Category Archives: First Session

Instilling Hope in a First Session

I’m starting a new placement next month, and I want to know how to be as helpful as possible in my client sessions. How can I handle the first session so they are likely to want to come back and continue therapy?

Starting your first placement is a big step and one that most clinicians approach with some amount of anxiety as well as excitement. It’s a good idea to start by thinking about the first session with clients and how to engage them from the beginning. There is a lot to do in a first session–getting informed consent, establishing a therapeutic alliance, following the client’s story, beginning an assessment, and responding to the client’s wishes and goals–and chapter 3 of my book covers this topic. Communicating empathy and understanding is crucial in the first session as clients share their distress and pain. They are motivated to continue therapy when they have a feeling of hope in the therapeutic process. In this blog, I will describe two ways to instill hope during the first session.

First, clients feel hopeful when they have an awareness of their strengths, which provides confidence that they can face and overcome their difficulties. It is important to hold a “both/and” perspective in talking about strengths, reflecting that you understand the seriousness of the clients’ concerns and problems while also pointing out the capabilities reflected in their life stories. Most often, clients enter therapy feeling discouraged and self-critical. Feelings of shame and fear are common, whether their symptoms are new, have occurred at other times, or have been ongoing. There are a number of ways to identify and highlight the client’s strengths, depending on the initial presentation and the flow of the session. When the client leads with a description of what isn’t working and how their life has been impacted negatively, you can ask how they have coped with this difficult situation and support whatever positive coping strategies they report using. An example is “It’s impressive that you’ve been able to connect with a friend at least once a week, even though your depression has interfered with your appetite and sleep and your mood has been very low.” You can also ask about different areas of the client’s life and contrast areas of success with areas that are more problematic by saying, for example, “It sounds like your anxiety has made it hard to speak up in meetings at work, but you were able to advocate for your daughter to get the help she needed at school.” It also helps to reflect the client’s statements of strength in addition to reflecting and empathizing with their problems.

Second, clients need to leave a first session with a sense of hope in and direction for the therapy. I use the last 5-10 minutes of the first session for this purpose, including asking the client how it has been to talk about her concerns, summarizing how I would anticipate working together on her presenting issues, and expressing confidence that therapy can be helpful. I emphasize the collaborative nature of therapy by using terms like “working together” or “what we might look at,” and I provide a realistic assessment of the uncertainty and difficulty of changing longstanding patterns along with my belief that things can improve. A short summary statement is “If you want to continue working together, I would recommend looking at the emotions that have led to your outbursts of anger and how you can develop different ways to express those emotions before they become really intense. I know you’ve avoided the fear and sadness we talked about very briefly today, but I believe those emotions are related to the anger outbursts. You said your goal is to reduce your anger, and if you’re willing to look at those other emotions as you’re ready, I think you’ll be able to do that.”

If you keep these two strategies in mind in your first session with clients, I believe you’ll help them feel hopeful about continuing to work with you in therapy. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Evaluation of Client Appropriateness for Treatment

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

It is a very good idea to ask the question of whether a client is appropriate for treatment with you before you begin with anyone new. This situation poses particular challenges because of the client’s recent suicidal thinking, but it is a good idea to take some time to evaluate that question with all new clients assigned to you. I will outline some factors to consider in the evaluation of your client’s risk.

Since you are in a practicum setting, the first step is to consult with your supervisor. She/he needs to know about your client’s hospitalization to determine whether she/he is comfortable supervising the case and proceeding with an initial appointment. If not, you’ll get suggestions on how to refer her to another resource either within or outside your agency. If you get approval to schedule an initial appointment, ask for your supervisor’s guidance about how to make an evaluation that will guide your decision to proceed with ongoing treatment.

Some of the factors I would consider in evaluating your client’s risk and the appropriateness of outpatient treatment are 1) her history of suicidality and hospitalization, 2) her ability to describe the precipitants and current strategies for managing suicidal thinking, 3) her level of engagement in treatment, and 4) the availability of other resources both within your agency and outside. I will discuss each of these factors briefly.

