Category Archives: Cultural Issues

Awareness of Cultural Influences

counselingI am a female therapist working with a young woman in her 20’s. She has an opportunity for a promotion which would involve business travel a couple times a month, and would be a good career move for her. However, she is considering turning down the promotion because she helps her parents care for her grandmother who has many health problems. It’s hard for me to see my client sacrifice her professional success for this family obligation. How can I help her with this decision?

This is an example of the influence of cultural values in psychotherapy. You and your client are both female, but you may be different in other cultural identities such as age, ethnicity, social class, sexual identity, religious affiliation, and immigration status. Our values and our views of relationships are shaped by the combination of cultural factors that make up our identity, and these differences between you and your client lead you to different cultural values. The topic of cultural issues in psychotherapy is covered in Chapter 4 of my book.

It is important for you to recognize that you have formed an opinion about what is best for your client based on your values, but she is letting you know that she views her situation differently. Assuming that she needs to come around to your point of view interferes with the understanding that can develop when you are curious and interested in her perspective. Take time to encourage her to explore and reflect on the values she is expressing by pursuing a career and by caring for her grandmother so she can become more clear about the dilemma she is facing. As you are more open to considering her point of view, you will be able to empathize with her complex feelings and to support her making a decision in line with what is most meaningful to her.

Be aware that your client may be making assumptions about what is and isn’t acceptable to her family, and she may not have discussed her decision openly with her family. Our beliefs about ourselves and relationships are often internalized early in life and may not be fully within her awareness or part of recent family conversations. Once you have helped your client become aware of her values, you and she can examine them together to see the extent to which they inform her decision. It may also be useful for her to talk with others in her cultural community to see whether there is more diversity of opinion than she assumes or than she believes based on her individual experience in her family. Getting consultation, especially from someone who is familiar with your client’s cultural influences, will be helpful in managing your feelings as she arrives at her decision.

In addition to your client’s values, examine the practical issues that may influence her decision to take this promotion. The immigration status of her parents and grandmother, the family’s financial resources, and the presence of other support in the community are all factors that may make it more or less difficult for your client to prioritize her career, if that is what she wishes to do. It may take time for her to disclose some of these details to you, depending on the extent to which she holds cultural values that consider such matters as private, not to be shared outside the family.

This career decision may be the beginning of numerous situations your client will face and need to discuss in therapy. Whatever she decides about this promotion, continuing to talk with her about her cultural values will be helpful in her developmental progress. It is likely that she will face similar choices in the future as she navigates her career and family commitments. If you recognize your values and assumptions as culturally influenced and develop an authentic interest and curiosity in your client’s perspective, the therapy is likely to develop into a deeper and richer relationship. You have an opportunity to provide your client with the experience of empathy, understanding, and respect that will build her confidence in making this and future decisions.

If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.


Nonverbal Cues Related to Culture

nonverbalculturalcluesI 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?

It is good for you to begin this therapeutic relationship with an awareness that you will need to make some adjustments in your usual therapeutic practices in order for this client to benefit from therapy. When we have significant cultural differences from our clients, it is our clinical responsibility to learn about the implications of these differences for establishing a therapeutic relationship.

The first step I would suggest is to get some education and consultation on your own, with supervisors, professors, and colleagues and by accessing professional publications in print or online. Since there are many cultural groups within India, it will be important to know your client’s geographic, religious, and class identifications. The easiest aspects of this education will be general information about views of health and mental health, symptoms, and treatment. Your client will also be able to tell you about her understanding of these aspects of her culture. Issues and struggles for first generation Indian clients are reflected in movies and books. The movie “Bend It Like Beckham” and the book “Life’s Not All Ha Ha Hee Hee” by Meera Syal are examples.

In general, boundaries within the Indian culture are very different from those in the West. Many generations live together, elders are expected to be cared for, and daughters in law are expected to bear the brunt of the work in traditional homes. Explore your client’s family structure and expectations, including the family members and living arrangement she left in India and whether she lives with family members or has acquaintances in the U.S. Approach these discussions with openness and keep in mind that individuation may not be the goal of therapy for your client. The structure of a family system that fosters both a sense of connection and a sense of individual wellbeing for this client may look different than for your clients who come from traditional Western culture.

