Author Archives: Diane

Cultural Factors in Diagnosis

new1I just had my first session with a 20-year-old woman who meets the DSM criteria for borderline personality disorder.  Her emotions are very labile, her relationship with her boyfriend is unstable and she was fired from her job as a nanny recently because she was often late and had frequent crying spells.  I think DBT would be a good treatment for her, but she immigrated from Thailand three months ago and I don’t know whether DBT has been used with Thai Americans.

It’s important to be aware of the importance of culture in choosing a treatment modality, but before addressing that question let’s look at the issue of culture related to diagnosis.  This young woman’s recent immigration is the context for her symptoms, which makes an initial diagnosis of adjustment disorder more appropriate than borderline personality disorder.  If she came alone to take a job as a nanny, the drastic change in cultures would be exacerbated by a loss of social support and the network of relationships she left behind.  If she came with her boyfriend, that relationship would be under tremendous strain as they both adjust to U.S culture.  In one session, you don’t have time to gather information about her history and background to know whether these symptoms have been longstanding, as required for a personality disorder diagnosis, or whether they developed around the time of her immigration.

Regarding the question of treatment modality, it is possible she would benefit from learning some of the skills that are part of Dialectical Behavior Therapy (DBT).  However, if you begin with a diagnosis of adjustment disorder, the initial focus of treatment will be on learning more about the circumstances of her immigration and her life in Thailand as well as her three months in the U.S.  You will also want to learn more about her previous strategies for coping with distress, her interpersonal relationships including the boyfriend, and her educational and work achievements.  It would also be advisable to learn more about resources appropriate for recent Thai immigrants as well as to research available mental health providers who are fluent in her native language.  It will be important to take a collaborative approach with the client, asking what she feels would be helpful and what steps she wants to take, as you talk with  her about different treatment options with you or other providers and social supports that are relevant to her circumstances.  Consulting with your supervisor, teachers and colleagues who have knowledge and expertise in clinical issues related to immigration and Thai-American culture will also be valuable.

If the client decides to continue in treatment with you, you can then move to the question of specific treatment goals and interventions.  Your consultation and supervision may give you information about interventions shown to be effective with Thai American immigrants, but your client’s responses and preferences about treatment are the best source of guidance.  You should be prepared to adapt interventions, like DBT, that were developed for a different cultural group and to pay close attention to the subtleties of the therapeutic relationship to gauge the impact of your interactions.

I hope you find these suggestions helpful in working with an individual or family who has recently immigrated from another country and culture.  Please email me with comments, questions or suggestions for future blog topics.

Client Requests for Records

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therapyI had a session today in which a client asked to see the notes I have taken that are part of her chart.  I told her I’d have to talk to my supervisor because I’ve never had a client ask for this before.  What choices do I have in deciding whether to give her the notes or not?

This issue was addressed by HIPAA, which created a national standard for client’s access to all medical records including records of psychotherapy.  Under HIPAA, the record belongs to the client and s/he has a right to request and receive a copy.  Exceptions are only made for instances where viewing the record would cause serious harm to the client and, in the case of child records requested by parents, harm to the psychotherapy relationship.  Most behavioral health agencies ask clients to make a written request and then provide a copy of the records within 1-3 weeks.

While HIPAA addresses client access to records from an administrative perspective, it doesn’t address the clinical issues that are often present when a client requests a copy of the current treatment record.  Your supervisor can be helpful in talking through the meaning and motivation for your client bringing this up with you.  Some factors to consider are the client’s previous experiences of secrecy and betrayal, issues of control and helplessness, interpersonal suspiciousness, and involvement in a legal case or application for disability.  Your client is more likely to tell you about the reasons she wants to see your notes if you make it clear first that you plan to honor her request.  In your next session, you can say “You told me last week you wanted to see the notes I have written for your chart.  I have the written request here for you to fill out, and I also am interested in what led you to ask for the notes.”  You can explore this further, if the client is willing to do so, by asking what she expects to see in the notes and how she feels about looking at them.

