Author Archives: Diane

Working with Separation and Divorce


diane suffridge therapistI was recently contacted by a single mom asking for therapy for her 8-year-old son.  She describes him having problems with anxiety and concentration, especially in the day or two after weekend visits with his dad.  They have had joint custody since their divorce two years ago, but mom says dad is skeptical of therapy so she wants to bring her son in for an initial appointment without talking to dad.  I usually like to meet with both parents at the beginning of child therapy, so I’m reluctant to make an exception in this case.  What should I consider in responding to mom’s request?  

Working with families involved with separation and divorce is complex, and you are wise to be thoughtful about how you approach the beginning of therapy in this case.  Chapter 7 of my book includes more detail about this topic, as well as other specialized areas of assessment.  I’ll review the legal and clinical implications of working with one or both parents in child therapy and discuss some of the factors that influence parents to request therapy for their children following divorce.

First, it’s important to consider the legal issues regarding parental consent for a child’s therapy.  If the parents share joint custody, the consent of only one is required; however, if the other parent objects at any point you will be required to end treatment.  It would be detrimental to the child to end therapy abruptly after a few weeks or months, and that is a risk inherent in beginning therapy without the consent of both parents.  At minimum, I would recommend asking the mother to provide a copy of the custody decree so you have confirmation of her report.

Although you might be legally permitted to begin therapy with only one parent’s consent, there are many clinical reasons to engage both parents in the therapy.  Your practice of meeting with both parents indicates you are aware of the importance of hearing both parents’ perspective on the child, the importance to the child of knowing that you maintain a relationship with both parents as he does, and the benefit to the child of providing consultation to both parents about their influence on him.  Part of the initial phase of any therapeutic relationship is establishing the frame, and making an exception to your usual practice would undermine the clarity of the frame and your role as a professional.

It is often helpful to reflect on some of the factors that may influence this mother to seek therapy for her son.  In addition to concern about his emotional wellbeing, she probably has other motivations, both conscious and unconscious.  She may wish to attribute any difficulty in her son’s emotions and behavior to his father in order to reduce her feelings of guilt and shame; she may be looking for an advocate in a legal proceeding regarding financial support or custody; or she may feel threatened by her son’s relationship with his father.  It is wise to assume that this mother’s request is more complex than it may initially appear and to remember that your role is to serve the child’s needs which overlap with but are not identical to those of his mother.

You may find it helpful to develop a standard way of describing your reasons for involving both parents in therapy, especially after divorce.  An example that would fit this case is “I understand your son’s dad has some reservations about therapy, but I have found it essential to talk with both parents in order to make sure I have the full picture.  I won’t be effective in helping your son if I’m not in touch with both of you.  How could we work that out?”.  It is possible that the mother will decide to look for another clinician, and you may feel pulled by your concern for the son.  However, maintaining a clear therapeutic frame is especially important in cases involving divorce.

Most clinicians find it challenging to work with families of divorce, so consultation with an experienced clinician will be helpful.  You may also find ongoing peer consultation to be a resource for navigating the emotionally charged issues that are part of this work.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Sources of Information for Assessment

I have had two therapy sessions with a 24-year-old woman who was hospitalized six months ago for suicidal ideation. She has been stable since then and wants to use therapy to understand what led to her suicidal thoughts. She has given me permission to talk with her psychiatrist and her parents with whom she lives, and she suggested I contact the hospital to get their report of her stay. I usually like to keep the therapy between me and the client, but in this case I think information from these other sources might help.

I agree that it might be necessary to expand beyond your client’s self report of history and symptoms in order to insure your client’s safety while she explores her past suicidal ideation. This question addresses the decisions inherent in conducting an initial assessment, which is discussed in Chapter 6 of my book. I’ll review whether and how to include information from other mental health providers, family members, and treatment records, after discussing the sources of information that come from your client sessions.