The more difficult aspects of your need for education will be learning about the relational expectations of your client’s culture including nonverbal cues (i.e., eye contact and other gestures) and boundaries. It may be helpful to supplement your education about your client’s specific culture by consulting with colleagues and acquaintances who have immigrated from other cultures. They may be able to share their observations about the unspoken practices and expectations of U.S. culture which are outside of your awareness.

Regarding Indian culture specifically, clients are likely to present as cautious, anxious, or even timid with limited eye contact. These nonverbal cues are not a reflection of avoidance or resistance to therapy, but are signs of deference. The client will expect guidance and direct instruction and will feel comfortable knowing that the clinician is the expert. Therapy initially should be somewhat structured and have clear goals.

If your client immigrated in midlife or later, be aware that many older generation Indians are not psychologically educated and as a result present with somatic problems. They may be referred by a physician rather than self-referred. Consider spending time understanding how the somatic issue affects the client’s life and overall sense of wellbeing including how it affects their spiritual practice, diet, and family life.

In addition to education and consultation, your attentiveness to your client in session will give you valuable information. You mention that she didn’t seem as receptive to therapy as other clients, so I recommend giving some thought to what you observed or inferred in her behavior. Notice the nonverbal aspects of her interactions with you, and see if you can match her level of engagement in terms of expressiveness and eye contact. This may increase her comfort by reducing the interactional discrepancies between you. Be attentive to times in the session when she seems more or less comfortable and think about what may have been different in your relational style at those times. Emotions are often communicated through nonverbal gestures as much as or more than our words, so be careful about making interpretations about her emotional state based on your cultural assumptions. Note that the meaning of nonverbal cues is different across cultures; for example, a nod of the head that indicates saying “no” in western culture means “yes” for Indians.

It may also be useful to have some direct discussion with your client about some of the structural aspects of therapy that are unfamiliar to her. Interpersonal boundaries are experienced very differently in different cultures, so the meaning of professional behavior may be different for your client than you intend. Consider telling your client about the meaning of your professional boundaries and the therapeutic frame, acknowledging that these practices may be unfamiliar to her and may even seem odd. Invite your client’s comments and be open to shifting some aspects of your boundaries in minor ways if that will facilitate the development of the therapeutic relationship. For Indian clients, examples of appropriate differences in boundaries are accepting a small gift or a hug offered out of gratitude from the client, joining in the use of humor to bring warmth to the session, and using a double-handed hand shake.

I hope you find these suggestions helpful in understanding the nonverbal aspects of the therapeutic relationship in a cultural context. Please email me with comments, questions, or suggestions for future blog topics.

My colleague, Fenella das Gupta, LMFT, Ph.D. Neuroscience, provided consultation in developing the content of this blog post.  See Fenella’s website at for more information about her practice.



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?counseling

This is a good question and brings up a common situation in therapy. You have information that may be useful for the client in understanding and resolving the difficulties that led her to seek therapy, and you are wise to think through the decision to take an educational role. I will share some of my thoughts about the factors to consider in deciding how and when to bring educational information into therapy.

First, I would affirm your sense that providing education can be a useful therapeutic intervention. As a mental health professional, I am aware of how do mental and emotional illnesses affect social health. Often, poor mental health leads to problems such as social isolation, which disrupts a person’s communication and interactions with others. We have knowledge about trauma, relationships, communication, human development, family dynamics, and many other topics that are relevant to our clients’ concerns. This particular client has introduced the topic of domestic violence, and it could be empowering for her to gain knowledge that she can apply to her life.

As you consider talking with your client about the impact of witnessing domestic violence as a child, pay particular attention to the timing of her decision to share this with you and to your countertransference feelings in learning this new detail of her history. She chose to wait six months before telling you about this powerful and traumatic experience, so this means she has been waiting to feel a sufficient level of trust before disclosing this to you. Think about what it means for her to have chosen this moment in the therapy to share the domestic violence and reflect on what she wants and needs from you in response. Notice how you felt when she told you and what you feel as you anticipate giving her educational information. There may be an intense emotion you are avoiding or attempting to modify by introducing psychoeducation, especially if it represents a shift from your usual therapeutic style. Consider the possibility that your client will benefit from education about the impact of domestic violence at a later time in the therapy after you and she have talked about the meaning and feelings she has about telling you now.