Most clinicians, especially those in field placement or practicum training, feel anxiety when a client requests the record.  You may anticipate, correctly or incorrectly, that the client will be upset or offended by things you have written in progress notes or the assessment.  Your assessment may include a diagnosis and case formulation that you haven’t explicitly shared with the client.  Your notes may accurately reflect some of the client’s obstacles to improvement and progress.  It is usually helpful to look at the record and to have your supervisor review it to identify anything that could be problematic.  Whether or not you anticipate a negative reaction from the client, it is usually wise to say “There may be portions of this record that spark questions or upsetting feelings for you.  I’d like to talk with you about anything that comes up after you’ve read it.”  Then you should follow up with a discussion in the following session about what it was like for her to look at her record.  If she has questions or was distressed by anything you wrote, I recommend being straightforward in your explanation.  If you regret anything you wrote, you can acknowledge that you wish you had used different wording or had described the situation differently.  In addition to negative feelings, she may feel pleased with her self-assertion and have an increased sense of empowerment when you respond to her request in a respectful, professional manner.

I hope you find this helpful in handling client requests for records.  Please email me with comments, questions or suggestions for future blog topics.

Contacting Other Professionals

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therapyI’m concerned that my client’s psychiatrist is prescribing the wrong medication.  She’s taking an anti-depressant instead of an anti-anxiety medication, and she says her anxiety hasn’t improved.  She signed a release giving me permission to contact the psychiatrist, so I plan to call him.

It’s often useful to talk with other professionals who are involved in your client’s health care, and preparing in advance makes the conversation more productive and collaborative.  In this instance, you have formed an impression of the psychiatrist’s professional judgment based on your client’s report which you should reflect on before contacting him.  I recommend approaching all conversations with other care providers with an assumption of competence and professionalism on their part.  There are many reasons your client may be telling you her anxiety hasn’t improved on her current medication regimen.  Before concluding that the psychiatrist has made a mistake, consider whether your client has been taking her medication as prescribed and for a sufficient length of time to be effective, whether she has tracked her anxiety symptoms on a regular basis to verify her subjective impression, and whether she has any history of addiction that could be related to her desire for and advisability of benzodiazepines for anxiety.  In addition, reflect on the interpersonal meaning of the client’s report to you and the triangle she has created between you, the psychiatrist and herself.  This may repeat an early family pattern related to conflict and loyalty that you want to handle differently than the client has experienced in the past.

Once you have checked your biases and can approach the conversation with an open, collaborative attitude, it’s good to take some time to prepare by writing down the questions you want to ask and a summary of information you want to share.  Make sure your questions are neutral and will not put him in a defensive position.  For example, it’s better to say “can you tell me how you made the decision to prescribe Zoloft?” than to say “do you think another medication would be more effective?”.  An open-ended question like “what information can you share that will help in my treatment of her anxiety?” is a good way to foster collaboration and may broaden your perspective.  When you write your summary or make notes about what you plan to share, remember to keep it brief, concise and relevant to the psychiatrist’s relationship with the client.  The client’s authorization gives you permission to exchange information, but HIPAA still obligates you to share only the minimum necessary information. When you talk with the psychiatrist by phone, start by asking questions and giving him a chance to share his ideas.  This will show you areas of agreement and consistency in your views of the client, and highlight what you may want to emphasize in your summary.  In your first conversation, I recommend that your agenda be only to establish a collaborative working relationship.  If you have areas of concern or disagreement, it is better to address those in a later conversation after some time has passed and you have had an opportunity to talk with a supervisor or colleague.

I hope you find these suggestions helpful in talking with a psychiatrist or other health care professional.  Please email me with comments, questions or suggestions for future blog topics.

Professional Practice Decisions

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therapy1I’m about to leave my counseling internship and I want to keep seeing a few of my clients.  Should I look for a private practice internship so I can continue working with these clients?

Leaving an internship is a big transition and it usually brings up many different feelings.  Transition always involves uncertainty and we sometimes deal with uncertainty by looking for something that can stay the same, to give us a feeling of security in the midst of change.  If you haven’t given thought to these issues, I encourage you to talk with your supervisor more about the upcoming change and the feelings you have about leaving your current placement.

Regarding the question of looking for a private practice internship, this is a decision to make based on your professional goals and direction rather than based on a desire to continue working with a few clients.  A private psychotherapy practice is a business that requires a significant investment of time, energy and money.  It only makes sense if it fits with your vision of what you want your professional life to be in the next several years.

