Category Archives: Case Formulation and Treatment Planning

Theoretically Based Concepts in Documentation

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

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

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

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

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

Sharing Client Information in a Team

Teachers TalkingI 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?

This is an example of working in a team with other professionals who have different expectations and requirements regarding confidentiality and privacy of information. Your client work is probably covered by the Health Insurance Portability and Accountability Act (HIPAA), which carries more limitations on sharing information than the regulations applicable to educational information. It is likely that the teachers know you can’t share fully with them, but your role in the school supports the students’ academic success so it is important to find ways to communicate productively with teachers. This requires that you create a collaborative working relationship with the teachers and other staff in the high school. I will recommend several steps you can take to establish yourself as part of a professional team.

One step is to have a short response regarding confidentiality requirements that you can use when a teacher asks you for specific information. An example is “you probably know I can’t share any details about the counseling, but I’d like to work together within the constraints I have to follow.” This establishes the limits of confidentiality while also communicating your desire to collaborate. Remember that teachers are often working in difficult circumstances and may be looking for support. When you can express your understanding of their concern for the students and the challenges they face in the classroom, the teachers will see you as an ally even if you can’t answer their questions. Follow your statement about confidentiality with an acknowledgement of their concern and desire for the student to get the help he/she needs.

Often, the next step will be to open a conversation with the teacher about how the student is doing in class. You might say “has anything happened lately that I should know about?” or “I’m interested in your perspective on how things are going.” The teacher’s question to you about the student’s progress may represent a desire to tell you something about the student’s life or a recent incident in the classroom. This information can be valuable background in your understanding of the student. Your client may present very differently in your counseling sessions than in the classroom or with teachers and peers. HIPAA limits the information you can share about treatment, but it doesn’t limit what you can hear from others.

You may also want to schedule a more formal conversation with one or more of your student’s teachers to ask specific questions that will aid in your assessment and treatment planning. It is wise to prepare a list of questions in advance so you can be focused in your discussion with the teacher and insure that you get the information you need. As treatment progresses, check in with the teachers periodically to get updates on the student’s progress in the classroom both academically and behaviorally. This information will enhance your review of treatment goals and help you to shape the direction of treatment.

Last, there may be times when you feel it would be helpful for you to share your impressions of the student with one or more teachers. You might have suggestions that the teacher could implement in the classroom or you might be able to provide an explanation for some of the student’s behavior that is otherwise confusing or creates conflict. If this is the case, you will need to have written permission from the parents and/or your client. Generally, parental consent is required for sharing treatment information for children under 18, but some states allow a minor to consent to treatment which would require that you get the student’s permission to share information. Even if it isn’t required by law, it is clinically sound to talk with the student about what you plan to share with the teachers and the reasons you think it would be helpful.

I hope you find these suggestions helpful in working as part of a team. Please email me with comments, questions, or suggestions for future blog topics.

Cultural Values in Treatment Goals

counselingI 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?

Before talking with your client about her goals, I would suggest doing some exploration of your views and how they differ from your client’s. This situation highlights the impact of cultural values on treatment goals, and it is important that we examine our values and assumptions before recommending a treatment approach.

The first step in this situation is to recognize that you have developed an agenda that is different from your client’s. Any time this happens, you need to pause, examine the discrepancy, and work to understand your client’s perspective on what is best for her. In this case, you seem to have made some assumptions about your client’s relationship with her elders that will interfere with the therapeutic alliance. Her alliance with your depends on experiencing your respect and support for her in working toward her priorities. Over the course of time, your client may come to desire greater independence from her elders, but your task at the beginning of treatment is to join with her in working toward reducing her anxiety. Otherwise, she may feel undermined in defining what she needs.

The second issue to recognize is the extent to which values and beliefs about developmental goals and relationships are embedded in a cultural context. Your view that independence from parents and other family members is a desirable goal for young adults is no doubt consistent with the values of your cultural community, but your client comes from a cultural community that values interdependence and respect for elders. Talking with your supervisor and other colleagues about these cultural differences will help you to identify the strengths and benefits of your client’s values rather than assuming that she should come to share yours.

Another more complex issue to consider is the extent to which your response to your client may reflect her own conflict about her family relationships. It is helpful to reflect on your countertransference feelings and to talk about them in supervision. If you usually find it easy to join with your client’s agenda, it is possible that your strong opinion about this client’s need for independence represents your resonance with a part of herself that she is reluctant to articulate. If this seems plausible, you can support your client to recognize and sort through the complicated nature of her feelings toward her parents and other family members. This will work in her best interest if you can express an attitude of curiosity rather than judgment and if you help her identify and honor the mixture of different feelings she holds.

