Blog

ALL BLOG POSTS

BEGINNING THERAPY WITH THE FIRST CLIENT CONTACT

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

MOTIVATIONS FOR BECOMING A THERAPIST

new2I just finished my first semester in a practicum placement, and I have begun to doubt my decision to become a therapist. I decided to enroll in graduate school because I liked to talk to people and heard from my friends that I was a good listener. Seeing clients this semester was much harder than I expected, and I didn’t feel like I was able to help them very much. How can I decide whether to stay in the program or leave to pursue a different career?

WHEN TO ENGAGE IN CLIENT ADVOCACY

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

THEORETICALLY BASED CONCEPTS IN DOCUMENTATION

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

NONVERBAL CUES RELATED TO CULTURE

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

STEPS TO DEVELOPING A DIAGNOSIS

My agency requires assigning a diagnosis after the first session, and this is very hard to do.  How can I give a diagnosis to my client when I don’t have complete information about them?

HAVING DIFFICULT CONVERSATIONS IN SUPERVISION

I have finished my first semester in a new practicum site, and my supervisor’s evaluation of me was less positive than I expected.  She’s been very supportive of me, and I expected her to understand why I’ve had some trouble keeping up with paperwork and applying the theoretical orientation used by my agency.  Should I talk with my supervisor about her evaluation of me?

HAVING DIFFICULT CONVERSATIONS WITH COLLEAGUES

I’m seeing a heterosexual couple in couples therapy, and a colleague at my agency is seeing the wife individually. Last week my colleague made a critical comment about the husband and questioned how helpful couples therapy could be. She said this in front of several of our peers, and I didn’t respond because I was shocked and hurt. I think I need to say something to her, because her negative view of the couples therapy will undermine the wife’s participation. There is a lot of conflict in the relationship but they have both expressed a commitment to work it out and stay together.

HAVING DIFFICULT CONVERSATIONS WITH CLIENTS

I have a client who has been 10-15 minutes late to every session since we started meeting three months ago.  My supervisor says I need to talk with her about this, but I’m afraid she might stop therapy if I confront her.  Is it possible to continue seeing her in therapy without talking about why she’s late?

EDUCATION AS A THERAPEUTIC INTERVENTION

I’ve been seeing a client for about six months, and she recently told me about witnessing domestic violence between her parents when she was young. I used to volunteer at a DV family shelter, so I have a lot of information about how she may have been affected by this. Is it appropriate for me to share what I know as part of her therapy?

SHARING CLIENT INFORMATION IN A TEAM

ITeachers Talking Diane Suffridge am a counselor at a high school, and the teachers often ask me about my clients’ progress. I know they have good intentions, but I’m uncomfortable answering their questions. How much should I share and how do I explain the reason I can’t answer some of their questions?

EVALUATION OF CLIENT APPROPRIATENESS FOR TREATMENT

A client was recently assigned to me, and when I contacted her to set up an appointment she told me she had been in the hospital a month ago because of suicidal thinking. I’m not sure whether I should take on this client since I’m in a practicum and have only seen clients for a few months. What should I do?

CULTURAL VALUES IN TREATMENT GOALS

I just completed my first session with a 21-year-old Latina who is a first generation American. She seems to rely too heavily on the opinions of her parents and other older members of her family in making decisions about her career and dating life. She said she wants to feel less anxious, and I think that will only happen if she becomes more independent of her family. How shall I talk with her about this?

TIPS FOR ESTABLISHING AN ALLIANCE

I’m starting my first practicum placement next week, and I’m both excited and nervous about having my first session. How should I prepare for my first client to make sure the session goes well?

LEGAL AND ETHICAL DECISIONS

I passed my licensing exam a few weeks ago and am opening a private practice. I understand I now have to attend continuing education or training in law and ethics during every two-year renewal cycle. My practice will be pretty simple, and I don’t expect any legal issues to arise. I’ve always been an ethical person, so I also don’t foresee any problems there either. What is the reason for the requirement for all licensed practitioners?  