I suggest asking yourself a few questions before exploring a private practice internship.  How will I feel if one or two of my clients don’t want to continue working with me after I leave the agency?  How will I feel in six months if I have no clients?  Am I avoiding some feelings of sadness or guilt about ending with these clients?  Am I worried that no one else can help them as much as I can?  Your honest answers to these questions will help you sort out your motivations and determine the right course to take.  Bringing these issues to supervision will also help you clarify what to do next.

If you do pursue a private practice internship, be sure you know the requirements of your agency in transferring clients to another setting and the requirements of your private practice supervisor in bringing clients with you into your new internship.  There are legal, ethical and licensing board issues and regulations that need to be met.  Make sure to have clear conversations with the private practice supervisor about the expectations that both of you hold about the business and clinical parts of your relationship.  Each of you may have assumptions about how you will operate, and these need to be shared to maximize your satisfaction and success.

Most importantly, use this transition as a time of personal and professional growth.  Take time to reflect on your training and supervision experiences, what you have learned and what you want to take on as your next step in training.  Think about all the clients you have seen and what you learned in working with them—about yourself as well as about clinical work.  Take time to say goodbye to your peers and supervisors as well as your clients.

Recognize what you’ll miss as well as what you’re glad to leave behind. Each phase of training contains lessons and prepares you to take on the next challenge.

Please email me with comments, questions or suggestions for future blog topics.

Responding to Client Requests

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therapyMy client is really pushing me to see her every other week.  I usually see clients every week but she insists she can only meet every other week because of her schedule and finances.  What should I do?

This is a common dilemma, and clients’ requests often seem straightforward and compelling.  Depending on your own personality and style, you may be inclined to be consistent with everyone or you may be inclined to be flexible and responsive to each client’s requests.  Rather than relying on your personal preference, the best clinical practice is to respond to the client’s request based on an understanding of her underlying motivations and the meaning it will have for you to be consistent or to be flexible.  This means reflecting not only on what she says about this issue but also on everything else you have learned about her so far.

Generally, the more serious the client’s diagnosis and symptoms, the more important it is to meet every week.  Weekly contact fosters the therapeutic alliance and improvement in symptoms, especially in the beginning of treatment.  If your client has a diagnosis of bipolar disorder, had a manic episode three weeks ago and has been in treatment for a month, cutting back to every other week is not advisable.  However, if her diagnosis is an adjustment disorder and she has experienced steady improvement during four months of treatment, it may be fine.

The client’s past and recent history helps you understand her reasons for cutting back.  If she grew up in a chaotic, abusive home and has been involved with abusive partners, she may need to assert control in her relationship with you in order to feel safe.  You would agree to her request in order to assure her that her needs are your concern.  On the other hand, if her early life was emotionally barren and she has suffered a recent loss, she may think of herself as not deserving care and attention from others.  You might talk about the benefit you believe she would receive from meeting weekly and state clearly that you want to work with her.

Next, reflect on how the client relates to you and whether anything might have gone awry in a recent session.  If your relationship has been generally smooth and positive without any interpersonal turmoil, think about whether anything different or unusual happened in a recent session.  You may have been more confrontive, may have mentioned an upcoming vacation, or may have misunderstood something the client said.  Sometimes, even a small misattunement can lead a client to withdraw out of disappointment or anger.  You can bring the conversation back to that incident and ask about the client’s feelings before making a decision about how often to meet.  If the treatment relationship has been volatile or stormy, this recent request may be a continuation of the client’s way of bringing her interpersonal challenges into treatment.  Agreeing to meet every other week is unlikely to improve this situation and may exacerbate the relational conflict.

Once you have reflected on her diagnosis, history and the treatment relationship, you can respond to her request, informed by your understanding of the meaning and motivation.  I recommend talking about the reasons for your decision as well as telling her whether or not you think it is a good idea to meet less frequently.  Whatever you decide, be sure to notice what happens in the therapy in that session as well as the next 2-4 sessions.  If your understanding and decision are consistent with the client’s underlying motivation, the treatment should progress in a positive way.  If not, you need to reconsider your decision, possibly with the help of a supervisor or consultant.

I hope you found this helpful in facing this common clinical dilemma.  Please email me with comments, questions or suggestions for future blog topics.

