Author Archives: Diane

What to do with Things that Can’t be Changed

therapyI’m working with a 20-year-old woman who has a bad relationship with her parents. I’ve been encouraging her to use better communication techniques with them but their conversations always end with the parents yelling and my client feeling blamed. She’s asked them to go to family therapy with her but they refuse. How can I help her when her parents won’t change?

As therapists, we focus on the potential for growth and change, and we maintain hope for our clients when they are discouraged. This is an important and effective trait in many clinical situations; however, it is equally important to recognize and help clients deal with circumstances that can’t be changed.

The first step I would recommend for you is to examine your countertransference. Sometimes we develop unrealistic goals with and for our clients because of personal issues and feelings. In this case, I would ask yourself if your relationship with your own parents is related in some way to your feelings about your client’s situation. You may be trying to achieve something that wasn’t possible in your own life or to replicate an aspect of your life that worked well for you. Either way, work to separate your parental relationship from your client’s relationship with her parents.

Another countertransference issue that may be present is related to feeling competent and effective. Therapists in training are often more comfortable when giving advice, teaching a skill, or proving an active intervention. Reflect on how you feel when your client follows your suggestions and reports they don’t work. If it is hard for you to sit with your client’s painful feelings, your definition of therapeutic success may be too restrictive. Talk with your supervisor about what it’s like for you to be less active in session and explore the usefulness of being emotionally attuned and present.

If you are able to sit with your own feelings of discomfort you will be better able to help your client with one of her therapeutic tasks: accepting what cannot be changed. It sounds like you and she have become invested in her parents changing their behavior toward her and that change isn’t possible right now. It will feel painful to both of you to face this, but it seems to be the current reality of her life. Acknowledging this and allowing her to express her anger, fear, helplessness, and loss will be an important therapeutic intervention. It may take time and will be painful but it is in the service of her developmental growth. Accepting the state of her parental relationship will facilitate her ability to focus on other aspects of her life. She is entering adulthood and facing decisions about work, friendships and intimate relationships. If she has put these on hold to resolve things with her parents, it may be time for her to shift her attention and energy.

Paradoxically, you may find that your client reports some improvement in her relationship with her parents as she moves toward acceptance. Sometimes relational conflict is exacerbated by an implicit desire for change that is experienced as an unwanted demand. Your client may have been communicating a more complex message than what you and she worked on with better communication skills. Her acceptance conveys a different message and may lead to a decrease in conflict.

Your question also raises an important issue related to treatment goals. Clients often enter treatment with a goal for change in something that is outside their control. You may have inadvertently agreed to a goal for individual therapy that can’t be achieved in that modality, so consider reviewing your treatment goals with your client. It sounds like a goal related to understanding her feelings about her parents and a goal related to de-escalation and detachment would be more appropriate than a goal about better communication between your client and her parents.

I hope you find this helpful in facing aspects of your clients’ lives that cannot be changed. Please email me with comments, questions or suggestions for future blog topics.

Documentation in Private Practice

man-taking-notesI’m going to be leaving my agency internship for a private practice internship. What are the differences in requirements for writing progress notes in a private practice compared to an agency?

The requirements for documenting your client sessions are not specific to the setting, but agencies often follow guidelines set by third party funders. These guidelines may not be applicable to your private practice internship if you are not billing a third party insurer.

Before directly addressing the specific requirements of documenting sessions with progress notes, I’ll review the reasons for keeping progress notes when your client is paying directly for treatment. Under the Health Insurance Portability and Accountability Act (HIPAA), each client is entitled to receive a copy of her/his treatment record on request and you are obligated to provide one if requested.

Client records might also be requested, with the client’s permission, by another health care provider, by an administrative organization evaluating your client’s application for assistance (for example, Social Security Disability Income, which you can learn more about via social security disability law), or by an attorney in a lawsuit brought by your client claiming damages for emotional distress. A client record would also be required if you need to respond to a complaint or lawsuit filed by a client against you. You may believe that all of these situations are unlikely to occur with your private practice clients, but being without an adequate record could place you at some degree of risk or could create a complication for your client. You might not release the full record in some of these situations, but you would need a record in order to respond to the request.