IMPACT OF A THERAPIST’S PERSONAL HISTORY

I have been assigned to see a 12-year-old girl whose father died a year ago, and her mom antherapy-teend teachers report she seems depressed. My mother died when I was 14, so I have a good idea of what she’s going through and think I’d be a good therapist for her. My supervisor said she’s concerned that this case could be too close to my own experience, but I think it’s good that I know what’s it’s like to lose a parent. 

USING THERAPIST EMOTIONS TO UNDERSTAND THE CLIENT

I have been seeing a 35-year-old woman for about six months at my practicum site. I left the last session feeling at a loss about how to help her. She was sexually abused as a child, and I’m afraid I don’t have enough experience to be an effective therapist for her. How can I decide whether to refer her to a more experienced clinician or get more training myself?

ASSESSING A CONFUSING INITIAL PRESENTATION

I just had the first session with a 22-year-old client at my practicum site. She seems depressed, but there is also something different about her than my other depressed clients. I found it hard to connect with her, which is unusual for me, and she couldn’t really tell me anything about her history. She says her childhood was fine, but she doesn’t remember much until she was about 11. How can I figure out what is going on for her?

ENDING THERAPY OR TAKING A BREAK

I am doing my practicum placement in a high school, and I plan to return there next year after a summer break. Several of my clients have said they want to see me again in the fall, so I’m wondering how to talk with them about taking a break and returning to therapy.

HOLDING DIFFERENT PERSPECTIVES ON A CLINICAL SITUATION

Couples CounselingI’m working with a couple who report very different versions of their interactions with each other. I trust the wife’s report more than the husband’s, but I don’t know how to figure out what really goes on between them. How can I determine who is more accurate?

RESOLVING PROBLEMS IN SUPERVISION

I am having problems with my supervisor and am thinking about requesting a new supervisor. She seems impatient and critical of me, so I feel intimidated and that makes it hard for me to take in her feedback. When I tell her how I feel, she says she’s trying her best to help me learn. I don’t know how to make this better so maybe I should change to someone else.

CLINICAL ISSUES RELATED TO MONEY

My internship is in an agency that charges sliding scale fees. One of my clients hasn’t paid for the last two sessions, saying he forgot his check both times. I know he can afford it because he just came back from a big vacation to Hawaii. How can I bring this up with him and get him to pay on time?

CLIENT REACTION TO THERAPIST ABSENCE

I took some time off for the holidays, and my clients seem to be reacting to this. A few have cancelled sessions, a few have arrived late when they’re usually on time, and one said he thinks it’s time to stop therapy even though there is clearly more to do. How can I bring up the possibility that they’re upset about my being away without making the therapy all about me?

CLIENT ATTENDANCEhispanic young woman in therapy

I’ve been seeing a client for three months, but she has only come to 7 sessions.  Sometimes she calls to cancel, but often she just doesn’t show up. I don’t know whether I should stop seeing her or if there is another way to help her understand the importance of coming in regularly.

APPLYING FOR INTERNSHIP TRAINING

I plan to apply for internship training in a few months, and I want to work with children and families. How can I make myself a competitive candidate when my clinical experience so far has been with adults?

CLINICAL ISSUES AT HOLIDAY TIMES

The holidays are coming up soon, and I am thinking about how to prepare my clients for the issues that are likely to come up.  This is my first year in a practicum placement, so I also wonder how much to be available to see my clients during the holiday season.  

CLIENT DISENGAGEMENT

I’ve been working with a client for about six months, and we’ve agreed on a treatment plan. However, he doesn’t seem very engaged in working toward his goals. My supervisor suggested I bring this up with him, so I asked if he has changed his priorities and he said no. How can I help him make progress when he isn’t motivated?

UPDATING CLIENT DOCUMENTATION

imgresI have seen a client for three months and have learned new information that changes my diagnosis from major depressive disorder to post traumatic stress disorder. In light of this new information, we’re also working on different treatment goals than we talked about at the beginning. What is the best way to document these changes in our work together?

SILENCE AS AVOIDANCE

I have a client who uses silence as a defense or avoidance. What can I do to make therapy effective when he isn’t engaging with me to work on his goals?

THE VALUE OF LISTENING

I’ve seen a client for three months and am at a loss for what to do. Her husband of 35 years died suddenly last year, and our work has focused on her grief and loss. Her feelings are still very intense, and I’m beginning to wonder if I can help her.

