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The Private Practice of Tory Hoff

 

 


Currently my private practice as a counselling psychologist consists of services to individual adults and couples, with a specialty in providing psychological therapy to those who have been in motor vehicle and work-related accidents. There is a wide range of presenting problems among those who meet with me but most are suffering chronic ailments such as chronic fatigue, fibromyalgia, and posttraumatic stress symptoms. The lawyers of my clients sometimes ask me to write a report regarding their psychological condition and prognosis.

On Tuesdays and one Friday a month patients meet with me at my Mississauga office in the Medical Arts Building at 71 King Street West, Suite 201, near Dundas and Hurontario. Other days, they come to my primary office at 2 Carlton Street, Suite 1009, on the Yonge subway line at the College Station.

In Mississauga, I am fortunate to have a clinical assistant under my supervision, Mr. James Whetstone, M.A. He is a senior driving instructor with the Ministry of Transportation, and his specialty is to offer driver reintegration within a vehicle for those clients who have become afraid to drive or ride in a motor vehicle. I sublet from a family physician, Dr. Talwalkar, and am assisted by his office manager, Arshi Daudi.

I am fortunate to have an office manager at my Toronto location, Ms. Debbie Murray, and our assistant, Ms. Kesla Forsythe, to handle the record keeping, billing, accounts, and numerous other tasks involved in operating a private practice.

As the Toronto office, I sublet from Christian Counselling Services and am also on staff part-time. As such, I work alongside several other staff members. In addition to meeting with a few clients of my own, I supervise these colleagues when their clients have an extended health plan through their place of employment that reimburses for the services of a psychologist. We also have an internship program in which M.A. level students provide counselling to clients who cannot afford our minimum fee of $75 per hour.

On occasion I manage to charge the full rate for a psychologist in Ontario, that being $225.00 an hour. In most cases, however, I offer a reduced hourly rate depending on the ability of the client to pay and whether or not he or she has access to insurance benefits. The rate of $150 an hour is common.

 


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Addresses

Dr. Tory Hoff, Psychologist
2 Carlton Street, Suite 1009, Toronto, Ontario M5B 1J3
(at College Street subway stop on Yonge)
phone: 416-429-9767
fax: 416-489-3351

Christian Counselling Services
2 Carlton Street, Suite 1009, Toronto, Ontario M5B 1J3
(at College Street subway stop on Yonge)
phone: 416-489-3350
fax: 416-489-3351

71 King Street West, Suite 201, Mississauga, Ontario L5B 4A2
(southwest of Dundas & Hurontario)
phone: 905-949-2112
fax: 416-489-3351

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Professional Training

Surrey Place Centre, Child & Youth Division, 1996-98
Wellesley Hospital, Department of Psychology, 1995-96
Personnel Performance Consultants, Saskatoon, 1990-92
Toronto General Hospital, Psychiatric Ward, 1984-85
Counselling and Development Centre at York University, 1983-84
Earlscourt Children's Home, Toronto, 1974-76

Received B.A. in psychology from the University of California at Davis in 1970, M.A. in psychology from Carleton University in 1980, and Ph.D. in psychology from York University in 1990. On faculty in the Department of Psychology at the University of Saskatchewan from 1987 to 1994. Published articles about 19th-century psychology. A registered psychologist in Ontario since 1996.

Referrals come from many sources including family physicians, psychiatrists, chiropractors, massage therapists, and legal representatives as well as former clients.

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Services Specific to Those Involved in Accidents

Most people are affected mentally due to an accident. A common result is anxiety when driving or riding in vehicles or when around machinery being used when the accident happened. It is not uncommon that these persons also find themselves irritable, frustrated, overly sensitive, and grieving about their losses. Sometimes they are off work, which leads to boredom, and financial difficulties increase, which causes more anxiety and depression. They then become more difficult to live with, and thus the accident puts a strain on their social relations. Also, the accident can result in cognitive problems such as poor concentration, forgetfulness, and mental confusion, even though an obvious head injury did not occur. Dealing with the pain, especially the headaches, and the poor sleep adds to the ordeal that the accident has become.

People with such symptoms usually benefit from talking with a mental health professional like myself who is trained to help them to understand, to deal with, and to overcome them.

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Fees

A person involved in a motor vehicle accident in Ontario is entitled to a psychological assessment, the cost of which is paid by that person's insurance company. If after the assessment I conclude that the person would benefit from counselling, then I propose a treatment plan consisting of a given number of hours. If the insurance company considers this plan to be "reasonable and necessary," then it pays my fees. If it refuses, then an impartial psychologist is hired to decide whether the insurance company must pay. Although this process can be stressful to the client, it reflects current legislation for the insurance and health care systems in Ontario. I do not withdraw services when my treatment plans are refused, as greater stress increases the need for services. Work-related accidents involves dealing with the Workers Safety and Insurance Board, the provincial insurer. Similar legislation governs the way that claimants seek out my services and how I get paid.