I hope you find this helpful in working with clients whose initial treatment goals are different from yours. Please email me with comments, questions, or suggestions for future blog topics.

Using Therapist Emotions to Understand the Client

new2I 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?

It sounds like you had a strong emotional response to the recent session with this client that brought up questions for you about your effectiveness. Before making a decision to do something different in the treatment, I would suggest reflecting on your emotions as a way to understand the client in a deeper way. Your feelings of inadequacy and self-doubt may reveal something important about the client’s experience in relationships and her view of herself.

The first step I recommend is to take some time to identify your emotional response to the client more completely. In addition to your own reflection, you may find it helpful to talk about this with your supervisor, therapist, and colleagues. When we feel uncomfortable emotions during and after a session, it is tempting to ignore or avoid them and to take action to reduce our discomfort. Instead, take time to go more deeply into your emotions by identifying the thoughts, images, and physical sensations that accompany the emotion. If you have a mindfulness practice, use that practice to engage with your emotional experience without judgment.

After you have a more complete understanding of your emotional response in this recent session, review what you know about your client’s history, developmental trauma and losses including the sexual abuse, and her current relationship patterns. All of these experiences may be relevant to the emotion that has been stimulated in you. Think about the connections you can make between your emotions and the client’s experience. It is likely that your emotions mirror a painful experience from her past and present relationships. Ask yourself when your client has felt inadequate and ineffective with others. She may or may not have been able to talk directly about these feelings, so you may need to make inferences about feelings she has kept outside of her awareness and aren’t accessible verbally. Supervision is helpful in identifying links between your emotions and the client’s.

Last, identify ways you can respond therapeutically to your client in the face of your feelings of inadequacy. It will help to think about capacities she needs to develop or how she could manage her feelings of inadequacy with greater strength and confidence. An example might be for you to say “it may feel daunting to face the impact of your past but I think our work together can result in you developing different ways of handling the triggers when they arise” or “I wonder if you sometimes feel like giving up and it’s hard to believe things can get better.” If your client is directly questioning your capacity to help her, you can acknowledge her worry along with your commitment with a statement like “you may worry whether your difficulties are more than I can handle and I think that’s an important issue for us to talk about together.”

As you respond therapeutically to the client using your understanding of your emotions as a connection to her experience, you will notice changes in her way of relating to you and changes in your emotional response to her. She may begin talking more directly about her feelings of inadequacy, she may deepen her engagement with the therapy and the pain of her abuse, or you may notice that you’re feeling more sadness about the impact of her trauma rather than worry about helping her. All of these changes are indications that you have used your emotions to further the therapeutic process. If your questions about the effectiveness of the therapy continue, talk further with your supervisor about whether a different therapeutic approach or a referral to additional services would be indicated.

I hope you find this helpful in using your emotional responses to understand your clients. Please email me with comments, questions, or suggestions for future blog topics.

Client Reactions to Therapist Absence

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

I agree with your assessment that your clients are having reactions to your absence and that it’s desirable to encourage them to talk about their feelings instead of demonstrating them in action. I’ll share some ideas about ways you can initiate this discussion and some of the reasons that clients may be reluctant to acknowledge and talk about their feelings.

Before talking with your clients about their reactions to your absence, notice and work to understand your countertransference feelings about this. You may feel annoyed, afraid, or guilty, reflected in thoughts like “don’t they appreciate how hard I work?” or “what if I lose clients every time I’m gone?” or “I guess I shouldn’t take so much time off next year.” These countertransference feelings can interfere with your ability to talk with the clients about their feelings, so wait to do so until you have understood and gotten support to process your annoyance, fear, guilt, or other feelings.

Your clients will probably have difficulty acknowledging to themselves and to you that they were affected by your absence. Our society generally values independence and autonomy over connection and interdependency, and it is unusual and unfamiliar for a professional to acknowledge the impact of a break in the relationship. Other health care and social service providers generally don’t acknowledge that the client may be affected by the provider’s absence or lack of availability. In addition, some of your clients probably coped with difficulties in their families of origin by denying their need for reliability and consistency and by shutting off their awareness of feelings of dependency and accompanying anger when their relational needs weren’t met.

Despite your clients’ reluctance and lack of practice, there are ways you can introduce the topic that will make it easier for them to engage in exploring their reactions to your time away. First, notice for yourself how the client’s behavior is different and mention this with an attitude of curiosity. For example, you might say “I notice that you were late for both of our sessions since I returned from my holiday break. That’s unusual for you, and I wonder if it might be related to the fact I was gone for a couple weeks.” This opening statement doesn’t make any judgment or assumption but simply tracks the change in behavior following your absence.