Therapy usually begins with a conversation between you and the client in which she tells you what difficulties are leading her to seek help. The initial phase of establishing a therapeutic alliance overlaps with doing an assessment of the client, so you develop a comprehensive picture of her life and circumstances that will guide your treatment approach. Your therapy sessions provide two sources of information about the client: her self-report and your observations. In the first two sessions, she has probably told you about her current concerns and symptoms, living circumstances, and relevant events from the past including her hospitalization. Whether you have been consciously aware of it or not, you are also observing her and noticing the nonverbal aspects of her presentation that are congruent or incongruent with her verbal presentation. Another aspect of the therapy sessions is the impact of the sessions on your own emotional state.

Client self-report and therapist observations are usually the primary source of assessment information, and sometimes are the only source. In this case, I would suggest expanding the client’s self-report by using one or more assessment measures. The Crpss-Cutting Symptoms Measure, contained in the Assessment section of the DSM- 5, is free and can be downloaded at https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures. Your agency may have other measures that are relevant to her presenting issues or you can find assessment tools at http://www.integration.samhsa.gov/clinical-practice/screening-tools. It may be useful to compare the client’s narrative report in session with her self report on an objective assessment measure. Your treatment approach will be different if her scores on objective measures indicate greater risk than she has reported to you in the first two sessions.

In terms of the other sources you mention, consulting with her psychiatrist seems essential so that you can develop a collaborative relationship as treatment providers. As your client explores the sources of her suicidal ideation, her symptoms may temporarily increase and her medication needs may change. The psychiatrist can also share the client’s treatment history and response, which you can compare with your client’s report. Talking with your client’s parents is more complicated and needs further evaluation. I recommend postponing that conversation until you know more about your client’s current relationship with her parents, past events in the family, and general family dynamics. Over time you will begin to make inferences about these issues as you hear more about her perspective on their interactions. I would begin this exploration by asking what she expects her parents would tell you and how she would feel about you hearing that from them.

Last, your client has suggested that you read the hospital record. This may contain useful historical and clinical information, so I would recommend requesting it. Be aware that it may be more difficult to obtain a hospital record than to talk with the psychiatrist, depending on the procedures in place there. The discharge summary is the most useful clinical document, so you can ask for that rather than for the full record which will include notes from each nursing shift during her stay that are less relevant to her current status.

Combining these sources of information will result in a comprehensive assessment, which is especially important in cases with elevated risk. Supplementing the therapy sessions with self-report measures, information from another provider, treatment records, and possibly family members will enable you to be clearer in your treatment approach. Your overall goal will be to respond to the client’s desire to understand her past suicidal ideation while helping her maintain physical and emotional safety.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Discussions of Diagnosis

writing-notebookI work at an agency that requires us to give a diagnosis to each of our clients. I’ve gotten comfortable with this requirement and the diagnoses I give to my clients, but I’m concerned that someone will ask me about their diagnosis. I think the clients will feel upset about knowing that I have diagnosed them, so I dread the possibility of someone asking me about it.

One section of Chapter 5 of my book specifically reviews how to discuss diagnosis with your client, and the case example at the end of that chapter includes an illustration of a therapeutic conversation about diagnosis. I’ll summarize some of the important points here.

Your concern is common among clinicians, who associate diagnosis with the medical model and a lack of subjective understanding and empathy for the client. Agencies whose clients rely on third party funding generally require that all clients receive a diagnosis because of funder requirements. Your clients might not be able to get the treatment they need without third party payment and your documentation of a diagnosis that meets medical necessity guidelines, but it does raise a clinical dilemma.

A place to start with this dilemma is to review your diagnoses and confirm that they are accurate based on the clients’ report of symptoms and your observation of them in session. It sounds like you’ve done this with your clients, but your level of concern may decrease if you go through this review systematically. If any of your diagnoses don’t fit the client’s report or if symptoms have changed during the course of treatment, you can modify the original diagnosis to fit the current symptom picture.

