Author Archives: Diane

Unplanned Endings

I have been working with a client for 3 months and I thought therapy was going well. Our last session was two weeks ago and since then, she hasn’t come to sessions and hasn’t responded to my phone calls. I’m confused about why she stopped coming in and don’t know how to find out what happened.

This situation is one of the most distressing circumstances for therapists in field placement training and continues to be challenging for experienced therapists as well. We develop a sense of our relationship with the client based on our shared experience, and it is disorienting when there is a sudden change in the client’s engagement in therapy. Often this change leads to an unplanned ending of the therapy and feelings of loss for the therapist. We usually don’t know exactly what happened and the ambiguity is unsettling. I will outline several factors for you to review in thinking about an unexpected change in the client’s engagement, and I will also suggest things to consider in your response.

When the client stops coming to session and doesn’t respond to your efforts to reach out, it is useful to review your last contact with the client. Maybe she disclosed some aspect of her history for the first time, engaged more deeply with her emotions, acknowledged the importance of therapy as a source of support, or made a plan to take a positive step toward growth and healing. Any of these developments can be a source of anxiety, and the client may need to suspend or end contact to avoid feeling overwhelmed or frightened.

It is also helpful to review the client’s history, particularly regarding early family relationships. She may have experienced repeated abandonment and loss, abuse and exploitation, or feelings of guilt and responsibility. Often the client becomes more worried about repetition of these early experiences, usually outside of awareness, as she engages more deeply in therapy. It seems paradoxical, but the client may feel more frightened in therapy as she becomes more attached.

A third area to examine is the client’s current life. She may be living in circumstances that are disruptive and distracting. Her attention shifts to more compelling priorities rather than her commitment to a weekly therapy session. Examples are volatile partner relationships, financial crises, challenges in parenting, and lack of control in job duties and scheduling. In addition, some clients find it hard to keep regular appointments when their symptoms recur or become more severe. An increase in depression or anxiety, recurrence of a manic or psychotic episode, or a relapse on substances may lead the client to withdraw from support and help when it is most needed.

Once you have considered the factors above, you can develop a preliminary understanding of the meaning of the client’s disengagement and a response that fits your understanding. Your supervisor’s input will be useful in this process both clinically and administratively, since your agency may have requirements regarding frequency of contact for open cases. Supervision is a time to reflect on your own feelings regarding this shift and potential loss. Your response to this situation will reflect your unique pattern of managing loss and rejection as well as specific thoughts and emotions related to your relationship with this particular client. There is a lot to learn about yourself and about the complexity of client engagement in psychotherapy when you face this type of disruption.

In most cases when the client has missed two or more sessions and hasn’t responded to phone calls, it is a good idea to make a final phone call in which you express your understanding that the client may have made a decision to end therapy and give a specified date about a week later that you will close the case if you don’t hear from her. I also recommend sending a written letter which acknowledges the ending, after the specified time period has elapsed. The letter can briefly summarize the issues the client discussed in therapy, describe progress that was made, and provide referrals or offer a return to you or another therapist at the agency in the future. You and your supervisor will decide the appropriateness and specific content of communication by phone and/or letter but generally it is preferable to provide a clear ending.

I hope you find these suggestions helpful in understanding and managing your feelings about unplanned endings. Please email me with comments, questions or suggestions for future blog topics.

Completing an Assessment

I am working at a new field placement which requires doing an assessment in the first session, which lasts 2 hours. How can I do this before I have established rapport and a therapeutic relationship with the client?

It is challenging to complete an assessment in your first contact with a client; however, there are also advantages to gathering comprehensive information about the client’s history and current circumstances early in the treatment process. I will outline some ways to approach the assessment that will facilitate rapport and relationship building so the session will have a therapeutic outcome as well as meeting your agency requirement.

I would first recommend that you talk with the client about the reasons for the assessment when you schedule the initial appointment. Express your desire to be helpful to the client and state that learning about his current symptoms, life situation and history will make the treatment more effective in working toward his goals. This communicates the message that your purpose and interest is aligned with the client’s, rather than simply meeting a bureaucratic requirement.