Your client’s history of suicidality and hospitalizations will assist you in determining whether you can help her to manage her symptoms on an outpatient basis. Her risk is lower if this was her first episode and is greater if she has had prior episodes especially if they occurred within the last year. Another area for evaluation of risk is her ability to describe the suicidal episode with some insight into the contributing factors and how she will manage suicidal thoughts that may recur. You’ll want to know whether she has a safety plan and how she has used it since being discharged from the hospital. Outpatient treatment is likely to be more successful if she has developed some insight into the recent episode and if she has strategies for managing recurring symptoms. Some clients adopt an attitude of distance from their symptoms after a hospitalization and are unwilling to talk about a safety plan, stating things are different and the symptoms aren’t going to recur. Although it may seem reassuring to hear this from a client, it is actually indicates a greater risk of future escalation.

While you are meeting with your client, you can assess her level of engagement in treatment by noticing whether she interacts with you in a collaborative manner and has ideas about her needs and plans for using therapy. If she is more passive or doubtful about the usefulness of therapy, it is less likely that you’ll be able to work with her productively. This is especially true if she is unable or unwilling to access other resources in addition to your individual outpatient treatment. Seeing a psychiatrist for medication management, attending a support or psychoeducational group, engaging in couple or family therapy, and/or receiving assistance with financial and housing needs are often vital to the success of therapy with someone who is recovering from an episode of suicidality.

A final step I recommend in evaluating the appropriateness of this client for your case load is to reflect on your experience with suicidality in your personal life as well as in a professional or volunteer capacity. This case may bring up past memories and difficult feelings if you have personal experience, and this is an area to discuss with your supervisor before and after your initial session. At some point, you will need to face this area of difficulty, but you should do this at a time that you feel as prepared and supported as possible.

I hope you find this helpful in evaluating the appropriateness of a client for treatment. Please email me with comments, questions, or suggestions for future blog topics.

Tips for Establishing an Alliance

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

This is an exciting time, and it is understandable that you have some mixed emotions. You have been preparing for this moment for a year or more while taking academic courses, and you may have had this career in mind for many years. As you move forward in your career, you’ll look back on this time as one of tremendous growth. You may find it helpful to look at my blog posting on general suggestions for orienting yourself to a new training site. I’ll focus here more specifically on preparing for your first client session. Research has shown that the quality of the therapeutic alliance is the most powerful predictor of successful psychotherapy outcome, and following the tips below will help you establish a positive alliance.

I recommend that you start by paying attention to the thoughts and emotions that are present for you as you learn about your new client assignments and begin to schedule appointments. It is often easier to think about the logistical steps or to focus only on the client’s issues than it is to notice our own experience. However, it is valuable to begin now to cultivate an attitude of self-awareness in your client work. Feelings of anticipation, excitement, nervousness, and fear are common at this stage. Talking about these feelings with your supervisor will give you support for managing your emotions in this early phase of your work.

Another strategy that helps with preparing for a first session with a client is to approach every contact with your client as part of the treatment. This means being aware of your role as a clinician in all aspects of the work, including an initial phone call to schedule an appointment and reviewing the intake information you receive before that appointment. Notice how the client talks with you in the phone call and how you are affected by your interaction. Imagine what the client may be expecting or fearing from the session based on what you know about her/his current situation and history. You can begin to develop a clinical understanding or formulation of your client even before you have seen her/him in person. Talk about these phone calls and intake assignments with your supervisor even before you have had an appointment so you can benefit from your supervisor’s experience and guidance in developing a formulation.

Last, use your preliminary understanding of the client to guide how you interact with her/him. You are probably familiar with the general principles of empathy and reflective listening that help with building an alliance. In addition to these general principles, think about what will be particularly helpful with this client. Some clients benefit from expressions of warmth and others prefer more reserve; some clients begin talking right away about their lives and others have a slower pace and need subtle encouragement. Your supervisor’s guidance will help you adapt your style to each client.

I hope you find these suggestions helpful in preparing to see your first client. Please email me with comments, questions, or suggestions for future blog topics.

Impact of Therapist’s Personal History

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

This situation illustrates how our personal history informs and affects our work with clients. We have similarities and differences with each client, but the balance between the two is different with each one. When you are working with someone who seems very much like you or with whom you are heavily identified, it is important to rebalance your attention by being aware of the ways in which your experiences diverge. Similarly, when you are struck with how different your life is or has been from your client’s, you need to look for commonality.

In this example, you and your client share the experience of losing a parent in your early adolescence. It is understandable that this common experience takes the foreground of your attention when you think about beginning to work with her. However, there are some important differences that are apparent even in the preliminary information you have: the death of a father compared to the death of a mother and being 12 or 14. Undoubtedly, there are other differences between you and your client in your specific family relationships, cultural background and identities, other developmental events, and personality characteristics. I’ll discuss three strategies to maintain your attention on your client’s needs while minimizing the potential interference of your experience of parental loss.

