected with this condition qualify for such services.

What is Oppositional Defiant Disorder (ODD)?

Oppositional Defiant Disorder (ODD) is a condition that involves a recurrent pattern of negativistic, defiant, disobedient and/or hostile behavior directed towards peers, parents, teachers, or other adult authority figures. “Defiance” is the hallmark characteristic of this disorder, and frequent temper outbursts are also quite common. Before puberty ODD tends to be more prevalent in males, but the rates of ODD are generally equal in both males and females after puberty. The rates of ODD have been reported as being between 1-11% of the general population (American Psychiatric Association, 2013). While ODD reflects a unique constellation of symptoms involving defiance, anger and disobedience, it is important to note that not every child who demonstrates these symptoms will meet the full criteria for ODD. Nevertheless, Arizona Child Psychology, PLLC believes that any child or adolescent who struggles with these symptoms to any degree should receive therapeutic assistance and support in order to help better manage their behavior. An essential part of childhood and adolescence is learning how to appropriately manage feelings of anger, hostility and defiance in socially acceptable ways, and how to emotionally regulate oneself. If successfully learned during one’s youth, such lessons should continue to serve an individual throughout his /her entire lifetime.

What is Behavioral Therapy?

Behavioral therapy is a foundational therapeutic approach for modifying and shaping human behavior, and research has shown that certain behavioral techniques can be especially helpful in modifying and altering problem behaviors in children and adolescents. Behavioral therapy involves the prescribed and systematic application of rewards or consequences to either strengthen or inhibit selected behaviors, and is based upon the work of noted academic psychologist John Watson (Johns Hopkins University) and academic psychologist B. F. Skinner (Harvard University). At Arizona Child Psychology, PLLC, behavioral therapy involves the application of positive, supportive and powerful behavior modification techniques. Much of our work with parents involves instruction and coaching regarding the correct application of behavioral techniques to produce desired behavioral results in children and adolescents. We also provide instruction and technical assistance with school-based behavioral interventions to address academic and classroom problems, in addition to providing individualized behavioral therapy interventions with children and adolescents.

What is Cognitive-Behavioral Therapy?

Cognitive-behavioral therapy (CBT) is a form of psychotherapy that challenges an individual's dysfunctional or unhealthy beliefs, thoughts, assumptions and behaviors. CBT involves a multitude of different therapeutic techniques and interventions designed to improve and enhance an individual's mode of living. Primary objectives of CBT typically involves the identification of irrational or maladaptive thoughts, assumptions and beliefs that are related to negative feelings and emotions, as well as interventions to alter such thoughts, assumptions and beliefs. Various CBT treatment techniques have been developed for specific problems and conditions, and research has tended to support the effectiveness of CBT for many different problems and conditions. At Arizona Child Psychology, PLLC, CBT is used in its various forms for different therapeutic purposes. As with all of our therapeutic interventions, modification of standard CBT protocols is often made in order to make our interventions "age appropriate" when working with children and adolescents.

What is Eye Movement Reprocessing and Desensitization (EMDR) therapy?

Eye Movement Desensitization and Reprocessing (EMDR) therapy is a method of psychotherapy that has been extensively researched and proven effective for the treatment of trauma. EMDR is a set of standardized protocols that incorporates elements from many different treatment approaches. In 1987, psychologist Dr. Francine Shapiro made the chance observation that eye movements, under certain therapeutic conditions, can reduce the intensity of disturbing thoughts and images. Dr. Shapiro studied this effect scientifically and, in 1989, she reported, in the Journal of Traumatic Stress, success using EMDR to treat victims of trauma (Shapiro, 1989). Since then, EMDR has developed and evolved through the contributions of therapists and researchers all over the world. Today, EMDR is a set of standardized protocols that incorporates elements from many different treatment approaches. To date, approximately 20 controlled studies have investigated the effects of EMDR, and these studies have consistently found that EMDR effectively decreases / eliminates the symptoms of post traumatic stress for the majority of clients. Clients also frequently report improvement in other associated symptoms such as anxiety. The current treatment guidelines of the American Psychiatric Association and the International Society for Traumatic Stress Studies designate EMDR as an effective treatment for post traumatic stress. EMDR was also found effective by the U.S. Department of Veterans Affairs and Department of Defense, the United Kingdom Department of Health, the Israeli National Council for Mental Health, and many other international health and governmental agencies. Research has also shown that EMDR can be an efficient and rapid treatment. At Arizona Child Psychology, PLLC, we offer EMDR therapy to clients who we believe would benefit from this therapeutic approach, including children, adolescents and adults. For more information on EMDR therapy, please visit www.emdria.org

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders - text revision (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Bellman, M. (1966). Studies on encopresis [Special supplement]. ActaPaediatricaScandanavica, 1970.

CDC: Department of Health and Human Services Center for Disease Control and Prevention (2008). Autism Information Center [Online]. Available: http://www.cdc.gov/ncbddd/autism/faq_prevalence.htm

Christophersen, E. R., &Mortweet, S. L. (2003). Treatments that work with children: Empirically supported strategies for managing childhood problems. Washington, DC: American Psychological Association. http://consensus.nih.gov/1998/1998AttentionDeficitHyperactivityDisorder110html.htm

Hibbs, E. D., & Jensen, P.S. (Eds.). (1996). Psychosocial treatment for child and adolescent disorders: Empirically based strategies for clinical practice. Washington, DC: American Psychological Association.

Levine, M. D. (1976). Children with encopresis: A study of treatment outcome. Pediatrics, 56, 412-416.

Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.

Monstrasa, V. J. (2005). Parenting children with ADHD: 10 lessons that medicine cannot teach. Washington, DC: American Psychological Association.

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223.