Before the assessment session, familiarize yourself with the format of the assessment template or report. You may want to bring a copy of the assessment template into the session or a list of general areas for questioning. If there are specific questionnaires for the client to complete, bring those with you as well. You may find it helpful to role play the introduction of the assessment with your supervisor or a colleague before you meet with your first client. The more comfortable and confident you feel, the more easily you will develop a therapeutic relationship with the client during the assessment session.

When you start the session, remind the client of what you discussed in your scheduling conversation about the assessment contributing to the effectiveness of treatment. Then begin with the client’s primary concern in seeking treatment and ask follow up and clarifying questions covering different areas of the assessment as they emerge from the conversation. It is more facilitating of the therapeutic relationship to engage in a dialogue that is relatively fluid and follows the client’s lead rather than imposing a standard order of questioning. It is also preferable to ask open-ended questions which allow the client to determine the direction and content of what he shares. The client’s answer to “can you tell me what your family life was like as a child?” will tell you more about him than the answer to “did you grow up in a two-parent or single parent household?”

If your agency practice requires you to be directive rather than following the client’s lead, you should acknowledge this at the beginning of the session and explain that this is different from the structure of future therapy sessions. For example, you could say “The assessment format we use here requires me to ask you about things in a fairly structured way, so I’ll be leading the conversation today more than I will in our future sessions. Please let me know if you feel uncomfortable about my approach at any time, or if there is something you want to share with me that isn’t directly related to my questions.”

Remember that you are asking the client about events and experiences that may be painful, may bring up feelings of shame and which the client may want to avoid rather than disclose. Expressing empathy, conveying acceptance rather than judgment and reflecting your understanding of what the client is saying will create a therapeutic atmosphere. For example, if the client describes a childhood history of physical abuse and adult relationships involving domestic violence, you might respond with a statement like “It sounds like your childhood taught you to expect physical violence as part of intimate relationships. It’s not surprising that you found that pattern repeating in your adult relationships.” Although you will not have time to explore the details of the client’s experience in the assessment session, you can respond therapeutically to the material he shares.

When you approach topics that you expect or know will be difficult for the client to discuss, it is helpful to let him know this information is asked of all clients and to ask his permission to inquire about those areas. For example, many clients come into treatment with shame and denial associated with past and current substance use. You can introduce the topic therapeutically by saying “We ask all clients here about their use of substances because we find that to be related to aspects of mental health. Is it all right if I ask you some questions about your past and current use of alcohol and other drugs?”

When you follow these tips, you’ll find the assessment session results in a positive therapeutic relationship as well as information that enhances your understanding of the client. I hope you find these suggestions helpful in completing assessments in the first session. Please email me with comments, questions or suggestions for future blog topics.

Concerns About Diagnosis

I just started my first practicum placement and I am supposed to give a diagnosis to each client. I’m worried that I don’t have enough experience to make a diagnosis and that my diagnosis might create problems for my clients later on, if they or someone else sees their records.

Your concerns are common among students in practicum training. It often feels daunting to take on the role of assigning a diagnosis to your client. You may be uncomfortable with the gravity of this professional responsibility, and you may have questions about the validity of diagnostic labels that don’t include consideration of the client’s strengths and capacities. Many clinicians are aware of the potential use of diagnosis in pathologizing or stigmatizing individuals who are vulnerable to being treated with discrimination and bias. I will share several steps you can take to maximize the likelihood that your diagnostic process will be beneficial to the client rather than harmful.

The first step is to be thorough and comprehensive in gathering relevant information and considering alternative diagnoses that fit your client’s symptoms and presenting problem. If you are required to assign a preliminary diagnosis after the first session, make sure to re-evaluate the diagnosis after you have completed a full assessment. Be careful of the tendency to jump quickly to a diagnosis that you consider to be non stigmatizing, such as an adjustment disorder, that may not be an accurate reflection of the full clinical picture. I recommend reading the DSM diagnostic criteria for three to five alternative diagnoses as well as the information about differential diagnosis considerations for these diagnoses. Once you have reached a conclusion about the client’s diagnosis, review this with your supervisor to insure that your final diagnosis is the most accurate and appropriate for the client’s presentation. With complex clinical presentations, you may have a primary diagnosis and one or more secondary diagnoses.