First, pay careful attention to your tendency to make assumptions in this case. It will be easy to believe that you understand your client’s thoughts and feelings without your usual level of curiosity and information gathering. Err on the side of caution by asking questions or being tentative in your reflections with statements like “are you saying you feel lost?” or “it sounds like you might be angry.” Remember that it is your job to help her on her own journey of grief and loss and that hers will inevitably differ from yours.  She may feel sad in a situation in which you felt angry, or she may feel burdened rather than afraid.

Second, be especially careful when you think about self-disclosure. You will probably think of several examples from your own life and experience that are related to your client’s pain and grief. It may seem as though sharing your experiences will let your client know you understand her and will give her a sense of hope for her own healing. However, self-disclosure always has a risk of diverting the client’s attention from her own experience to yours, especially when she hasn’t asked about your life. In this case, it may be appropriate to share minimal information with your client if she asks. For example, if she asks whether anyone close to you has died, you could say “yes, that did happen when I was a teenager” and you might tell her that your mother died if she asks for any other details. Then I would turn attention back to her experience and how she feels knowing this about you.

Third, a case in which your personal history is similar to your client’s makes supervision extremely important. You may feel that your knowledge of your client’s experience means you don’t need as much guidance from your supervisor as with your other cases. However, as noted above, there is a potential for your clinical judgment to be clouded by this similarity, so discussing this client and her progress in treatment is essential. Your supervisor’s concern suggests that she is aware of this difficulty and will be able to support you in thinking through your emotional responses to the client. You may also find it helpful to talk with your personal therapist about the emotions and memories that arise for you in working with this young woman. You may find that your grief and loss emerge in a new way as you face the issues as a therapist.

I hope you find this helpful in managing the impact of your personal history in your clients’ treatment.

Assessing a Confusing Initial Presentation

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

You have identified several factors in your client’s initial presentation that leave you feeling uncertain about your diagnosis and conceptualization of her difficulties. An important first step in understanding your client is to acknowledge the confusion you feel rather than rushing to a premature conclusion. It may take several sessions to begin to piece together a cohesive picture, but it is preferable to move slowly than to attempt to resolve your questions too quickly. I’ll outline some approaches I would recommend for the next 3-4 sessions to move toward understanding your client more fully.

It seems likely that this client will benefit from your direct expressions of empathy and understanding. This is the basis of all therapeutic relationships, but your experience that it was hard to connect with her suggests that she has more fear and expectation of harm or rejection than many of your other clients. This may be outside of her awareness, so she probably didn’t say anything directly to reflect fear or mistrust. However, pay particular attention to making reflective statements, summarizing what you understand, and validating her decision to seek help for her distress. This will create a therapeutic atmosphere in which she will gradually develop trust and will be more open in talking about herself.

Since you have identified differences between this client’s presentation and others who describe their problems in a similar way, I would also recommend asking clarifying questions in order to avoid making assumptions about the meaning of her statements. For example, when she says she is depressed, you could say “people experience depression differently—how does it affect you?” or “can you tell me more about what is happening with the depression?” Since aspects of her presentation indicate the possibility of early trauma, I would also recommend reviewing the diagnostic criteria for PTSD and dissociative disorders so you are familiar with symptoms that could be interpreted as depression but are actually the result of trauma. A way to begin to identify dissociation would be to ask something like “would you describe yourself as more sad or more numb?”

As your client feels more comfortable with you, she may begin disclosing unusual symptoms and experiences that go beyond depression. This is another reason to familiarize yourself with other diagnoses, including dissociative and psychotic disorders, that could present similarly to depression. You may want to ask direct questions about these symptoms in order to identify an accurate diagnosis, and it is best to do this in a straightforward, normalizing manner. Examples are “Some people find themselves hearing voices when no one is around. Does this ever happen for you?” or “Sometimes people feel detached from their surroundings or themselves, as though they’re looking at themselves from the outside. Have you ever had that experience?”

Last, I recommend continuing to be aware of your observations and emotional responses to this client. Since she seems to hold large parts of her experience outside of awareness, the nonverbal communication between the two of you will be central in your understanding of her. Including this information in your assessment will lead you to a more accurate diagnosis and case formulation. It is also likely that you will continue to have some questions for the next several months, so continue move slowly in reaching conclusions. Identify what things seem clear and what things are uncertain about her presentation, and hold the ongoing ambiguity.