In anticipating a conversation with your client, there are several things to keep in mind. One issue is to think about the meaning of diagnosis at this particular time in treatment. A client who raises a question about diagnosis in the second session probably has different reasons for wanting to discuss it than a client who raises the question after six months. When a client asks about diagnosis, you can explore the meaning by saying something like “I’m happy to talk with you about this, but I’m also curious about what goes into your question.” Starting with reassurance that you will answer the question makes it more likely that the client will be open in sharing her/his motivation. You can then discuss the diagnosis in a way that addresses the client’s concern. For example, if the client expresses worry that she/he is “crazy” you will answer differently than if the client wonders what the number means on the statement she/he received from the insurance provider.

A second issue to consider is the emotional response your client is likely to have to the specific diagnosis you have assigned. Approach this conversation in the same way you approach any topic in the therapy. It is best to say a few sentences initially, then ask the client for her/his reaction and be alert for nonverbal cues that provide additional information. If the client’s diagnosis is something that may be negatively charged for your client, consider prefacing disclosure of the diagnosis by a statement like “You may have some preconceptions about what this particular diagnosis means, so if it’s all right, I’d like to tell you why I have used this diagnosis for you.” Then summarize the aspects of the client’s report of symptoms and your observations that support the diagnosis. You can then ask the client if your summary seems accurate. After you and the client have agreed on the symptoms and issues, you can then say “In the field of psychotherapy, that combination of difficulties is described with the diagnosis of (the name of the disorder)” and pause for the client’s response. If the client is concerned about whether this diagnosis means she/he will be unable to improve or to achieve life goals, you can discuss the treatment approaches that you are using and express realistic optimism that the client’s symptoms can be managed effectively.

Probably the most important way to insure a productive and therapeutic conversation about diagnosis is to continue to reflect on your views of diagnosis and the stigma you may hold about diagnosis in general or about specific disorders. If you develop the skill to speak openly about diagnosis, your clients’ shame, self-judgment and suspicion will be minimized. My personal definition of diagnosis is that it is a standard, professional way of summarizing a broad range of information about the client’s present and past symptoms and experiences. For me, a diagnosis doesn’t reflect a feeling or judgment about the client and it doesn’t imply a prediction about the client’s overall capacity to lead a fulfilling life. Holding the meaning of diagnosis in this way enables me to respond to my clients’ questions with confidence that the conversation will not have a negative impact on our therapeutic relationship.

I hope these suggestions are helpful in having conversations about diagnosis with your therapy clients. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Awareness of Cultural Influences

counselingI am a female therapist working with a young woman in her 20’s. She has an opportunity for a promotion which would involve business travel a couple times a month, and would be a good career move for her. However, she is considering turning down the promotion because she helps her parents care for her grandmother who has many health problems. It’s hard for me to see my client sacrifice her professional success for this family obligation. How can I help her with this decision?

This is an example of the influence of cultural values in psychotherapy. You and your client are both female, but you may be different in other cultural identities such as age, ethnicity, social class, sexual identity, religious affiliation, and immigration status. Our values and our views of relationships are shaped by the combination of cultural factors that make up our identity, and these differences between you and your client lead you to different cultural values. The topic of cultural issues in psychotherapy is covered in Chapter 4 of my book.

It is important for you to recognize that you have formed an opinion about what is best for your client based on your values, but she is letting you know that she views her situation differently. Assuming that she needs to come around to your point of view interferes with the understanding that can develop when you are curious and interested in her perspective. Take time to encourage her to explore and reflect on the values she is expressing by pursuing a career and by caring for her grandmother so she can become more clear about the dilemma she is facing. As you are more open to considering her point of view, you will be able to empathize with her complex feelings and to support her making a decision in line with what is most meaningful to her.

