Category Archives: Case Formulation and Treatment Planning

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.

Responding to Client Requests

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.

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?


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.

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.