MAKING REFERRALS TO ADDITIONAL SERVICES

I have been seeing a client for a couple months and I think she needs more help than I can provide with individual psychotherapy. I have recommended that she get a psychiatric evaluation, join a DBT group, and sign up for a subsidized housing program. All of these services are available at the agency where I am doing my practicum training, but so far she hasn’t followed up on any of my referrals. How can I encourage her to get the additional help she needs?

CLIENT RESPONSES TO THERAPIST LEAVING

I am leaving my practicum placement at the end of the training year in six weeks and have just told all of my clients. Most of them didn’t seem to have much of a reaction to this news. What can I expect between now and when I leave?

MANAGING SILENCE

LGBT therapyI have a client who has a hard time talking in our therapy sessions. I want him to benefit from therapy so I prepare for the session by having topics for us to talk about. This has been going on for several months now, and I’m beginning to wonder if there’s a different way to handle this situation.

GENERATIONAL DIFFERENCES IN THERAPY

I have been working for the past year with a 78-year-old woman who has a moderate level of depression. She has a limited income, lives alone and has very little contact with other people. I have suggested several resources, including some that are online, that she could use to reduce her isolation. She agrees with me in session but doesn’t follow through. I’m starting to feel both frustrated and discouraged about being able to help her. I talked with my supervisor about ending the therapy but she told me to keep trying.

THERAPIST SELF-DISCLOSURE

I was recently assigned a new client who is a gay male in his 40s. He had a recent relationship breakup and is depressed. In his intake interview he requested a gay male therapist and was told the agency would try to honor his request but couldn’t guarantee it. I am a straight female but I am very close to my gay brother, his husband and their two kids. I also have a number of gay friends, both men and women. What should I tell the client to help him feel at ease with me?

CULTURAL COMPETENCE WITH LGBT CLIENTS

I was recently assigned a new client who is a gay male in his 40s. He called for services because of depression after a relationship breakup. In his intake interview he requested a gay male therapist and was told the agency would try to honor his request but couldnt guarantee it. I am a straight female but I am very close to my gay brother, his husband and their two kids. I also have a number of gay friends, both men and women. What should I tell the client to help him feel at ease with me?

WHAT TO DO WITH THINGS THAT CAN’T BE CHANGED

I’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?

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?

USING SUPERVISION

I’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.

MANDATED TREATMENT

I 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?

SELF CARE FOR ENHANCING WELL-BEING

img-article-are-you-too-stressed-outI’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?

SELF CARE IN WORK HABITS

I’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?

CHANGES FROM DSM-IV TO DSM-5

I 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?

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?

PERSONAL PSYCHOTHERAPY

My 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.

ADJUSTING TO DIFFERENT CLINICAL ROLES

I have worked as a 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?

UNPLANNED ENDINGS

worried therapistI 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.  

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?

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.  

WRITING PROGRESS NOTES

portrait-female-therapist-office-her-patient-44629457I 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? 

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.

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 dont 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?

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?

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.

SEQUENTIAL TREATMENT

teen-in-psychology1I 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.

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?

CULTURAL FACTORS IN DIAGNOSIS

I 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.

CLIENT REQUESTS FOR RECORDS

I 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?

CONTACTING OTHER PROFESSIONALS

I’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.

PROFESSIONAL PRACTICE DECISIONS

I’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?

RESPONDING TO CLIENT REQUESTS

My 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?

TERMINATION TASKS

new1I 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?

 

PSYCHOTHERAPY TERMINATION

I 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?

CROSS-CULTURAL MENTAL HEALTH TREATMENT

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?

WORKING WITH DEPRESSION

depressed-womanI’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?

EVALUATING FIRST SESSION OF BEHAVIORAL HEALTH TREATMENT

I 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?

BEGINNING BEHAVIORAL HEALTH TREATMENT

My agency has a lot of forms for clients to fill out at the first session. I want to build rapport in the first session but instead I’m explaining forms and getting the client to sign them. Are these forms really necessary?

FIELD PLACEMENT TERMINOLOGY

What’s the difference between psychotherapy, case management, mental health and behavioral health programs?