Let’s return now to the issue of requirements for progress notes. All aspects of the treatment you provide are measured against the professional standard of care. The standard of care is the generally accepted practice used by other professionals providing a similar service. The codes of ethics of the professional associations for psychologists, marriage and family therapists, and social workers state that clinicians should keep accurate records documenting their work, without specifying the content of those records. Therefore, keeping progress notes for psychotherapy sessions is the standard of care.

There are several methods you can use to guide you in writing progress notes in a private practice setting. First, I would suggest asking your supervisor for her/his standards for the format and content of progress notes. If your supervisor doesn’t have a specific format, you could adapt the format you used at your agency internship to fit your private practice. You can also check with colleagues and your local or state professional association for templates used by other therapists.

Two resources you can check in print or online are the American Psychological Association Record Keeping Guidelines and a book by Donald Wiger entitled “The Psychotherapy Documentation Primer” published by John Wiley & Sons in 2012. These resources contain a list of the information that should be included in a progress note for each service provided. To summarize, the most important elements to include in a progress note for a psychotherapy session are: the context of the session (date, time, length, who attended, location, service provided), status of the client’s symptoms and functioning, any assessment you conducted and the actions taken as a result of the assessment, interventions provided, plan for future treatment, and your signature including your licensure status and date signed. You probably also need to include some narrative description of the topics covered in the session.

One additional issue to keep in mind is that HIPAA defines psychotherapy notes as distinct from progress notes. Psychotherapy notes are kept by you for your own analysis and may contain conjecture, inference, judgments and emotionally charged material. Psychotherapy notes are not part of the official treatment record and do not have to be released to the client or other parties. Progress notes should be factual and objective in describing your observations and interventions without the more subjective material that can be kept in a psychotherapy note.

I hope you found this information helpful in writing progress notes in a private practice internship. Please email me with comments, questions or suggestions for future blog topics.

Using Supervision

therapyI’ve been meeting with my supervisor for about six months. I find it helpful but wonder if I could be getting more out of it. My supervisor is very experienced and I’m not sure I’m using her expertise to my best advantage.

You are wise to look for ways to maximize the benefit of your supervision. It is generally the most powerful tool for examining and improving your work as a therapist. I’ll address your question in two parts, in terms of the content and the process of supervision.

There are three content areas to cover in supervision. In order of importance or urgency, they are 1) crisis or emergency situations, 2) new clients, and 3) regular review of ongoing therapy with all of your clients.

When one of your clients is in crisis or there is an emergency such as an abuse report or need for hospitalization, you should contact your supervisor between scheduled sessions to discuss crises and emergencies when they arise, then give an update and develop your plan for follow-up in the next supervision hour.

When you begin with a new client, spend time in supervision talking about the client’s clinical presentation and issues of concern or difficulty. You should develop a diagnosis, case formulation, and treatment plan within the first four to six sessions so that your work is focused and effective. Your supervisor’s input is vital in answering your questions, helping you understand the client from a conceptual framework, and suggesting appropriate interventions.

Most of your supervision time can be spent reviewing your ongoing work with clients whose treatment is established and progressing toward the clients’ goals. Talk with your supervisor about the best way to review your ongoing work, since there is a choice to be made between breadth, or giving brief updates about all clients each week, and depth, or spending more time each week on a few clients. Make sure to present each client on a regular basis, including those who you enjoy and are making progress. It is easy to focus supervision time on your challenging clients but there is much to learn in sharing your successes and going into more depth in understanding the clients with whom you feel an easier bond.

Attending to the process of supervision will allow you to get the most benefit. One aspect of process is the quality of your organization and preparation. As you go through the week, reflect on your client sessions and make note of issues that are a priority for your next supervision hour. Examples are differential diagnosis questions, changes in the clients’ symptoms, progress or lack of progress in therapy, questions about treatment approach and interventions, conflict or ruptures in the therapeutic alliance, and strong countertransference. Your supervisor will be able to give you more guidance when you have prepared in advance and lead with the questions that are most pressing.