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Short Articles

The following are two short articles that are a product of the sessions I have had with various people in comparatively minor motor vehicle accidents. The stories they tell are very similar in terms of symptoms, impact on life, and problems dealing with the insurance, legal and medical systems here in Ontario.



Reflections on the Human Inability to Understand the Effects of Trauma
Regarding my experience assessing and counselling people who have been in motor vehicle accidents, perhaps the first thing to say is that the ones I see have not sustained "life threatening" injuries, but have been in accidents ranging from minor fender bumpers to ones serious enough to leave them unable to perform their daily activities including duties at work.

Those clients having the most difficulty are those with incessant headaches and related intellectual impairments. Sometimes a minor closed head injury and concussion to the brain is documented in reports. In other cases, however, no such injury is evident. Nevertheless the person is suffering headaches and, for instance, is unable to maintain mental focus on a task such as reading. It is not only that their pain focus leaves them unable to pay attention to other things or that they have become too anxious and depressed to concentrate, but that mental confusion and disorientation persist.

Physicians, lawyers, and insurance adjustors too readily attribute these impairments to previous psychological problems, particularly if the tests for physical injury reveal nothing. The implication is that a well functioning person without an identifiable head injury would not have these intellectual difficulties, and that therefore something must have already been mentally wrong with the client to predispose him or her to acquire these unexpected, lingering symptoms. This reasoning is not entirely fair, and is not of any therapeutic value to the person who is struggling with headaches and intellectual deficits and is therefore emotionally distraught.

What seems helpful to these unfortunate clients is the more holistic idea that the collision led to shock and trauma that has affected their selfhood deeply, that is, profoundly affected them in the physical, psychological and spiritual dimensions of their being. The result is a kind of post-traumatic stress, but the condition of these clients requires a much broader concept that goes beyond notions such as flashbacks, emotional numbness, and irritability. A way to understand these clients is to realize that the trauma of the accident can include a disturbance of self identity and personal beliefs brought on by a sudden loss of who they were and what they did. Thus what physically speaking was not diagnosed as "life-threatening" actually was.

Medical science does not have a good diagnostic category for these individuals. The closest are perhaps post-traumatic fibromyalgia and chronic fatigue syndrome. Likely the people that these categories include are diverse medical groups with similar presenting problems, some of whom can point to an identifiable trauma event/injury that precipitated their symptoms. In other words, medical diagnosis in this area of the impact of trauma on a person's life is currently not much more advanced that the eighteenth century diagnoses in which many disorders among men were called "hypochondriasis" and many ones among women were called "hysteria." What is clear is that before the traumatic event, the person was functioning reasonably well and after the accident he or she does not recover within "the usual" expected time such as six to eight weeks.

A good percentage of my psychological practice consists of people in motor vehicle accidents who are not recovering as expected. In most cases a whiplash injury occurred. Exactly what is going on physically seems to be something that few medical people are understanding, which is not surprising given current diagnostic confusion. What also is not surprising, to me at least, is that the injury does not show up on x-rays, CAT scans and MRI's. The psychophysical reaction to the motor vehicle accident instead appears as the headaches and cognitive deficits already mentioned, plus fatigue, depression, poor sleep, and chronic pain to name the most common problems. Also, there is emotional instability and the inability to regulate affect as is common with post traumatic stress in general, plus whatever corresponding dysfunction is occurring biochemically and physiologically including neurophysiologically. Prescription drugs aimed at knocking out the symptoms have their place as they can help the person function. The problem, however, is that these drugs do not promote systemic, psychophysical recovery of person, and might actually impede it.



Reflections About Those He Loves
I need a better theology of trauma. What I mean is, I am learning more about the psychological and physical aspects of trauma, but the spiritual aspects regarding how our faith life relates to the impact of a life-threatening event are less clear to me.

Let me first say that many of my traumatized clients do not understand their psychological injuries very well. They think that they are mental cases because they have "become paranoid," for instance, about going out of their houses, about sexual involvements with their mates, about others acting maliciously, or about traumatic events happening again. They avoid aspects of the world, and they want to withdraw socially. They do not know why. They also start believing that they are "going crazy" because of the way that they have changed emotionally. They observe that they have developed an "I don't care" attitude in which they are highly irritable and they readily "let everyone have it," yet at the same time feel emotionally numb and indifferent.

Furthermore, their sense of self is shaken, that is, they report feeling like they are not the same persons. "This is not me!" When the trauma results in an inability to work and to conduct the usual daily routines, then this threat to self is further intensified. It is almost like a personal identity crisis because some kind of inner disintegration is occurring. The integrity of self is disrupted. Likewise, their basic sense of trust and of the world being safe is taken away from them. That which did not upset them emotionally now becomes an object to fear.