Termination Tasks

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I have a final session scheduled with someone I’ve seen for 6 months.  What should happen in the session to make the ending go well for the client?

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This blog focuses on the tasks of termination.  If you haven’t read the previous blog on Psychotherapy Termination, you’ll find that helpful before you focus on the logistics.

The main goal of termination is to create an ending that is less traumatic than the client’s prior experiences of separation and loss and that honors the client’s way of managing loss.  The tasks of ending treatment are the same regardless of whether the ending is planned or unplanned and whether it is initiated by you or by the client.  I will discuss one way to organize the ending into three tasks: reviewing the work you have done together, discussing future circumstances when therapy could be helpful, and sharing the experience of saying goodbye.  It can be helpful to share these tasks with the client in preparation for a final session, since most clients have little experience of ending a relationship with thought and acknowledgement of the emotions surrounding the loss.

The first task is to review the therapy, with you and the client sharing your thoughts about what you have worked on together and the changes that have occurred.  When you share your perspective, it is especially meaningful to the client to hear your memories about the early sessions.  An example is “When we began working together, you were really depressed and you had a hard time imagining how you could ever feel better.  Now you seem to be enjoying your job and time with your kids and you have ways to cope with sad feelings when they come up.”  If there are issues that are still problematic or have not been a focus of your work with the client, you can acknowledge those with a statement about how the client might address them on her/his own.

Second, the end of therapy is a time to provide support and education regarding returning to treatment in the future.  People often wait until symptoms are debilitating or until their lives are seriously impaired before seeking help, and a reminder about the steps that led up to the client’s presenting symptoms and condition may help her/him seek treatment more quickly.  Also, you can talk with the client about life transitions or developmental stages that may present a risk or vulnerability.  For example, a woman who was sexually abused at age 8 is likely to experience increased anxiety and reminders of her trauma if she has daughter who reaches the age of 8.  An adolescent who loses a parent will be vulnerable to episodes of depression or other grief-related symptoms when losses and transitions occur throughout adolescence and adulthood.  You can provide encouragement for future treatment by saying “If you find your symptoms returning again, I hope you’ll seek help again.  People often find it helpful to see a therapist when times are stressful or when there are life changes that may bring up some of the issues we’ve worked on here.”

The last task is to share the experience of saying goodbye.  Many clients are avoidant of emotions related to loss, and the depth and extent of this part of your conversation about ending may be limited.  However, at minimum you can make a statement like “I want you to know that I have enjoyed getting to know you and participating in the progress you have made.  I feel some sadness in saying goodbye, and I wish you well.”  This direct expression of your feelings provides the client with a different experience of ending, even if s/he doesn’t share her/his feelings.

I hope you find this structure helpful in organizing your final session.  Please email me with comments, questions or suggestions for future blog topics.

Psychotherapy Termination

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therapy1I will be leaving my practicum training placement 4 months from now in the summer, and this is the first time I’ve worked with people more than 12 sessions.  Some of my clients have been coming in for more than 6 months.  How much time do clients need to end therapy?

Starting at a practical level, it is usually helpful to let clients know about your departure 4-6 weeks before the end of your work if the treatment has lasted between 4 months and a year.  Less time is generally needed if the treatment is shorter and more time if it has been longer. Anyone that begins treatment with you now should know from the beginning how long you will be able to work with them. A related question that is often unacknowledged by clinicians in training is how much time you need to end therapy with your clients.  I find that the ending process is much smoother when the clinician has spent at least a month, preferably longer, reflecting on her/his feelings about leaving clients and the placement before beginning to have conversations with clients.  Supervision, sharing with fellow clinicians and personal therapy are all places to talk about this.

All of us have personal experiences with loss and we bring those feelings and reactions to professional experiences of loss.  Even though moving to a new training placement is a move toward professional growth, you are also ending relationships that have been important in your intellectual and emotional learning.  Using self-awareness about how you approach this move will tell you a lot about the ways you are accustomed to managing grief and loss.  You may minimize the importance of this step, find fault with your current placement, become preoccupied with the welfare of your clients, focus on the logistics and required documentation, or remind yourself of the exciting opportunities ahead of you.  I encourage you instead to take time to acknowledge you are saying goodbye to people who have touched your life in unique ways.