Another factor to consider in your decision is your client’s culture and what this means for her expectations of you and the therapy. She may view you as an expert who has knowledge that she is lacking, and it may be more therapeutic for you to work on developing a more collaborative alliance before you adopt an educational role. Alternatively, it is possible that conforming to her expectations of your role may help her to feel more safe and trusting. Reflection on the therapeutic process so far and consultation with your supervisor will help you to sort out the cross-cultural implications of sharing your knowledge about this topic. If your client comes from a different cultural community than you, also give thought to her cultural values and norms for family relationships and the presence of physical violence in the home. Providing education requires sensitivity to cultural differences and to her current relationship with the cultural values of her childhood.

Last, I would recommend thinking about your client’s general description of her relationship with her parents and how your use of education may provide a different experience for her. If she experienced her parents as unavailable and preoccupied, you will provide a different experience by being engaged and attuned to her needs and questions. If she experienced her parents as intrusive and acting on their own agenda, it will be helpful to introduce your ideas tentatively and ask for her responses and thoughts about the information you provide.

I hope you found this blog post helpful in considering the use of psychoeducation in therapy. 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.

Clinical Issues Related to Money

LGBT therapyMy 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?

This is a difficult clinical issue, and it’s a good experience to have during your training. If you plan to work in a private practice after licensure, you will find that the meaning and emotions associated with client payment and fees become more complicated when it represents your income and livelihood. Having this experience while you are in training and not dependent on the fees for income allows you to come to a better understanding of the issues involved for you as well as your clients.

I recommend that you approach the exploration of money and fees by reflecting first on the meaning and emotions that are present for you both personally and professionally. Often money is a way of expressing and experiencing value or validation, and it may be used as a tool to exert interpersonal power. Feelings related to self-worth are often associated with the exchange of money in a relationship. These may include entitlement, comfort, envy, shame, deprivation, and pride. Think about the role that money plays in your family relationships and the meaning of money in your cultural community. You may become aware of implicit messages like “it’s not polite to talk about money,” “you have to fight for everything you get,” “you’re only worth what people give you,” or “if you work hard enough you’ll get what you deserve.”

In addition to your personal and cultural history with money, your current status as a therapist in training includes complex relationships with money. You may have taken on significant student loan debt or received support from a partner or family member. You are probably working as a volunteer or receiving a small salary while you are accumulating hours toward licensure, and you may be working another job in or outside the mental health field to pay your expenses. All of these factors will contribute to the feelings that arise in you when your clients pay or don’t pay their assigned fees. These will become heightened when you are in a private practice and your client fees are a source of income.

Once you have become more clear about how money impacts you in your clinical work, you can move to reflecting on the meaning of money for your client. Some of the things to consider are his early family experiences related to money, value, and power; cultural messages related to money and gender, since there may be different expectations for men and women; the meaning it has for him to seek services at an agency that offers a sliding scale; and the emotions associated with his financial choices. Think about conversations and interactions you have had in setting his fee, in sessions when he brings payment and when he doesn’t, and when he tells you about purchases or expenses like his recent vacation.

Your understanding of how you and your client think and feel about money will help you begin to identify the relational and cross-cultural dynamics in this therapy relationship and specifically in his recent lack of payment. A few possibilities to consider are: your client feels shamed by requesting a sliding scale fee and manages his shame by withholding payment; you are reluctant to discuss money openly and have had difficulty setting an appropriate fee and clear expectations about payment; your client devalues his emotions and needs for nurturing leading him to forget payment for a service that involves both emotions and needs for nurturing; your client associates masculinity with interpersonal power and is attempting to balance the power differential. What is important in your examination is to consider the contribution that you and the client are each making to this current conflict which will help you identify what you need to do internally and interpersonally to address your client’s lack of payment.