A second aspect of process in supervision is your degree of openness in the supervisory relationship. Supervision includes mentoring and support as well as evaluation and constructive guidance. Your awareness of the evaluative component of supervision may make you reluctant to bring in difficulties or mistakes, but the greatest learning occurs when you bring in situations that trigger uncertainty, distress, self-doubt and other strong feelings in you.

It is often useful to talk with your supervisor directly about your fears of looking bad, about your own self-criticism, and about what you feel you need from your supervisor. These conversations are good practice for talking directly with clients about emotionally challenging issues, which is part of every therapist’s repertoire. You are also likely to feel more supported by your supervisor when you take the risk to express your vulnerability and your needs.

I hope you follow some of these suggestions and increase the benefit you get from your supervision. Please email me with comments, questions or suggestions for future blog topics.

Mandated Treatment

mandated therapyI have been assigned to work with a client who has to attend therapy as part of his probation requirement. How can I build trust with someone who probably doesn’t want to be in treatment?

It is challenging to work with someone who isn’t seeking therapy voluntarily. Therapy is sometimes required as part of probation, a child abuse investigation, or other legal situation. There are complications in developing a therapeutic relationship when treatment is mandated by a third party. This blog contains a few suggestions that will help you work through some of these complications.

First, I recommend that you get clear information at the beginning of treatment about what you will be required to report to the mandating authority. Your client may come with a referral form or blank progress report that will have these instructions, or you may need to ask for his authorization to talk with the mandating authority about their expectations and requirements. If possible, it is best to report general information only, such as dates of attendance, issues discussed and treatment goals. As a therapist, you are not evaluating your client in relation to his legal situation so you cannot advocate for a specific outcome or express an evaluative opinion.

Once you are clear about what the mandating authority requires, you should share this with your client, letting him know what you will share and what you can keep confidential. This conversation is in addition to a discussion of the general limits of confidentiality you have with all clients. By talking openly with him about the reporting requirements, you establish clear and direct communication which is the beginning of a therapeutic relationship.

Second, acknowledge that your client has mixed feelings about being required to attend therapy and talk about the impact the mandate has on his ability to feel open and trusting of you. An example would be “Since coming to therapy is required rather than something you decided on your own, I imagine it will be hard to decide how much you want to talk about with me.” Acknowledging his ambivalence is likely to help him feel more trusting rather than less, and it communicates your ability and willingness to discuss things that are difficult. This should be an ongoing issue for discussion, since he will continue to have questions about trust as the relationship develops.

Third, bring up the possibility that the client may not feel comfortable sharing truthfully with you. He may have other requirements like maintaining sobriety, attending parenting classes, or detaching from conflictual or violent situations and it will be difficult to know whether he is being truthful when he reports complying with those requirements or reaching treatment goals. One way to discuss this is to raise a hypothetical question like “If you had started drinking again, do you think you’d be able to tell me?” In this way, you bring the issue of truthfulness into your relationship without being accusatory. Even if the client assures you he would be able to tell you, raising this question acknowledges the impact of the mandated requirement on his communication and relationship with you. As with the issue of ambivalence, you should raise this periodically as an ongoing issue in the relationship.

I hope you find this helpful in doing therapy with clients whose treatment is mandated. Please email me with comments, questions or suggestions for future blog topics.

Self Care for Enhancing Well-being

calmI’m in my second year of practicum placement and I feel really burned out. What can I do to keep going in this career without constantly feeling depleted by my work with clients?

This blog continues the topic of self care, which I introduced with suggestions about work habits. We’ll look at additional strategies for self care to enhance physical, mental and emotional well being. As I mentioned before, I recommend that you choose one or two small steps to try out first, see if they are helpful, modify them if necessary, then build on those after you have had some success. It may seem as though making drastic changes is necessary, but it is easier to start with something small. You are more likely to be successful and less likely to feel discouraged by the enormity of what you are taking on. Remember you can always start again if you slip back into old habits.