Be aware that your client may be making assumptions about what is and isn’t acceptable to her family, and she may not have discussed her decision openly with her family. Our beliefs about ourselves and relationships are often internalized early in life and may not be fully within her awareness or part of recent family conversations. Once you have helped your client become aware of her values, you and she can examine them together to see the extent to which they inform her decision. It may also be useful for her to talk with others in her cultural community to see whether there is more diversity of opinion than she assumes or than she believes based on her individual experience in her family. Getting consultation, especially from someone who is familiar with your client’s cultural influences, will be helpful in managing your feelings as she arrives at her decision.

In addition to your client’s values, examine the practical issues that may influence her decision to take this promotion. The immigration status of her parents and grandmother, the family’s financial resources, and the presence of other support in the community are all factors that may make it more or less difficult for your client to prioritize her career, if that is what she wishes to do. It may take time for her to disclose some of these details to you, depending on the extent to which she holds cultural values that consider such matters as private, not to be shared outside the family.

This career decision may be the beginning of numerous situations your client will face and need to discuss in therapy. Whatever she decides about this promotion, continuing to talk with her about her cultural values will be helpful in her developmental progress. It is likely that she will face similar choices in the future as she navigates her career and family commitments. If you recognize your values and assumptions as culturally influenced and develop an authentic interest and curiosity in your client’s perspective, the therapy is likely to develop into a deeper and richer relationship. You have an opportunity to provide your client with the experience of empathy, understanding, and respect that will build her confidence in making this and future decisions.

If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

 

Instilling Hope in a First Session

I’m starting a new placement next month, and I want to know how to be as helpful as possible in my client sessions. How can I handle the first session so they are likely to want to come back and continue therapy?

Starting your first placement is a big step and one that most clinicians approach with some amount of anxiety as well as excitement. It’s a good idea to start by thinking about the first session with clients and how to engage them from the beginning. There is a lot to do in a first session–getting informed consent, establishing a therapeutic alliance, following the client’s story, beginning an assessment, and responding to the client’s wishes and goals–and chapter 3 of my book covers this topic. Communicating empathy and understanding is crucial in the first session as clients share their distress and pain. They are motivated to continue therapy when they have a feeling of hope in the therapeutic process. In this blog, I will describe two ways to instill hope during the first session.

First, clients feel hopeful when they have an awareness of their strengths, which provides confidence that they can face and overcome their difficulties. It is important to hold a “both/and” perspective in talking about strengths, reflecting that you understand the seriousness of the clients’ concerns and problems while also pointing out the capabilities reflected in their life stories. Most often, clients enter therapy feeling discouraged and self-critical. Feelings of shame and fear are common, whether their symptoms are new, have occurred at other times, or have been ongoing. There are a number of ways to identify and highlight the client’s strengths, depending on the initial presentation and the flow of the session. When the client leads with a description of what isn’t working and how their life has been impacted negatively, you can ask how they have coped with this difficult situation and support whatever positive coping strategies they report using. An example is “It’s impressive that you’ve been able to connect with a friend at least once a week, even though your depression has interfered with your appetite and sleep and your mood has been very low.” You can also ask about different areas of the client’s life and contrast areas of success with areas that are more problematic by saying, for example, “It sounds like your anxiety has made it hard to speak up in meetings at work, but you were able to advocate for your daughter to get the help she needed at school.” It also helps to reflect the client’s statements of strength in addition to reflecting and empathizing with their problems.

Second, clients need to leave a first session with a sense of hope in and direction for the therapy. I use the last 5-10 minutes of the first session for this purpose, including asking the client how it has been to talk about her concerns, summarizing how I would anticipate working together on her presenting issues, and expressing confidence that therapy can be helpful. I emphasize the collaborative nature of therapy by using terms like “working together” or “what we might look at,” and I provide a realistic assessment of the uncertainty and difficulty of changing longstanding patterns along with my belief that things can improve. A short summary statement is “If you want to continue working together, I would recommend looking at the emotions that have led to your outbursts of anger and how you can develop different ways to express those emotions before they become really intense. I know you’ve avoided the fear and sadness we talked about very briefly today, but I believe those emotions are related to the anger outbursts. You said your goal is to reduce your anger, and if you’re willing to look at those other emotions as you’re ready, I think you’ll be able to do that.”