I hope you find this helpful in assessing clients who have a confusing or puzzling presentation. Please email me with comments, questions, or suggestions for future blog topics.

Managing Silence

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

This is a common question for therapists in training. Since the nature of our work is listening and talking, we tend to feel uncomfortable when the back-and-forth flow of our interactions with clients is interrupted by silence. One aspect of professional growth as a therapist, though, is becoming comfortable with therapeutic interactions that are different from social interactions we have with friends, family and co-workers.

When I am working with a client who doesn’t initiate conversation or falls into silence, I usually respond first by simply sitting quietly myself. Often the client will then continue with the previous line of thought or bring up a new issue that we can explore together. In the beginning of therapy, I don’t let the silence continue for more than 20 or 30 seconds especially if the client seems uncomfortable, but that is often enough time for the client to guide the direction of our conversation.

If I do choose to break the silence, I ask an open-ended question rather than bringing up a specific topic. Examples are “is there more you’d like to say about that?” or “what’s on your mind?”. If I notice something in the client’s body language, I might say “it looks like you’re feeling sad about that” or “maybe it’s hard to realize how much pain you’re in.” If you use this type of question or statement, your client will know you’re interested in his inner experience and that he sets the direction of the therapy. Usually he will feel encouraged to continue exploring the thoughts and feelings related to the current issue or to shift to an issue that feels more relevant.

When silence is a recurring part of the therapy and the client doesn’t respond to your open-ended questions or reflective statements, your task becomes one of assessment or conceptualization of the reasons for his behavior. Some possibilities are a lack of familiarity with therapy and self-reflection, social anxiety or skill deficits, and cognitive limitations. Talk with your supervisor about your client’s history, diagnosis and relationship experiences as well as the therapy process and your countertransference responses. This discussion will help you develop an understanding of your client’s experience of the therapy and choose the most therapeutic way to engage him. You may also need support from your supervisor in managing your countertransference with a client who seems passive and disengaged.

When silence is recurring, it is sometimes helpful to provide some education about the therapy process. Clients who are new to therapy may be unsure of what is expected, and clients who have a history of contact with social service systems may have been socialized to take a passive role with professionals. Giving a short description of therapy and your approach and expectations provides guidance in these situations.

Another helpful intervention is to make a process comment or question related to the silence itself. Examples are “what’s it like for you to sit quietly here?” or “it looks like you’re not sure what to say next” or “how would you like me to respond when you’re quiet?”. You may learn that the client has assumptions about your role or your reactions to him that lead to a fruitful discussion between you. For example, the client may express a desire for you to provide an answer to a complicated emotional dilemma or may be worried that you are bored by the circumstances he is describing. In general, process comments and questions serve the purpose of communicating your presence and interest in the client and provide an opportunity to talk directly about obstacles to the client’s engagement.

I hope you found this helpful in managing silence in your therapy sessions. 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.

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.

Mandated Treatment

mandated therapyI have been assigned to work with a client who has to attend therapy as part of his probation requirement. How can I build trust with someone who probably doesn’t want to be in treatment?

It is challenging to work with someone who isn’t seeking therapy voluntarily. Therapy is sometimes required as part of probation, a child abuse investigation, or other legal situation. There are complications in developing a therapeutic relationship when treatment is mandated by a third party. This blog contains a few suggestions that will help you work through some of these complications.

First, I recommend that you get clear information at the beginning of treatment about what you will be required to report to the mandating authority. Your client may come with a referral form or blank progress report that will have these instructions, or you may need to ask for his authorization to talk with the mandating authority about their expectations and requirements. If possible, it is best to report general information only, such as dates of attendance, issues discussed and treatment goals. As a therapist, you are not evaluating your client in relation to his legal situation so you cannot advocate for a specific outcome or express an evaluative opinion.

Once you are clear about what the mandating authority requires, you should share this with your client, letting him know what you will share and what you can keep confidential. This conversation is in addition to a discussion of the general limits of confidentiality you have with all clients. By talking openly with him about the reporting requirements, you establish clear and direct communication which is the beginning of a therapeutic relationship.

Second, acknowledge that your client has mixed feelings about being required to attend therapy and talk about the impact the mandate has on his ability to feel open and trusting of you. An example would be “Since coming to therapy is required rather than something you decided on your own, I imagine it will be hard to decide how much you want to talk about with me.” Acknowledging his ambivalence is likely to help him feel more trusting rather than less, and it communicates your ability and willingness to discuss things that are difficult. This should be an ongoing issue for discussion, since he will continue to have questions about trust as the relationship develops.