People going through these things find it helpful when I explain that their "symptoms" are consistent with post-traumatic stress. I further explain that the trauma involves a disinhibition of emotional energy and thus an inability to regulate emotion, though I usually put it in less technical language. Although such explanations do not take away the symptoms, they at least help traumatized people stabilize. It means a lot to them to feel understood and that someone can help them understand better.

Sometimes these traumatized clients do not understand their physical injuries very well either, for the longer their physical pain persists and the more they are sent for tests that are unable to detect any structural problems, the more they wonder if it is "all in their heads" or somehow imagined by them. However, I explain that in addition to any structural damage they might have received due to the accident, this business of being nearly scared to death affects them physically in the form of abnormal physiology including disrupted brain processes. For instance, all of the emotional/mental disturbances they are experiencing are from a physical point of view physiological disturbances.I further explain that people who have been nearly scared to death are of course shaken and shocked at a fundamental level of their being, that is, deep within themselves, which of course includes their physical nature. So of course this shock is followed by aches and pains including headaches, by problems thinking clearly due to "mental fog" and poor concentration, and by lack of energy and feelings of depression and malaise. Sometimes when I first meet a client, the body language of the person suggests that the trauma occurred earlier that day. Further inquiry, however, reveals that the original trauma occurred weeks if not months or years ago. Somehow this traumatic event is still live for the person and has stuck, and possible retraumatization in one form or other needs to be explored. I try to communicate that the more the original event was traumatic and the more additional trauma occurs, the more likely their "symptoms" will persist. I raise the possibility that a more serious situation has developed such as when their presentation suggests post-traumatic fibromyalgia.

Even a brief discussion of possible methods to "treat" these post-traumatic "symptoms" requires more space than this newsletter provides. Let me say, however, a few words about a counterproductive thing that most clients do, especially those who before they were injured took charge, stayed in control, organized themselves and others, and tackled problems head on. Many clients fight their psychophysical symptoms, saying they "should not" have them, and thus try to control, bully, or stamp them out. Guess what, this does not work.

What I encourage these clients to do instead is, in essence, to forgive themselves for having their psychophysical wounds. This requires a kind of acceptance, of course not one in which they conclude that it is okay to have their injuries but one in which they admit that they are injured and that therefore they must change their self expectations during a perhaps extended period of recovery.

The treatment of trauma requires a holistic perspective in which the trauma is primarily viewed as an injury to a psychophysical self. To see only the injuries that may have been sustained by body structures is to miss what has occurred physiologically as well as psychologically, the result being that the medical profession blames the patient for not getting better on time. To see only the injuries that occurred psychologically is to forget that psychological life has its bodily correlates and social context. Then the mental health professional unfortunately approaches the problem irrespective of correlates and context. For instance, I am becoming more convinced that it is nearly impossible for someone to recover from traumatic experience if they lack support from family and friends, if they have become financially stressed, and if they are not eating and drinking properly and not involved in some sort of physical rehabilitation. So what is missed when the spiritual dimension of their traumatic experience is disregarded? And does not a holistic perspective include the spiritual aspects of how the trauma has impacted on clients' lives? Furthermore, what might be a Christ inspired way to understand the spiritual dimensions of their trauma? These questions of course can be answered in many different ways. Among other things, what makes sense to me so far is the Christian concept of suffering, in which the psychophysical wounds resulting from life threatening trauma are somehow a blessing. How can this perplexing if not offensive assertion be true? Its reality, I believe, is reflected in the Beatitudes that start with "Blessed are those who are poor in spirit for they shall see God." Paraphrased it reads, blessed are those who have the breath/spirit [knocked] out of them and are hence dispirited and disheartened, for they shall have a sense of God's presence. How can this be for those whose emotional lives are entirely disrupted to the extent that they can feel irritable and numb and the same time?

Entering into this reality requires accepting our status as creatures, acknowledging that we are nothing in ourselves and that ultimately who we are is given to us. God is the giving agent and we are the receiving patient. Indeed that patience of Job we have learned about refers to the way that he accepted his role as patient despite the fact that emotionally speaking he was irritable, angry, disconsolate, and grief struck, in sum, entirely not patient. Spiritually speaking, he came to see his own arrogance before God and in the process submitted to the creaturely status of patient. When traumatized persons are able to accept their injuries spiritually, then they are able to transcend the previously haunting question, "Why me?" Once they have experienced their own "nothingness," then recovery becomes more possible. This healing from trauma includes a rebuilding of basic trust, not only in regards to people around them, but also with respect to their God.

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Tory Hoff. All Rights Reserved.    Contact Dr. Tory Hoff, Psychologist at drhoff@drhoff.com