If you keep these two strategies in mind in your first session with clients, I believe you’ll help them feel hopeful about continuing to work with you in therapy. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Beginning Therapy with the First Client Contact

Client DisengagementI have been assigned to see a 47-year-old man who told the intake worker he had been depressed for over a year but isn’t willing to take medication. I was finally able to reach him by phone after trying 3 times, and he scheduled a first appointment. Since then, he has cancelled twice saying he is too depressed to come in. I don’t know what more to do and don’t know whether I can help him if he can’t even come to the office.

It is difficult and often frustrating to have multiple phone interactions and messages with a client you haven’t met who seems unwilling or unable to participate in therapy. One way to think about this situation, which is covered in Chapter 2 of my book, is that the therapy begins with your first contact with the client. Sometimes we think of our first telephone interactions as administrative or business tasks taking place before the therapy itself. However, the therapeutic relationship actually begins when you first learn about the client, and you are likely to have the best chance of engaging him when you approach these initial conversations as the beginning of the therapy.

In this case, thinking therapeutically begins with evaluating the meaning of the information you have so far. Your client is developmentally in mid life, and his depression could be related to circumstances that commonly occur in that life stage—loss of a job, ending of a relationship, onset or exacerbation of a medical condition, or death of a parent or another loved one. It can be more difficult to recover from disappointments and losses at mid life, when people begin to experience the narrowing of opportunities that seemed open in earlier in adulthood. His sense of worth and value may be at a low ebb, and asking for help is associated with admitting weakness in many cultures, especially for men.

You also know he says he isn’t willing to take medication. Although you don’t know why he has made this decision, it is meaningful that he shared this with the intake worker. I would hypothesize that he wishes to maintain a feeling of control in the course of his treatment, probably offsetting other ways in which he feels helpless, frightened, and despairing. He is most likely to engage in therapy if he is able to feel a sense of control with you, and so far he seems to be exerting this control by cancelling scheduled appointments.

Before contacting your client again, I would encourage you to think about how you could approach a conversation with him with the goal of communicating a view of him as capable, rather than weak, and an approach to therapy that is collaborative rather than hierarchical. He might respond well to you reframing his decision to cancel your appointments and to not take medication, then you can move on to putting the decision about scheduling in his hands. An example would be “It seems like you’ve been able to reach some clarity about what is most helpful for you in managing your depression. Would it work best if I wait for you to contact me about setting up another appointment?” If he says yes, you could ask if he would like you to be in touch in a week if you don’t hear from him or if he would prefer to contact you when he feels ready. If he says he wants to schedule a session, I would recommend offering him at least two different times so he can retain a sense of control. For example, you could say “I’m in the office three days a week, and right now I have openings on Mondays at 2, Wednesdays at 10, or Thursdays at 6. Are any of those times possible for you?”

It is possible that using the approach I recommend will result in him not beginning therapy, but I believe it represents your best chance of engaging him. Regardless of the outcome, I believe you always will be most effective as a therapist when you think about establishing a therapeutic relationship with your client from the first contact.

I hope you found these comments helpful in your initial interactions with clients before seeing them in person. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Motivations for Becoming a Therapist

I just finished my first semester in a practicum placement, and I have begun to doubt my decision to become a therapist. I decided to enroll in graduate school because I liked to talk to people and heard from my friends that I was a good listener. Seeing clients this semester was much harder than I expected, and I didn’t feel like I was able to help them very much. How can I dnew2ecide whether to stay in the program or leave to pursue a different career?

The experiences that lead us to enter the field of counseling or psychotherapy are varied but often include ways we have taken a helping role in our personal relationships. The topic of our motivations to become a therapist, covered in Chapter 1 of my book, is complex because it includes emotions outside of our awareness as well as thoughts and feelings that we can identify directly. I’ll discuss some ways you can identify aspects of your motivation that may be influencing your doubts, then recommend how to approach your career decision.