Third, bring up the possibility that the client may not feel comfortable sharing truthfully with you. He may have other requirements like maintaining sobriety, attending parenting classes, or detaching from conflictual or violent situations and it will be difficult to know whether he is being truthful when he reports complying with those requirements or reaching treatment goals. One way to discuss this is to raise a hypothetical question like “If you had started drinking again, do you think you’d be able to tell me?” In this way, you bring the issue of truthfulness into your relationship without being accusatory. Even if the client assures you he would be able to tell you, raising this question acknowledges the impact of the mandated requirement on his communication and relationship with you. As with the issue of ambivalence, you should raise this periodically as an ongoing issue in the relationship.

I hope you find this helpful in doing therapy with clients whose treatment is mandated. Please email me with comments, questions or suggestions for future blog topics.

Completing an Assessment

therapyI am working at a new field placement which requires doing an assessment in the first session, which lasts 2 hours. How can I do this before I have established rapport and a therapeutic relationship with the client?

It is challenging to complete an assessment in your first contact with a client; however, there are also advantages to gathering comprehensive information about the client’s history and current circumstances early in the treatment process. I will outline some ways to approach the assessment that will facilitate rapport and relationship building so the session will have a therapeutic outcome as well as meeting your agency requirement.

I would first recommend that you talk with the client about the reasons for the assessment when you schedule the initial appointment. Express your desire to be helpful to the client and state that learning about his current symptoms, life situation and history will make the treatment more effective in working toward his goals. This communicates the message that your purpose and interest is aligned with the client’s, rather than simply meeting a bureaucratic requirement.

Before the assessment session, familiarize yourself with the format of the assessment template or report. You may want to bring a copy of the assessment template into the session or a list of general areas for questioning. If there are specific questionnaires for the client to complete, bring those with you as well. You may find it helpful to role play the introduction of the assessment with your supervisor or a colleague before you meet with your first client. The more comfortable and confident you feel, the more easily you will develop a therapeutic relationship with the client during the assessment session.

When you start the session, remind the client of what you discussed in your scheduling conversation about the assessment contributing to the effectiveness of treatment. Then begin with the client’s primary concern in seeking treatment and ask follow up and clarifying questions covering different areas of the assessment as they emerge from the conversation. It is more facilitating of the therapeutic relationship to engage in a dialogue that is relatively fluid and follows the client’s lead rather than imposing a standard order of questioning. It is also preferable to ask open-ended questions which allow the client to determine the direction and content of what he shares. The client’s answer to “can you tell me what your family life was like as a child?” will tell you more about him than the answer to “did you grow up in a two-parent or single parent household?”

If your agency practice requires you to be directive rather than following the client’s lead, you should acknowledge this at the beginning of the session and explain that this is different from the structure of future therapy sessions. For example, you could say “The assessment format we use here requires me to ask you about things in a fairly structured way, so I’ll be leading the conversation today more than I will in our future sessions. Please let me know if you feel uncomfortable about my approach at any time, or if there is something you want to share with me that isn’t directly related to my questions.”

Remember that you are asking the client about events and experiences that may be painful, may bring up feelings of shame and which the client may want to avoid rather than disclose. Expressing empathy, conveying acceptance rather than judgment and reflecting your understanding of what the client is saying will create a therapeutic atmosphere. For example, if the client describes a childhood history of physical abuse and adult relationships involving domestic violence, you might respond with a statement like “It sounds like your childhood taught you to expect physical violence as part of intimate relationships. It’s not surprising that you found that pattern repeating in your adult relationships.” Although you will not have time to explore the details of the client’s experience in the assessment session, you can respond therapeutically to the material he shares.

When you approach topics that you expect or know will be difficult for the client to discuss, it is helpful to let him know this information is asked of all clients and to ask his permission to inquire about those areas. For example, many clients come into treatment with shame and denial associated with past and current substance use. You can introduce the topic therapeutically by saying “We ask all clients here about their use of substances because we find that to be related to aspects of mental health. Is it all right if I ask you some questions about your past and current use of alcohol and other drugs?”

When you follow these tips, you’ll find the assessment session results in a positive therapeutic relationship as well as information that enhances your understanding of the client. I hope you find these suggestions helpful in completing assessments in the first session. Please email me with comments, questions or suggestions for future blog topics.