Once you have spent some time acknowledging your own emotions about the loss of your clients, supervisor and peers, you can begin to plan your conversations with clients about ending the treatment.  The main goal of termination is to create an ending that is less traumatic than the client’s prior experiences of separation and loss and that honors the client’s way of managing loss.  Your supervisor can help you review what you know about the client’s past experiences of separation and loss and how s/he manages feelings of grief and sadness in the present.  Based on this knowledge, you will be equipped to identify what can be different in your ending with the client.  You can also develop hypotheses about how the client is likely to respond.  You can expect that some of your clients will avoid coming to the final session, and saying goodbye by telephone, email or letter may be the best possible ending for some of these clients.

I hope you have found some food for thought as you anticipate saying goodbye.  The next blog will continue on this theme with some more specific ideas about what to include in your ending process with clients.  Please email me with comments, questions or suggestions for future blog topics.

Cross-Cultural Mental Health Treatment

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I have just been assigned to see a client who is from a culture that is completely unfamiliar to me.  She immigrated to the U.S. three years ago and speaks English, but I’m concerned about being able to do psychotherapy with her.  How can I make sure I don’t over diagnose symptoms that may have a different cultural meaning for her than for my other clients?

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It’s good that you’re aware of the importance of your client’s culture in your diagnosis and psychotherapy.  When working with a client whose culture is unfamiliar to you, I recommend doing some research into the culture to learn some basic facts about her country of origin.  If you haven’t worked with other individuals who are recent immigrants, doing research into this area will also be valuable.  However, also remember that your client is the best person to educate you about herself.  She is presenting for behavioral health treatment because she is in distress and wants help with some issues that are troubling her.  The skills you use in the first session with any client will serve you well in this situation.  In addition, you may want to ask her how her family members or friends in her country of origin would understand or interpret her symptoms to provide some cultural context for her concerns.

One way to keep the cultural context in mind when using the DSM for diagnostic purposes is to ask about events leading up to the client’s immigration and conditions since she arrived in the U.S.  It is possible that an adjustment disorder or posttraumatic stress disorder diagnosis may be appropriate.  If her symptoms don’t fit either of these diagnoses, you can use an initial “not otherwise specified” or provisional diagnosis, which will note your lack of sufficient information to make a full diagnosis.  This can be changed as you learn more about her history and current life circumstances.

Another way to use the DSM as a resource for assessment is to incorporate the cultural formulation found in Appendix I of the DSM-IV and in Section III of the DSM-5.  The outline for cultural formulation includes cultural identity, cultural conceptualization of distress, psychosocial stressors and supports, and cross-cultural features of the treatment relationship.  The DSM-5 also includes a set of interview questions that can be used in assessing the cultural context of the client’s clinical presentation.

A final issue to consider in your initial assessment and ongoing psychotherapy is the cultural context of your role as a professional in the therapeutic relationship.  If you are still in training, you may not think of yourself as an expert, and many of your U.S. born clients may treat you as a peer or make comments about your status as an intern or trainee.  Many other cultures hold a value of deference to authority, however, and this may make your client reluctant to disagree with you or to express her preferences about the treatment.  In addition, recent immigrants and other cultural groups often have experiences of discrimination and misunderstanding by officials, administrators and service providers.  It can be helpful to directly express your interest in the client’s ideas, to ask open-ended rather than closed questions, and to acknowledge the extent and limitations of your knowledge.  Even so, it may take more time to develop a therapeutic alliance with this client than with clients who are from cultural backgrounds similar to yours.

I hope you find this blog helpful in working cross-culturally.  Please email me with comments, questions or suggestions for future blog topics.

Working With Depression

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I’m worried about one of my clients who was very depressed and overwhelmed in our last session. How should I decide whether to call her before our next session?

This is a common and distressing situation for students in psychotherapy training. You may find yourself preoccupied with worry and uncertainty about your client’s wellbeing, especially if you are personally vulnerable to anxiety. Part of the developmental process in clinical psychology training is expanding your focus from alleviating your own distress to evaluating the impact on your client of different interventions. As behavioral health professionals, our primary responsibility is client welfare so all of our clinical interactions should be centered on that consideration.