Your enjoyment of conversations with your friends and feedback about your listening skills are common factors in leading someone to consider the psychotherapy field. An initial step in identifying more about your motivation is to reflect on what aspect of these conversations was most enjoyable to you. Did you like the process of getting to know someone more intimately, did you like to follow their stories, were you attracted to analyzing their problems or understanding their feelings? Getting more specific about the experiences that led you to this field will give you more information about your choice to enroll in a graduate program.

Next, it is important to look at aspects of your motivation that are less obvious and may not have entered your conscious awareness. Reflect on what you didn’t do or say in your social interactions or what you avoided by being a good listener. It’s possible that you are uncomfortable with the vulnerability that comes with sharing your own thoughts and feelings. You may have adopted a caretaking role because it was expected and/or rewarded in your family and culture or you may focus on others in order to avoid facing painful memories or being alone with your struggles.

Once you have looked more deeply at your motivation, examine the benefits that have come with your interpersonal style. Being a good listener may enable you to feel effective and empowered, and it may be a source of positive self-esteem as well as praise from others. If you help your friends and family members solve their problems, you can be less worried about your own difficulties. It is natural to assume that you will feel the same rewards with your clients, but clinical work is slower and more complex than personal interactions. It can be discouraging to face the difference between your expectations and the reality of working with clients whose problems involve psychological distress, sociocultural stressors, and mental health conditions. If you decide to stay on your path to becoming a therapist, you will need to adjust your expectations and find rewards in clinical work that are different than in your personal relationships.

Having engaged in self-reflection, I recommend that you reach out to others who can assist you in addressing your career question. Discouragement and doubt is often part of the learning process, and you are likely to feel understood and reassured by talking with professors and fellow students in your academic program and with supervisors and colleagues in your practicum setting. If you’re not already seeing a psychotherapist, this is a good time to begin personal therapy to learn more about the experiences that contributed to your career choice and to explore the meaning of your disappointment as a new therapist.

I hope you found this helpful in understanding more about your motivations for becoming a therapist. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

When to Engage in Client Advocacy

I have had six sessions with a client who initially presented with symptoms of depression. Since the first session, she has tohispanic young woman in therapyld me about being treated unfairly at her last job, which resulted in her being laid off and led to her depression. She has filed a complaint against her employer and has asked me to talk with her attorney. She would like me to write a letter supporting her complaint and describing the impact of her former employer’s unfair treatment. I feel strongly about advocating for clients in issues of justice so I would like to support her, but my supervisor has advised against doing this.

Like your supervisor, I generally recommend against taking a direct position in a complex legal case like this. I’ll outline some of the ways in which advocacy can be helpful and the reasons it is inadvisable to become involved in a legal or administrative dispute between your client and a third party.

Client advocacy is an important part of psychotherapy with many clients, especially those who come from minority cultural communities and other disenfranchised populations. Advocacy often has the purpose of facilitating access to needed resources such as contacting another agency or a government department to gain information about your client’s eligibility, accompanying your client to an intake appointment for social services or public assistance, or providing verbal or written support for your client’s application for services. We also provide advocacy to our clients when we encourage them to act in the service of their needs and goals, by providing information and/or support. For example, if your client wants to attend a community college course but doesn’t know how to apply, you might get the application information for your client, pass this on to her, and talk with her about the thoughts and feelings that arise as she completes the application. This information and support serves to empower your client in acting on her own behalf.

Your client’s request for advocacy goes beyond the functions of accessing resources and supporting her empowerment. There are several issues that are wise to consider when your client asks you to become involved in a legal or other type of dispute. First, it is important to keep in mind that you are hearing only your client’s side of the conflict and that the other party has a different perspective on the events. The ability to hold more than one point of view on the same situation is a skill that develops as part of professional development, and that ability is useful in this type of case. It isn’t necessary to challenge your client’s perspective or to try to arrive at an objective view, but it is important to remember that your view is based on your client’s interpretation of the events and their meaning.