A second step to take regarding diagnosis is to include a description of the client’s initial symptoms and presenting issues in the client record, in addition to the diagnosis itself. Usually you will complete an initial assessment which should contain the client’s report and your observations that support the diagnosis. Your progress notes should track the client’s thoughts, affective states and behavior related to the diagnosis and any changes to the diagnosis resulting from new information or progress. This insures that anyone viewing the client’s record at a later date will have a more complete picture of the client’s symptoms and functioning than is conveyed by the diagnosis alone.

A third step to maximize the benefit to the diagnostic process is to discuss the diagnosis with the client. Clinicians are often reluctant to do this because of the worries mentioned in your question. However, a collaborative discussion often results in relief and clarity for the client who may feel confusion, self-criticism and shame about her condition. I generally enter these discussions by summarizing what the client has told me and my observations, then sharing the diagnosis that fits the clinical picture. An example is ” You’ve told me that you don’t enjoy anything, that your sleep and appetite are disrupted and that you feel really down. I’ve noticed that you are pretty harsh in judging yourself and your energy seems low. All of these things are signs of depression, and I believe the diagnosis of major depressive disorder fits what you’re experiencing now.” I then ask the client what her thoughts and reactions are to hearing this and engage in a discussion of any questions or concerns she may have. If there is any indication at that time or later in treatment that the client may want her record to be shared with another party, you can remind her that the diagnosis is part of the record and talk about the implications that may have.

I hope you find these suggestions helpful in making diagnoses with more confidence. Please email me with comments, questions or suggestions for future blog topics.

Writing Progress Notes

I am in a new practicum placement and this is my first experience with writing a progress note after each session. So far it takes me almost an hour to write each note, since I want to write down
everything that happened in the session. How can I write notes in a shorter time and how do I decide what to leave out?

This is a common dilemma for new trainees and it is important to develop facility with writing concise progress notes that include only the details that are appropriate for the client’s record. At your stage of training, it is probably realistic to work toward writing a progress note in 15-20 minutes. Allowing time for this within 24 hours of your session is important in order to not fall behind and develop a backlog of incomplete or unwritten notes.

Let’s look first at the purpose of a progress note. Progress notes are part of the client’s treatment record and may be viewed by the client and other third parties who are not clinicians. Therefore, they should be relatively objective and descriptive without conjecture or emotionally charged judgments. You should also avoid including details of the client’s current life and history that are emotionally sensitive and could bring psychological harm or shame to the client if they were revealed to a third party. You do need to include enough detail about the client’s symptoms, therapeutic interventions and client’s progress to provide an accurate picture of the client and the treatment.

You will probably find it helpful to keep notes on the details of the client’s life and history, suggestions and guidance from supervision or consultation, a detailed description of the therapeutic interactions (sometimes called a process note), questions or hypotheses, and your emotional countertransference responses. These are defined as psychotherapy notes which you keep for your own understanding rather than being part of the client’s record. I recommend keeping psychotherapy notes in a separate file, using client initials or a random number in place of identifying information such as the client’s name or date of birth on these notes, and shredding these notes when you no longer need them.

Your agency probably has a specific format for the structure and content of a progress note. In addition to the body of the note which describes the session, you need to provide information about the type of service you provided (individual or family therapy, group therapy, case management, home visit, collateral parent session); the date, time and length of the session; who attended; location of the session; and your hand or electronic signature including your degree and licensure status or title. In some cases, your supervisor’s signature may be required as well.

The body of each progress note is a report on the status of the client’s symptoms and functioning and the progress in treatment. It should include both the client’s report and your observations of her/his symptoms and current functioning, a description of your interventions and the client’s response, your assessment of areas of crisis or danger, the client’s general progress toward the treatment goals, and your plan for continued treatment or changes in the treatment plan. It is helpful to include general information about the content or topics you talked about, with a phrase like “client discussed conflict with her partner about financial issues” or “client reported having contact with her mother which brought up painful feelings of rejection.” A guide for the appropriate level of detail is that a progress note for a session lasting 45-60 minutes should generally be a half-page to a full page unless the client is in crisis or at risk, which requires documentation of your assessment and plan for safety and may extend into a second page.