We’ll start by looking at physical health and well-being. This is an area that is easy to neglect especially with the pressure of classes and practicum or internship training. However, neglecting your physical health will take a toll on your mental and emotional health as well. Examine how you are caring for your basic needs for nutrition, movement and rest. Small changes in eating, exercise and sleep habits can yield significant benefits. I find that paying attention to my body’s signals results in being more productive since I’m bringing more resources to bear on my work.

Being in graduate school is a time for developing the mind. You are gaining knowledge and putting a lot of attention to your intellectual growth. This may mean that your mind is working at maximum capacity and you may find it hard to shift out of a preoccupation with your thoughts and ideas. Introducing a mindfulness practice may be helpful in balancing your mental energy. Meditation, progressive relaxation, stress reduction, and guided visualization are all readily available in online formats if taking a class isn’t feasible in your schedule. If doing a structured mindfulness practice doesn’t fit for you right now, simply spending time in nature is a great alternative. You can also go to services that provide medical marijuana cards in Clearwater, FL if you want access to medical marijuana to help alleviate stress.

Your emotional equilibrium will continue to be challenged as you progress through your training. Supportive relationships are the most helpful resource for building and restoring your emotional reserves. Personal psychotherapy gives you a chance to talk confidentially about the emotions that are triggered by your clients as well as your academic courses, trainings and supervision. Supportive relationships with peers and mentors in the field can help you share some of the experiences common to clinicians. In addition, strive to maintain and establish supportive personal relationships both individually and in community. It is important to engage in relationships and activities unrelated to the mental health field to provide perspective and balance.

It may seem like a big task to attend to these three areas of your health, but you can choose one activity that serves several functions. For example, following a YouTube yoga instruction will move your body and still your mind. Sharing a healthy meal or going on a hike with a good friend will meet your physical and emotional needs. In addition, any change you make that improves your health in one area will help in other areas because our physical, mental and emotional well-being are interconnected.

I hope you find these suggestions helpful in sustaining and improving your health in all aspects. Please email me with comments, questions or suggestions for future blog topics.

Self Care in Work Habits

Iimg-article-are-you-too-stressed-out’m in my second year of practicum placement and I feel really burned out. What can I do to keep going in this career without constantly feeling depleted by my work with clients?

Your concern is a universal one for clinicians. We tend to enter this field with a predisposition for caregiving others and neglecting ourselves. The emotional demands of doing psychotherapy with highly distressed individuals and families are intense and most of us reach the limits of our previously developed coping strategies during our training. This is a good time to create new routines and habits that will serve you throughout your career.

In this blog, I will suggest some general strategies that will help to build your emotional reserves and detach in a healthy way from the intensity of clinical work. The next blog will address more specific ways to attend to your physical, mental and emotional health. I recommend that you choose one or two small steps to try out first, see if they are helpful, modify them if necessary, then build on those after you have had some success. You will probably find it hard in the beginning to give attention to yourself, as you go against longstanding patterns. Be gentle with your expectations and remember that you can always start again if you slip back into old habits.

It will be easier to sustain your physical and emotional energy if you build in breaks for yourself, both on a daily basis and throughout the training year. Look at your daily routine and schedule one or two breaks if you have a full day at your placement. Use your break to eat a meal or snack, take a walk, read or watch something unrelated to your work, or talk to a colleague. Turning your attention away from your work for a period of 15 minutes to an hour will enable you to be more engaged when you return to it. If you have classes and clinical work in the same day, give yourself some transition time in addition to your commute.

Another aspect of your routine to examine is the structure of your day. It is helpful to alternate more and less demanding tasks throughout the day. Consider taking an hour to work on paperwork or do some research into resources for a particular client to break up your client hours. If you have several particularly complex or challenging clients, schedule them on different days or at different times of the day so you have other work or less challenging clients between them.

Clinicians often have a very hard time taking a vacation from clinical work. Because of our pattern of caregiving, we often feel as though we must be available at all times. We don’t feel comfortable having someone else provide coverage. However, we cannot maintain our own equilibrium if we never take a break to restore ourselves. Throughout the training year, take vacation time as it is permitted at your agency and have a colleague provide coverage for your clients so you can be free of responsibility and preoccupation. It is tempting to check voice mail or email when you’re away from the office but you will benefit more from your time off if you fully detach. Keep in mind that taking a vacation means being away from the office and not having any client contact for at least a week. Taking short periods of a few long weekends will not allow you to truly rebuild your reserves and return feeling restored.