Regarding a depressed, overwhelmed client, your first step should be consulting with your supervisor. This is especially important if you are in your first practicum or field placement setting and you should continue to consult with your supervisor throughout your training whenever you are concerned about a client’s safety. These situations bring up intense feelings for clinicians and it is hard to be objective in evaluating the most appropriate response when you are caught in the emotional intensity. Some of us respond to intense emotions by shutting down and minimizing the client’s risk and others of us become agitated and overestimate the risk.

Some of the factors to consider in evaluating your client’s risk, in consultation with your supervisor, are the length of your relationship with the client, whether the client’s emotional state is a change in response to a recent stressor or is more longstanding, how the client has coped or reacted to similar feelings in the past, and what internal strengths and external supports are available to the client. Clients who are new to you, who are reacting to a recent precipitating event, who use self-destructive or impulsive coping strategies, and have few strengths and supports are at greater risk. If you are concerned about suicidality, use a risk assessment tool such as the Suicide Assessment Five-step Evaluation and Triage.

If you and your supervisor agree that the client’s risk is high, you should contact the client to make a further assessment. If the client’s risk is low, you can wait until your next session to do further assessment. If there is a moderate level of risk, your decision will be based on your understanding of the meaning your intervention will have to your client. You may contact the client as a way to communicate your care and concern, but the client may experience your call as intrusive and undermining. You can develop an understanding of your client’s likely interpretation of your interventions based on your knowledge of her/his early experiences with parents and other caregivers and your observations of her/his relational patterns. A client who experienced neglect and has an expectation that others will be absent and uncaring will respond more positively to an unexpected call from you than a client who experienced abuse and intrusion. However, because psychotherapy always has the overriding goal of supporting client autonomy and self-determination, it is safer to refrain from initiating contact with a client unless there is a clear reason to do so.

After consultation and consideration of your client’s welfare, you may determine that contact with the client isn’t appropriate but still feel worried. This is the time to refocus your attention on your own coping strategies and self-care. Learning psychotherapy involves strengthening your ability to manage intense emotions and placing the client’s welfare above your personal needs. It also involves differentiating between your relationships with family and friends and your professional relationships with clients.

I hope this has been helpful to you. Please email me with feedback or suggestions for future blog topics.

Evaluating First Session of Behavioral Health Treatment

therapy1I just completed a first session with a new client. I feel like it went pretty well, but I’m not sure how to tell. What should I think about before I see the client again next week?

Generally, we end a client session with a general feeling about how it went, as you did. It seemed like a good session, a great session, a terrible session or just okay. That general feeling is the combination of a number of factors which can be helpful to separate out. It is also important to integrate your feeling about the session with your thoughts about the clinical work and what you will do next.

Often our feeling about a client session, especially the first session, comes primarily from our experience of the therapeutic alliance. The therapeutic alliance refers to a shared feeling of working together toward the same goal. After the first session, we have a sense of whether the tone was collaborative, distant or adversarial and how easy or difficult it was to feel empathic and warm toward the client. We also get a sense of whether there were obstacles to the alliance which mean it will be more difficult to establish a sense of collaboration. When you feel the session went well, it can be helpful to think about the nature of the therapeutic alliance and how that contributes to your general feeling.

During the first session you probably got an idea of why the client is coming for treatment and learned some information about his or her life and history. You may find it useful to write down your client’s primary concerns, any safety issues that are present, and questions you want to follow up. This will help to organize your thoughts and identify areas to explore in subsequent sessions. Many clinicians feel a conflict between a desire to build rapport and an agency requirement to do an assessment and/or develop a treatment plan. However, one of the best ways to build rapport is to express your desire to understand the client’s life and goals, and this understanding is the basis for your assessment and treatment plan. You can provide focus and structure by combining empathic listening with sensitive questioning and summarizing comments. This is useful to clients whose lives are somewhat chaotic and unpredictable.

Identifying issues to discuss with your supervisor is also part of beginning treatment with a new client. You may have questions about the client’s symptoms and diagnosis, the appropriate unit or modality of treatment (seeing the client individually or as part of a family unit, referring for medication), safety concerns, or feelings that have arisen for you about or with the client. Even when you feel good about your first session and don’t have any pressing concerns, it is wise to mention the client to your supervisor so she/he is updated on your case load.

I hope some of these suggestions help you in preparing for early sessions when you are getting to know a new client. Please email me with comments, questions or suggestions for future blog topics.