I hope you are able to use these tips to write progress notes more easily and quickly. Please email me with comments, questions or suggestions for future blog topics.

Intersection of Personal and Professional Lives

My current placement is located in the same town where I live. I like having a shorter commute than last year but I’m worried about seeing my clients outside of our session, when I’m on my own personal time. I think I would feel awkward and wouldn’t know what to do.

The intersection of the personal and professional life of a psychotherapist can happen at any time, but it is more likely when we live and work in the same community. It is also more common when the therapist and client are members of the same cultural community and may have shared interests, activities and acquaintances. Even when we maintain boundaries and refrain from disclosing personal information about ourselves, it is impossible to avoid all situations in which clients view aspects of our personal lives. The experience of myself and my colleagues includes seeing a client while shopping with a spouse or children, working out at the gym, going to back-to-school night, and having dinner with friends or family.

It can feel burdensome and intrusive to be faced with these situations, but it is a reality of being a professional, especially when your community is small geographically or culturally. When you see your client outside of a therapy session, you are still the therapist and your interactions should maintain the same level of professionalism. Since our preferences about the degree of separation we maintain are based in part on our cultural identities, the nature of your conversation and the strategy you use will be different based on the cultural expectations and norms for you and your clients. Discussing this with your supervisor is important, to make sure you are keeping appropriate therapeutic boundaries within the cultural or cross-cultural context of the therapy.

Generally, it is best to keep conversations in a social or public situation short and cordial without disclosing more about yourself than is disclosed by the situation. You also need to maintain confidentiality regarding your role as the client’s therapist if others are present during the conversation. This may mean asking your family members to wait for you to introduce and include them in a conversation with someone unknown to them. It is usually best to not include family members in a client conversation and it is a good idea to explain the reasons for this to them in advance, as a general issue regarding your role as a psychotherapist.

At the beginning of treatment, you can sometimes anticipate that you and the client may see each other outside of your therapy sessions. Examples are when your children attend the same school or when you and the client belong to the same religious, political or professional organization. When you recognize this possibility, it is often useful to have a conversation ahead of time with the client after discussing the issue with your supervisor. I recommend not taking initiative in greeting the client in a public setting, unless there are diagnostic or cultural issues you discuss with your supervisor that make another approach more appropriate. I generally begin this conversation with a statement like “I’m aware that we both attend the same meditation center, so it’s possible we will see each there. If that happens, I won’t acknowledge knowing you unless you approach me. I want you to do whatever is most comfortable to you at the time.” I then respond to the client’s questions or comments.

If you see a client unexpectedly, I still recommend following the client’s lead in acknowledging that you know each other. She/he may choose to simply make eye contact, may greet you with a simple hello or may start a conversation. If there are others with the client, do not make any reference to your therapist/ client relationship unless she/he does so. If the client does introduce you as her/his therapist, stay away from any discussion of the therapy itself. It is also possible she/he doesn’t notice you, which has been my experience at times and is another reason to not initiate contact.

I recommend talking with the client in the next session about any interaction you have outside the therapy. It is helpful to ask the client what it was like to see you and what thoughts and feelings came up during or after your interaction. If you saw the client but she/he didn’t acknowledge seeing you, you can preface your comment by saying “I’m not sure if you’re aware that we were both shopping at Safeway on Saturday.” You can include an explanation of your practice of waiting for the client to acknowledge knowing you, if you haven’t already discussed it.

In your discussion of the client’s reactions, be aware of what the client learned about you and how that knowledge may affect your therapeutic relationship. For example, the client may have seen your spouse, partner or children; may have seen you with a glass of wine at a restaurant; or may know what movie you saw or what purchases you made. These interactions may be relieving, distressing or meaningful in different ways depending on the client.

I hope you find these suggestions helpful in handling interactions with clients in a public or social context. Please email me with comments, questions or suggestions for future blog topics.