It may be helpful to use some of the guidance in a prior blog post about client attendance to identify a therapeutic response to your client forgetting his payment. Attendance and payment are two therapeutic frame issues that are often avenues for clients to repeat problematic relational patterns, especially those they aren’t able to articulate directly.

I hope you are able to use these suggestions in understanding clinical issues related to money. Please email me with comments, questions, or suggestions for future blog topics.

Generational Differences in Therapy

stock-photo-27330798-senior-woman-and-psychiatristI 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.

This question highlights the way in which generational differences can enter into therapy. When we work with individuals who are separated by one or two generations from us, we need to be aware of the age-related psychological issues facing our clients as well as the cultural differences that exist between us.

Starting with the psychological issues facing your client, she may be facing a high degree of loss and grief related to each of the risk factors you mention: limited income, living alone and lacking contact with others. Find out whether there were significant changes in your client’s life in the two to five years before she became depressed. If so, she may still be grieving the loss of income and financial status, the death of a spouse or close friends, and/or facing health problems that reduce her mobility. Even if these risk factors were present before she became depressed, she may have become less able to stretch her budget, participate in social activities or function independently as she ages. If you haven’t given her an opportunity to talk about feelings of loss or offered your empathy for her grief, I would suggest doing so. She will need to feel understood emotionally before she is ready to follow your suggestions about other resources that might help to improve her depression.

Another set of psychological issues arises in the fact that your relationship with your client mirrors a parent/child or grandparent/grandchild relationship for both of you. On your side, your frustration and discouragement probably include feelings you have about your parents or grandparents who faced or are facing some of the same issues as your client. Talk with your supervisor and therapist about these personal relationships to gain a better understanding of your countertransference. On your client’s side, working with a therapist who is young enough to be her child or grandchild exacerbates the sense of invisibility and devaluation she may feel as an older person in a culture that equates youth with worth. Your suggestions may feel condescending or invalidating if you are assuming you know more than she does about her experience and needs.

Moving to a cultural perspective, your client’s values and world view are different from yours due to the generational differences between you. Your client was a child during the Great Depression and World War II, came of age during a time of nationwide financial expansion, and experienced the civil rights, anti-Vietnam War and feminist movements as a young adult. Her experience of technology has spanned the period from radio and black-and-white television to internet and smart phones. It is a mistake to assume that she is comfortable, either emotionally or technologically, using online resources to reduce her social isolation. Her agreement with your suggestions may reflect a deferential attitude toward professionals who hold positions of authority, based in the values of her generation. Viewing your relationship as a cross-cultural one may help you to bridge your differences and approach your client with curiosity and interest.

I hope you find these suggestions helpful in working across generational differences in therapy. Please email me with comments, questions or suggestions for future blog topics.

Therapist Self-Disclosure

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

The previous blog discussed issues related to cultural competence in this case. This blog will discuss the issue of therapist self-disclosure. Self-disclosure refers to the choices we make about sharing personal information explicitly with clients, in addition to what they may infer or assume about us based on our appearance and style of relating. There are complex clinical questions involved in decisions about self-disclosure so it is important to be cautious and thoughtful.

One area to consider regarding self-disclosure is your client’s need and right to have information relevant to his treatment. You are required by law in California to let clients know your status as a clinician in training working under supervision. It is also good clinical practice to answer clients’ questions about the amount of experience you have, the graduate program you currently attend or from which you graduated, and special training your have received.

Disclosing personal information brings up more complicated issues. The first is the question of the therapist initiating self-disclosure or responding to client questions. I do not recommend disclosing personal information unless the client asks a specific question, unless you have discussed it thoroughly in supervision and your supervisor agrees it would be a therapeutic intervention. The motivation to volunteer personal information often reflects unconscious countertransference rather than an accurate understanding of the impact on the client.

A second issue about personal self-disclosure relates to your preferences and comfort about sharing aspects of your life. You can anticipate questions about your marital status, your sexual identity, racial or ethnic background, whether you are a parent or are in recovery, or if you have a history of childhood trauma from some clients. I recommend talking with your supervisor at the beginning of your practicum placement about the information you are willing to share and how you will respond to questions about aspects of your life that you want to keep private, like your sexual partners or if you use free sex websites to meet people.