I hope you can use these tips for developing some work habits that counter your feelings of depletion. The next blog will continue on this topic, addressing specific ways to care for your physical, mental and emotional well-being. Please email me with comments, questions or suggestions for future blog topics.

Changes from DSM-IV to DSM-5

dsm-5I am starting work at an agency that uses the DSM-V or 5 rather than the DSM-IV which I have been using at my previous agency.  What should I know about the changes between the two versions?

The DSM-5 (it is “5” rather than “V”) was published in May 2013 but many agencies are not yet using it or are just beginning to transition to the new version.  There are a number of structural changes in the organization of the DSM-5 and a number of revised or new diagnoses as well.  The DSM-5 itself contains a summary of the changes in an appendix, which you may find helpful to review.  In addition, I recommend that you look up the criteria for each diagnosis as you begin to use the DSM-5 to make sure you are applying it correctly.  I have summarized the structural and diagnostic changes below.

Structural Changes

The DSM-5 no longer uses a five axis diagnostic system as has been true in DSM-III and DSM-IV.  Instead of five axes, you list the mental health and substance use disorders that apply in the order of their clinical relevance to your treatment, followed by listing the client’s medical conditions.  Many of the psychosocial stressors that were previously listed on Axis IV are contained in an expanded section of “other conditions” called V codes or Z codes so they are included in your diagnostic list.  The GAF is no longer used, but several assessment measures are included in the DSM-5 as alternatives to the GAF for assessing the client’s level of functioning.

Some diagnoses are combined on a continuum with codes for severity rather than having different diagnoses corresponding to different levels of severity.  Autism spectrum disorder and substance use disorders are two commonly used diagnoses that have been changed in this way.  The DSM-5 calls this a dimensional approach to diagnosis rather than a categorical or binary approach. Instead of “alcohol abuse” and “alcohol dependence” disorders, DSM-5 uses “alcohol use disorder” with a code for severity based on the number of criteria met by the client’s use.

The organization of diagnostic categories has been revised so that the categories are more clearly differentiated from each other.  For example, all disorders formerly in the category of “disorders usually first diagnosed in infancy, childhood or adolescence” have been moved to the category of the diagnosis itself (e.g., attention deficit hyperactivity disorder moved to neurodevelopmental disorders).  In addition, some categories have been divided into two smaller categories (e.g., bipolar and depressive disorders, anxiety and obsessive-compulsive & related disorders) or have been combined differently (e.g., trauma & stressor related disorders).

The category of “Other Conditions” has been greatly expanded to cover some of the conditions previously listed on Axis IV as well as other historical and current situational circumstances that may be relevant to the current treatment.

Diagnostic Changes

There are a number of new diagnoses in the DSM-5 as well as revised criteria for other diagnoses.  Below is a partial list of new diagnoses:

  • Disruptive mood dysregulation disorder (age of onset between 6 and 10 years of age)
  • Persistent depressive disorder (combines dysthymia and major depressive disorder, chronic)
  • Premenstrual dysphoric disorder (previously listed as a condition for further study)
  • Hoarding disorder
  • Excoriation disorder
  • Disinhibited social engagement disorder (differentiated from reactive attachment disorder)
  • Gambling disorder (previously listed as a condition for further study)
  • All disorders in the category of “somatic symptom and related disorders” (renamed from “somatoform disorders” in DSM-IV)

This is a very brief summary of the changes between DSM-5 and DSM-IV.  As mentioned above, you should look closely at the diagnostic criteria for each client’s diagnosis when you begin using the DSM-5 and also look at the listing of categories and diagnoses to see if there is a new diagnosis that fits your client’s symptoms more closely than a diagnosis which is familiar to you from the DSM-IV.

I hope you found this blog to be a helpful introduction to DSM-5.  Please email me with comments, questions or suggestions for future blog topics.