Social Media

One of my clients recently mentioned a post I put on my Facebook page and I just received an invitation from her on LinkedIn. My social media presence is part of my personal life, and I don’t want her or other clients to be part of it. How do I talk to her about this and ask her to respect my privacy?

The increasing use of social media by therapists highlights one way in which our personal and professional lives intersect. A starting point for creating more separation between the two is to maintain control over access to your profile and posts by choosing more restrictive privacy settings. However, this may be in conflict with your professional goals on a site like LinkedIn where your goal is visibility and access for colleagues and other behavioral health professionals to find you. You’ll need to balance your desire for privacy with your desire to be visible to the professional community in deciding how to restrict access to information about you on Facebook, LinkedIn, Twitter, Google Plus and other social media sites.

Your question suggests that you are thinking about talking with your client about this issue and are aware the conversation may be difficult. It is preferable to have a standard policy regarding all electronic communication including social media and to talk about this when you begin treatment. If your agency doesn’t have such a policy, you can talk with your supervisor about the advisability of bringing up the subject in the first session when you talk about other issues related to your client’s privacy and confidentiality. When this issue comes up after treatment is underway, there is some risk that the client will experience your desire for privacy as a personal rejection; however, being aware of that risk will help you talk with her with sensitivity that minimizes her feelings of rejection and hurt. Keep in mind that your client may have cultural expectations about personal contact and disclosure that are different from yours and this is important to acknowledge and discuss.

I recommend being straightforward with clients about all issues related to boundaries and limits, whenever they arise. This includes acknowledging that the boundaries are often based on your needs and preferences. In this instance, you might say something like “I realize I neglected to talk with you at the beginning of our treatment about my preferences for social media. I prefer to keep my social media presence limited to personal friends and professional colleagues. I don’t respond to client invitations or other communication on social media sites, and my privacy settings limit the information clients can see about me. I’m happy to talk with you about how this feels to you, since my preference may be different than yours. I also think it’s important that we talk about what you saw about me and what reactions to you had to my profile and post.” This communicates both a clear boundary and an openness to talk about the impact of your boundary and your inadvertent self-disclosure on the client.

My next blog will address the issue of how the personal and professional intersect in the lives of psychotherapists more generally. In the meantime, I hope you can use these suggestions in having conversations about social media. Please email me with comments, questions or suggestions for future blog topics.

Electronic Communication

One of the clients at my field placement has been using email to reschedule appointments and let me know about things she wants to talk about in our next session. This has been fine with me since it’s easier for me to read and answer a quick email than a phone message. However, her emails are getting longer and I don’t want to take the time to read and respond to them between sessions. How can I let her know this without causing a rupture in our relationship?

This is a good example of how communication in the therapeutic relationship can move quickly from simple and straightforward to complex and entangled. This can happen with conventional communication in person and by phone, but there are many more possibilities for complexity with electronic communication.

When communicating with clients by email, you need to be aware of security and privacy as well as clinical issues. Regarding security and privacy, email is not considered a secure form of communication under HIPAA, so you need to inform the client of the risk to her privacy for anything she sends you by email. In the future, you can include this discussion early in treatment, but you now have an opportunity to do so in response to the client’s expansion of her email communication with you. I recommend documenting your conversation about email security in a progress note so it is clear you have informed the client of the risk to her privacy and that she is making an informed choice to communicate by email.

There are also clinical issues related to email communication with clients, as you have found. Email is best used only for scheduling appointments. Some clients may also send information to you that is related to their treatment, in order to talk about it in the next session. Examples are a client forwarding an email from a family member or partner with whom she is in conflict, a parent forwarding information from a teacher about your child client, or a client wanting to tell you about something that happened or an insight she had during the week. It is safest to either let the client know you won’t respond directly to emails containing clinical information or to limit your response to these email to a simple acknowledgement and invitation to talk more in person in the next session. I recommend printing email exchanges with the client that contain clinical information and including them in the client’s record. Check with your supervisor about the policy at your field placement site.