A third issue to consider is the extent to which you or the client may be trying to address issues of trust through disclosure of personal information. Clients enter therapy with varying levels of fear and concern about trusting someone with their painful emotions and experiences. They may believe or wish that their fear will be lessened if they know more about the therapist. Therapists also have varying levels of confidence or doubt about their ability to help and may see self-disclosure as a way to boost the client’s trust (for example, by saying “yes, I’m a parent too”). The solution to the client’s fear and the therapist’s self-doubt does not lie in therapist self-disclosure, however. It lies in the therapist being attuned and empathic to the client’s fears, approaching therapy collaboratively, and using supervision to address self-doubt and other countertransference.

Regarding your new client, after you have heard his concerns about seeing a female therapist rather than a gay male, it might be appropriate to tell him about your experience working with gay male and female clients, your experience working with gay and straight individuals who are depressed after a relationship breakup, your support for same-sex relationships and marriage, or the fact that you have relationships with family members and friends who are gay. If he asks directly if you are gay or straight, I would recommend answering truthfully but not being specific about having a gay brother who is married and has kids. Your client’s relationship has just ended and it could be a distraction for him to have this information.

I hope you find this information useful in making decisions about self-disclosure. Please email me with comments, questions or suggestions for future blog topics.

Cultural Competence with LGBT Clients

LGBT therapyI 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?

Your question raises two related issues that are present when working with a client whose cultural identifications are different from ours: cultural competence and therapist self-disclosure. This blog will discuss the issue of cultural competence and the next one will discuss self-disclosure.

Cultural competence refers to having the necessary knowledge and skill to treat a member of a particular cultural community. You have identified two areas of cultural difference: gender and sexual identity. Being able to provide competent treatment to this client requires knowledge about the influence of his gender and sexual identity on his psychological development and functioning. You can acquire knowledge related to culturally competent treatment of a gay male client through a combination of academic courses, clinical training, personal research and personal relationships. Your skill in applying this knowledge comes from clinical experience and guidance in supervision.

Cultural competence also requires an attitude of openness and the absence of bias or assumption when working with a member of a cultural minority or non-dominant group. As you anticipate working with this new client, give thought to any areas of knowledge or skill that you may need to develop, and be aware of the potential bias that is present in any cross-cultural therapeutic relationship. Your personal experiences with gay men and women are useful but not sufficient to providing cultural competent treatment.

Assuming that you have the knowledge and skill to provide culturally competent treatment and that you can approach your client with openness and awareness of potential bias, let’s turn to the question about your new client. He is a gay male who requested a gay male therapist, which you are not. You don’t know the meaning of his request or his feelings about working with a female therapist, straight or gay. You have the same task with him that you have with all clients at the beginning of treatment, which is to establish a therapeutic alliance. Your question assumes he will be uncomfortable with you, and you have developed an agenda of putting him at ease. If you can let go of that agenda, you will be better able to establish a therapeutic alliance based on understanding and responding to the concerns that are leading him to seek treatment as well as his desire to see a gay male therapist.

You can open the issue of his request in your first session by saying “I know you requested a gay male therapist, and I’m a female. Can you tell me more about your request and how you feel seeing a woman?” If the client raises the issue of his request when you contact him to schedule the first appointment, see if he is willing to come in for an initial appointment so you can discuss his concerns in person rather than by phone.

Once your client tells you about his concerns and feelings, you should respond to them with honesty and empathy, acknowledging his need to make a decision about working with you based on what he believes to be in his best interest. It may help to remind him that clients are often unsure at the beginning of treatment whether it will be helpful and that getting to know you over the first few sessions may help him decide. If he decides to continue in treatment with you, the gender and sexual identity differences between you may remain a prominent issue throughout the treatment or they may recede as you work together. Most important is that you approach this client knowing that the differences between you are one factor among many that will influence the development of your therapeutic relationship.

I hope you found this helpful in thinking about culturally competent treatment. Please email me with comments, questions or suggestions for future blog topics.

Intersection of Personal and Professional Lives

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

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

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

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

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

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

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

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

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

Social Media

new1One 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?

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

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

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

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