Tips for Developing Treatment Plans

I am working with adolescents who have a variety of presenting problems including grief and loss, depression, anxiety, and PTSD.  How can I develop an effective treatment plan for each of these presenting problems?

It has become standard practice in most behavioral health settings to develop a treatment plan with the client in the early sessions, to guide the direction of your work together.  Treatment plans have two parts: 1) the goal, objective or target for change in the client’s symptoms or behavior and 2) the interventions and therapeutic modality you will use, informed by a theoretical orientation.  I will discuss tips for each part of the treatment plan below.

The first part of the treatment plan, the target for change, is often written in behavioral terms in order to be clear about how you and the client will know that treatment is successful.  Clients sometimes begin treatment with a clear idea of what they want to change and other times are confused or vague.  Their initial discussion with you may focus on the desire for a change in others or a situation rather than something that is within their control.  If this is the case, you’ll need to take some time to talk about what is possible for you and the client to achieve.  With adolescents, you generally need to consider the priorities of parents and sometimes teachers and other school personnel in developing treatment goals.  Some negotiation may be necessary in developing treatment goals that are acceptable to all parties.

Once you and the client have agreed on the focus of change, identify goals that are achievable within the period of time you have to work together.  You will specify more modest goals if you have a limit of 12 sessions than if you are able to work for a school year of 8-9 months.  Your goals should also take into account the current baseline, length and severity of the problem, and complexity in terms of multiple diagnoses or family dynamics.  Your client and parents may be unrealistic about the degree of change that is possible or may transfer their feelings of pressure to you.  Sometimes you can compromise with writing shorter term goals that can be updated when they are reached.  For example, if a 17-year-old girl rates her depression at 8 on a 1-10 scale you might have a target of reducing to a 6 within 6 weeks, then a further reduction to a 5 within another 6 weeks if the initial target is reached.

The second part of the treatment plan, your interventions, comes from your case formulation of the reasons for the client’s presenting problems.  The case formulation is grounded in a theoretical orientation and provides an explanation for how and why the presenting problem developed and is held in place.  For example, you might develop a cognitive-behavioral formulation of your client’s depression with inferences about her automatic thoughts, leading to interventions targeting these thoughts.  You could also develop a family systems formulation with inferences about the client having an overly parentified position in the family, leading to interventions with the family system.  A psychodynamic formulation might view the client’s depression as a response to the anticipated loss of her needs for dependency as she and her parents plan for her to leave for college, leading to interventions interpreting her conflict about individuation.

Some clinicians believe that behavioral treatment goals require behavioral interventions, but this is not the case.  All approaches to psychotherapy exist for the purpose of facilitating change in the client including symptoms, emotions and behavior, and treatment goals can target any of these areas of change.  Your choice of interventions should be based on your preferred theoretical orientation and your client’s preferences and expectations, some of which are influenced by cultural identifications.  The choice of treatment modality, individual or family, is influenced by your theoretical orientation as well as the practices and policies of the setting in which you are working.

I hope you can use these tips for developing clear, effective treatment plans with your clients.  Please email me with comments, questions or suggestions for future blog topics.

Personal Psychotherapy

therapy1My graduate program requires all students to have our own psychotherapy while we are in school. I don’t know how to find a good therapist or what to talk about in therapy since I’m not in a crisis.

It is good practice for programs to require personal psychotherapy as part of clinical training. It will give you an experience of being in the client role that will inform your practice as a therapist. It will also be a source of support as you go through the emotional growth and challenges that are part of the clinical training process.

The question of how to find a good therapist is an important one, involving issues of therapeutic approach and style as well as practicalities. I recommend starting with the question of therapeutic approach and style since finding a match on those dimensions is essential to finding a therapist who will be useful to you. You can begin your search by asking friends or fellow students for recommendations, using the mental health benefit provided by your health insurance, and doing a search on the websites of local professional organizations. In addition, your graduate program may have a directory of recommended therapists, often alumni of the program, and you can also ask faculty for recommendations.