At this point, you need to talk with your client about both security and clinical issues related to email. The conversation is likely to be less disruptive to the relationship if you begin by acknowledging your oversight in not talking about this sooner. You should let the client know about the risk to her privacy with email communication and ask if she wants to continue using email despite the risk. You can then move to a discussion of your preferences about the issues discussed by email, preferably by again acknowledging your oversight in not discussing it sooner. A straightforward description of the limits of email would be “I prefer to use email only for scheduling purposes and to save our discussion of other issues for when we meet in person. If there is something you want to let me know about, you can certainly send me that to me by email but I will wait to comment on it until we see each other.” You then can invite the client’s thoughts and reactions, again acknowledging that this is a change on your part if the client expresses confusion or worry about having done something wrong. This will relieve you of the burden of responding between sessions and will redirect the client’s communication to your sessions where you can talk about the issues in depth.

I hope you found this helpful in dealing with electronic communication. Please email me with comments, questions or suggestions for future blog topics.

Clinical Approach to Case Management

I have a part-time job as a case manager at a homeless shelter while I am gaining hours toward licensure. I don’t know what to do when my clients don’t follow through on the referrals and other support I give them. Since I’m not their therapist, I can’t talk to them as I do with my therapy clients to understand what’s getting in the way.

It is true that your relationships with clients as a case manager are different from the relationships you have as a therapist. However, some of the interventions you use as a therapist are valuable in case management, and your clinical knowledge is a valuable tool for understanding the reasons for your clients’ lack of follow through.

Motivational Interviewing is a useful approach when clients show ambivalence about getting help or about changing aspects of their lives that are problematic (www.motivationalinterview.org). Using this as the basis for your work helps you establish a collaborative relationship and puts the client at the center of the decision making about change. Identifying and resolving ambivalence is a central feature. Talking with the client in a way that is consistent with Motivational Interviewing may help you to shift from a position of responsibility to help the client use your referrals and support to a position of supporting the client to identify her/his goals and the steps s/he is ready to take.

Your experience as a therapist may also be helpful in understanding the basis for the client not following through with your referrals or suggestions. You can develop a conceptualization of the client’s difficulties and strengths as you would do with a therapy client, based on the information you have about her/his history and diagnosis. As a case manager, you are probably working with more limited information than you have in psychotherapy, but you may have enough information to make some inferences about the underlying reasons for the client’s lack of follow through. For example, clients with a history of trauma may be sensitive to feeling coerced, clients who have a psychotic disorder diagnosis may misinterpret your suggestions or be confused about the information you give them, and clients who have lived on the streets for many years may need the sense of community and self-identity of homelessness to feel safe.

Another application of your clinical skill is in identifying the client’s interpersonal style with you as a way to understand her/his internal template for relationships. This will help you develop ways to work with the client based on her/his assumptions and fears about relating to others. For example, if you feel intimidated by the client you can infer that s/he organizes relationships around issues of power with one person holding power and the other being powerless. This would indicate that interacting with the client in an authoritative but non-punitive way is likely to be more productive than either attempting to take charge or responding passively. A statement reflecting this middle ground would be “I have some ideas that might be helpful to you, but it’s hard for me to sit here with you when you’re yelling at me. Would you be willing to stop for a moment and see if any of these resources are relevant for you?” Using your clinical skill in this way will result in subtle but important differences in how you talk with different clients and is likely to be more effective in helping the clients use the resources you have to offer.

I hope you are able to use these suggestions in bringing your clinical knowledge into case management work. Please email me with comments, questions or suggestions for future blog topics.

Sequential Treatment

Two women talking I just started in a new practicum training placement and one of my new clients has seen three different therapists at this agency in the last five years. I’m not sure how much of her file to read before I meet her and how to continue the work she started with her previous therapist who left last month. They agreed on new goals before that therapist left and I don’t know how to help the client meet those goals.

This is a common situation in training agencies, since many individuals who are seen in these settings need and benefit from long-term treatment over many years, but the nature of training institutions is that the clinicians usually stay only one to two years. As a result, long-term treatment is often provided in training agencies by several clinicians sequentially rather than by the same clinician. This means the clients experience some recurring disruption and loss as they form attachments and say goodbye repeatedly. Many clients seem to develop an attachment to the agency which helps to maintain a sense of continuity. Their agency attachment, or institutional transference as it is sometimes called, helps the clients weather the coming and going of individual clinicians.