Second, when your client is involved in a legal case she probably has at least two sources of motivation for treatment. One is to reduce her symptoms and improve the quality of her life, and another is to build support for her argument that she has been wronged and deserves compensation. The presence of these conflicting sources of motivation makes your therapeutic relationship complex, and being clear about your role and boundaries is especially important. You are on solid ground in your role as her therapist, working to help her improve her quality of life, and that requires you to refrain from taking an advocacy role in her complaint.

Third, providing an opinion in a legal case requires special training and expertise which is usually obtained after licensure. Individuals who work with the legal system in this way are functioning in the role of evaluator, with the goal of forming an objective opinion, rather than therapist, with the goal of understanding the client’s point of view. It is unlikely that you have sufficient information to determine a causal relationship between your client’s symptoms and her employer’s actions, and you are have entered a therapeutic rather than an evaluative relationship with your client.

I hope this expands your understanding of the complexity of client requests for advocacy. Please email me with comments, questions, or suggestions for future blog topics.

Theoretically Based Concepts in Documentation

person-apple-laptop-notebookI’m using a psychodynamic theoretical orientation in my work with clients, and I don’t know how much explanation of these concepts to put in my client’s progress notes and assessment. If anyone else looked at my notes, they might not understand why I chose particular interventions without the theoretical background. However, I learned from my supervisor that documentation should be behavioral rather than psychodynamic.

This is an important issue to consider in creating a client record, since your record may be viewed by other professionals or by your client. The primary interest for others viewing the client’s record is less about the reason for your interventions and more about what you did and how your client responded. When a client or another professional requests a record, it is most often for the purpose of insuring continuity of care or to learn about your client’s presenting problem and progress. You can maximize the value of the record for those purposes when you use language that is easily understood by people who are unfamiliar with psychodynamic or other theories of psychopathology and psychotherapy. It is likely to be distracting rather than helpful to try to explain the theoretical basis for your interventions.

One way to create a record that others can understand and use is to translate theoretically based concepts into terms that are more descriptive and objective. An example is to describe the client as “protecting herself from painful experiences” rather than “using the defense of projection” or to describe your intervention as “assisting the client to develop insight in order to modify his habitual patterns” rather than “interpreting unconscious motivations for self-sabotage.” This approach may be contradictory to assignments in your academic courses, where you are being evaluated on your understanding of and ability to apply theoretical concepts. That is an important skill, and it is a crucial element to an effective treatment plan. However, clinical documentation serves a different purpose and is written for a different audience than academic papers or a clinically oriented theoretical formulation of a case.

Another way to focus your attention in writing clinical documents is to keep the client’s goals uppermost in your mind. This means being aware of the context of your interventions as working to help the client make the changes they want to make. This might lead you to say “declined client’s request to extend the length of the session and supported her ability to self-regulate intense emotions” rather than “set limit on client’s attempt to test boundaries when in a dysregulated state.” Your documentation will convey a more collaborative tone when you focus on the desired outcome of your interventions, which is preferable when the record is viewed by others including the client.

I hope you can use some of these suggestions in writing clinical documentation that is understandable to professionals who have a different theoretical perspective and to nonprofessionals. Please email me with comments, questions, or suggestions for future blog topics.

Nonverbal Cues Related to Culture

nonverbalculturalcluesI recently had a first session with a client who immigrated from India last year. I’m Caucasian and haven’t lived outside the United States. My client didn’t seem as receptive to therapy as most of my other clients, and I assume this has to do with our cultural differences. What can I do to make it easier for her to benefit from therapy?

It is good for you to begin this therapeutic relationship with an awareness that you will need to make some adjustments in your usual therapeutic practices in order for this client to benefit from therapy. When we have significant cultural differences from our clients, it is our clinical responsibility to learn about the implications of these differences for establishing a therapeutic relationship.