If you haven’t been in therapy before, it may be helpful to meet with more than one therapist before committing to work with someone for a number of months. Some people develop a list of questions about information that will guide their decision, although each initial session will have a unique flow, rhythm and outcome. At this point, you will begin to sort through the practical aspects of choosing a therapist. For most graduate students, time and money are in short supply. Keep in mind that the financial and scheduling arrangements for therapy should be sustainable for at least the period of time required by your graduate program, and possibly longer. Many licensed therapists are willing to work with graduate students at a reduced fee especially if you are able to come during day time hours that are in lower demand.

The question of what to talk about with a therapist is also an important one. The short answer to that question is that you can talk about anything that is on your mind. You may want to talk about your personal life and the changes that have been caused by your entry into a clinical graduate program; your academic courses and the personal reflections stimulated by your course work; or your clinical training and the emotional challenges of working with clients who are in distress. Most students find that clinical training is emotionally disruptive in bringing issues to the surface that you have worked on in the past or that are new and unfamiliar to you.

It is useful to enter therapy before beginning your fieldwork or practicum placement, since it is unexpectedly overwhelming to begin seeing clients. You and your therapist will have a chance to identify some of the patterns that are present in your relationships, your familiar coping strategies, and the signs and triggers of stress. This will enable you to use therapy as a source of support when you face the intense emotions that come up for new clinicians.

I hope you find these suggestions helpful in entering therapy as a graduate student. Please email me with comments, questions or suggestions for future blog topics.

Adjusting to Different Clinical Roles

I have worked as new2a crisis hotline counselor and a client advocate in a domestic violence support agency. Now I am starting my first practicum placement as a graduate student and will be doing psychotherapy with women and children who have experienced domestic violence. How will this be different than the work I have done in the past?

Your question is a common one, since many people work in paid or volunteer positions in a social service agency or helping profession before entering graduate school. There are both similarities and differences between your role as a counselor and advocate and your role as a psychotherapist.

Let’s begin with what is similar in those roles. As a psychotherapist, you will continue to be supportive of your clients and to prioritize your clients’ safety and well-being. You will also be personally touched and emotionally engaged by your clients. Your relationship with them and belief in their strengths will continue to be an importance source of healing in your clients’ growth and therapeutic progress. Many of the qualities that have made you a successful and committed counselor and advocate will continue to serve you well as a psychotherapist.

There are important differences in these roles too, as your question suggests. One of these is related to professional boundaries. As a psychotherapist, you will see clients at a specified time and place, usually once a week for a 50-minute session. You will limit your self-disclosure of personal information about your life or experiences that may be similar to your clients’ lives and experiences. You will also keep confidentiality of all information shared with you, with exceptions for safety of your client or others, unless your client gives written permission for you to share information. As a psychotherapist, you are bound by the legal and ethical requirements of the profession which are more stringent than the requirements for paraprofessional counselors and advocates.

A second difference in these roles is that a psychotherapist is less involved in taking direct action for or on behalf of the client, with the exception of situations involving imminent danger. In psychotherapy, you will be facilitating and supporting your client taking action and examining the obstacles she faces both internally and externally. A psychotherapist provides information to clients about resources that may be helpful, for housing or employment or financial assistance. Generally, a psychotherapist does not contact the resource directly, make an appointment for the client, provide transportation or assist the client in completing an application as a client advocate often does. If you believe it is in your client’s interest for you to do take direct action in these ways, I recommend talking with your supervisor to insure that is in the client’s best interest.

A third difference in the role of psychotherapist and the role of counselor or advocate is that psychotherapy includes a focus on building skills and capacities that reduce future risk or vulnerability. When the client enters psychotherapy in crisis, there is an initial focus on safety and stability of the immediate situation. Even in a period of crisis, however, there is an emphasis on developing and using coping skills. As the client’s situation becomes more stable, the therapy process moves toward exploration of more longstanding patterns that contributed to the crisis. Most psychotherapists have a goal of assisting the client to understand and shift these longstanding patterns. Crisis counseling and client advocacy generally ends when the immediate crisis is resolved and the client has reached stability.

I hope you find this explanation helpful in beginning to work as a psychotherapist. Please email me with comments, questions or suggestions for future blog topics.