One dilemma highlighted in your question relates to getting information from prior therapists rather than directly from the client. Some therapists prefer to meet the client without reading background information in order to form an unbiased impression while others prefer to prepare by reading the previous therapist’s description of the client and treatment. There are advantages to both approaches, but my preference is to read the most recent assessment and treatment summary in order to have a general idea of the client’s current life difficulties and the nature of the therapeutic relationship. I hold this as the previous therapist’s subjective opinion, however, and expect that my experience and observations of the client will differ. I pay particular attention to what the therapist found effective in helping the client make progress, so I can use a similar approach if possible.

Another dilemma is whether and how to continue a treatment that is incomplete but didn’t include you. It isn’t realistic to think that you can simply pick up where the last clinician left off and at the same time, it is frustrating for the client to feel she is starting over in telling her story. I recommend giving a brief summary in the first session of what you have read and what you understand the client’s issues and goals to be, then asking what else she would like to tell you as the two of you begin this new relationship. I usually add that I may ask her questions about her past or present life that she has told the previous therapist because it is helpful for me to hear some things in her own words. I acknowledge that there may be times she will feel frustrated at having to repeat things she told the previous therapist and I encourage her to let me know when that happens so we can talk about it.

In addition to these dilemmas, being part of a sequential treatment allows for a fresh look at the client’s symptoms and situation as you and she form a relationship that is different from her previous therapy relationships. You are in a position to re-evaluate the case formulation and treatment plan and to take a different approach to helping the client in areas that may not have responded to other therapists’ interventions. Each therapist-client relationship is unique and creates new possibilities for growth. You and she will discover what is possible as you learn about each other and develop your own pattern.

I hope you find these comments helpful in working with a client who has had a series of different therapists. Please email me with comments, questions or suggestions for future blog topics.

Orientation to a New Training Site

I just started at my practicum or field placement site and I feel pretty overwhelmed. What can I do to reduce my anxiety?

Starting at a new training site can be stressful, whether it’s your first placement or your fourth. There are several things you can do to feel more confident and grounded. As you read the suggestions below, you will probably find that some seem more relevant than others, based on your typical response to a new situation.

It is often helpful to review the requirements and procedures for your new site during the first week or two before you see your first client. Some training agencies have a formal period of orientation and training and others are more informal. Whatever the practice at your site, you will feel more prepared if you know 1) the treatment frame, i.e., where and when you will see clients, whether and how the client pays for sessions, how long sessions last and whether there is a limit on the number of sessions you will have; 2) the forms to be completed and signed by you and the client in the first session; and 3) agency procedures for clinical emergencies and back-up emergency supervision. If this information isn’t provided in a formal orientation process, you can ask your supervisor or another more experienced colleague.

A second way to reduce anxiety is to think about ways to connect empathically with your assigned clients or the client population at your training site. Often you will be working with clients who have survived serious trauma and are living with discrimination, prejudice, and poverty. Instead of focusing on the client’s history and current circumstances, which can leave you feeling inadequate to make an impact, think about what your client may be feeling in coming to a session with you. It is likely that she/he brings fear, shame and distrust to your first encounter as well as coping strategies that have enabled her/him to survive painful experiences. Remember that your desire to understand your client is an essential and powerful first step in your relationship and will instill hope that you may have something helpful to offer.

Another very important aspect of managing the stress of starting in a new training site is to pay attention to your own physical, mental and emotional health. You may be juggling school, job and family responsibilities in addition to your field placement limiting the time you have to take care of yourself. In addition, many of us come into the behavioral health field with patterns of caretaking and self-neglect. Working to balance our own needs with those of our clients is as much a part of the learning process as gaining clinical knowledge and skill. You can start with something relatively simple like taking a 10-15 minute break to walk, stretch or do a mindfulness exercise during your day or bringing a healthy snack to work. Supportive personal and professional relationships are also important, and personal psychotherapy is especially useful during clinical training.

I hope some of these suggestions help you in this overwhelming time. Please email me with comments, questions or suggestions for future blog topics.

Diane A Suffridge, Ph.D

Consultant, training and author in behavioral health.