Second, it may help to make a statement that normalizes the fact that clients are affected by a break in the flow of therapy and that these emotions can be at odds with their rational or intellectual understanding of the reasons for the break. A sample statement would be “Many clients find they have feelings about missing a week or two of therapy, even though they understand the reason for my being away. Could that be the case for you?” With a client who is especially reluctant to look at her feelings about the therapy relationship, you might also talk about why this could be important to look at in light of her presenting issue or the focus of treatment. An example is “It may seem odd for me to ask about your feelings related to my being away for two weeks, but we’ve been talking about how you feel when your husband is on a business trip. It might help us understand that better if we also look at your feelings when I’m away.” This gives the client an explanation for why you think it is important to explore this and how it could help her in the area of concern to her. In some cases, it can be helpful to make a statement about the early experiences and coping strategies that interfere with acknowledging the impact of your absence by saying something like “We’ve been discussing how hard it was for you to come home to an empty house when both of your parents were working, and some of those feelings may have returned when I was away. You’ve worked hard to not let yourself know how painful that was, and it may be hard to recognize how you felt while I was gone.”

Last, let the client know that you’ll continue to notice and bring up the question of her feelings when you are away in the future. Sometimes the repetition over time helps the client to develop more awareness of the underlying emotions that aren’t accessible in your initial discussion.

I hope you are able to use these suggestions when working with client reactions to your absences. Please email me with comments, questions, or suggestions for future blog topics.

Client Attendance

young woman in therapyI’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.

This is a common dilemma, especially for clinicians in training or agency settings. It is difficult to make therapeutic progress when clients miss one or more sessions each month, and it is often challenging to engage the client in examining the reasons for irregular attendance. I will describe two approaches to this issue, and you may find either or both of these approaches helpful with this client and similar situations.

The first approach involves having a standard policy regarding attendance, setting a limit on the number of missed appointments or late cancellations. Your agency may have such a policy or you may develop one if you are working in a private practice setting. This policy should be part of your informed consent process, and I recommend that you remind the client about this each time she misses an appointment without notice or with late notice. A common standard is to allow three missed appointments or late cancellations (usually less than 24 hours’ notice) in a four month period before ending treatment. You may decide to make exceptions for illness or unavoidable emergencies, but be sure to discuss this with the client and let her know the reason for making an exception. The purpose of this type of policy is to insure that there is discussion about the issue of attendance and that the client is able to make progress on the issues she wants to address.

The second approach, which can be used instead of or in addition to an attendance policy, is to handle the client’s sporadic attendance as a clinical issue. The basis for this approach is an assumption that the client is repeating a traumatic or maladaptive interpersonal relationship and that you can provide the client with a different experience that will have a therapeutic outcome. I will outline a three step process for making such a clinical decision.

The first step in understanding the meaning of the client’s missed sessions is to reflect on her developmental history, especially regarding attachment and loss, and her descriptions of current relationships with intimate partners. Identify one or two themes that are present in these early and recent relationships. One common theme is an unpredictable attachment figure which leaves the client with feelings of longing and inadequacy. Another is an intrusive or abusive attachment figure leading the client to sacrifice safety to meet her need for connection. Think about the implications of these interpersonal experiences for the client’s view of herself and expectations of others.

The second step is to examine your countertransference and identify the interpersonal experience that the client is repeating with you. Be honest and thorough in reflecting on all of the thoughts, emotions, and images that are present when you wait for your client or when you pick up a message cancelling a few hours before the appointment. Notice any attributions you make about the reasons for the client missing the appointment and about the value of the therapy or your value as the therapist. Think about parallels between your thoughts and emotions and the client’s interpersonal themes. The client may be placing you in the position of the attachment figure or in the more vulnerable position she was in as a child.

Once you have identified the relevant experience and the roles being enacted by you and the client, you are ready to decide on a response that will allow the client to experience this interaction differently. This third and final step usually begins with shifting your countertransference state so that you are in touch with your therapeutic intentions and skills. You can then talk with the client in a different way than is possible when you are in the grip of the client’s enactment. In the best of circumstances, your response allows the client to become more engaged in the therapy whether or not she gains insight into the nature of the repetition. At other times, the client continues her side of the repetition, and you will need to decide whether to introduce limits as discussed above. Even in these situations, however, there is an opportunity for your learning and you can end the therapy, if necessary, knowing that you provided every opportunity for a therapeutic outcome.

I hope you are able to use these suggestions when working with clients whose attendance is irregular. Please email me with comments, questions, or suggestions for future blog topics.

What to do with Things that Can’t be Changed

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

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

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

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

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

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

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

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

Tips for Developing Treatment Plans

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

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

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

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

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

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

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

Adjusting to Different Clinical Roles

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

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

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

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

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

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

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

Sequential Treatment

Two women talkingI 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.