The first step I would suggest is to get some education and consultation on your own, with supervisors, professors, and colleagues and by accessing professional publications in print or online. Since there are many cultural groups within India, it will be important to know your client’s geographic, religious, and class identifications. The easiest aspects of this education will be general information about views of health and mental health, symptoms, and treatment. Your client will also be able to tell you about her understanding of these aspects of her culture. Issues and struggles for first generation Indian clients are reflected in movies and books. The movie “Bend It Like Beckham” and the book “Life’s Not All Ha Ha Hee Hee” by Meera Syal are examples.

In general, boundaries within the Indian culture are very different from those in the West. Many generations live together, elders are expected to be cared for, and daughters in law are expected to bear the brunt of the work in traditional homes. Explore your client’s family structure and expectations, including the family members and living arrangement she left in India and whether she lives with family members or has acquaintances in the U.S. Approach these discussions with openness and keep in mind that individuation may not be the goal of therapy for your client. The structure of a family system that fosters both a sense of connection and a sense of individual wellbeing for this client may look different than for your clients who come from traditional Western culture.

The more difficult aspects of your need for education will be learning about the relational expectations of your client’s culture including nonverbal cues (i.e., eye contact and other gestures) and boundaries. It may be helpful to supplement your education about your client’s specific culture by consulting with colleagues and acquaintances who have immigrated from other cultures. They may be able to share their observations about the unspoken practices and expectations of U.S. culture which are outside of your awareness.

Regarding Indian culture specifically, clients are likely to present as cautious, anxious, or even timid with limited eye contact. These nonverbal cues are not a reflection of avoidance or resistance to therapy, but are signs of deference. The client will expect guidance and direct instruction and will feel comfortable knowing that the clinician is the expert. Therapy initially should be somewhat structured and have clear goals.

If your client immigrated in midlife or later, be aware that many older generation Indians are not psychologically educated and as a result present with somatic problems. They may be referred by a physician rather than self-referred. Consider spending time understanding how the somatic issue affects the client’s life and overall sense of wellbeing including how it affects their spiritual practice, diet, and family life.

In addition to education and consultation, your attentiveness to your client in session will give you valuable information. You mention that she didn’t seem as receptive to therapy as other clients, so I recommend giving some thought to what you observed or inferred in her behavior. Notice the nonverbal aspects of her interactions with you, and see if you can match her level of engagement in terms of expressiveness and eye contact. This may increase her comfort by reducing the interactional discrepancies between you. Be attentive to times in the session when she seems more or less comfortable and think about what may have been different in your relational style at those times. Emotions are often communicated through nonverbal gestures as much as or more than our words, so be careful about making interpretations about her emotional state based on your cultural assumptions. Note that the meaning of nonverbal cues is different across cultures; for example, a nod of the head that indicates saying “no” in western culture means “yes” for Indians.

It may also be useful to have some direct discussion with your client about some of the structural aspects of therapy that are unfamiliar to her. Interpersonal boundaries are experienced very differently in different cultures, so the meaning of professional behavior may be different for your client than you intend. Consider telling your client about the meaning of your professional boundaries and the therapeutic frame, acknowledging that these practices may be unfamiliar to her and may even seem odd. Invite your client’s comments and be open to shifting some aspects of your boundaries in minor ways if that will facilitate the development of the therapeutic relationship. For Indian clients, examples of appropriate differences in boundaries are accepting a small gift or a hug offered out of gratitude from the client, joining in the use of humor to bring warmth to the session, and using a double-handed hand shake.

I hope you find these suggestions helpful in understanding the nonverbal aspects of the therapeutic relationship in a cultural context. Please email me with comments, questions, or suggestions for future blog topics.

My colleague, Fenella das Gupta, LMFT, Ph.D. Neuroscience, provided consultation in developing the content of this blog post.  See Fenella’s website at http://www.innermirror.com for more information about her practice.