Category Archives: First Session

Aging and its many challenges

Aging is a natural process that may present challenges for some individuals and their families. Often seniors are unaware of the resources and services available to assist them to remain independent, healthy and safe in their homes and senior communities like those at carltonseniorliving.com/community/san-leandro/ for as long as possible so that they can continue to live a happy life! Although many older adults look forward to moving from middle age into their later years, it may be difficult for others to adjust. Another major concern for older persons is the loss of independence that is often associated with entering a nursing home or long-term care facility where they must rely heavily on the assistance and personal care of others to meet their basic needs of eating nutritious foods.

Geriatric Therapy: How to Help Older Adults With Depression
All adults may experience health issues and stress as they approach and pass middle age, and the support of a therapist or other mental health professional may help ease the transition. Middle Age and Beyond: A Positive Approach offers simple approaches to applying therapy interventions to common problems in aging individuals such as family transitions and functional impairment at home as well as caring for spouses with dementia while sharing suggestions for building resources to support these critical relationships. For this, senior memory care services like Summerfield of Encinitas memory care are available. Therapy professionals may also use the materials included in the kit to provide self-care to individuals wishing to enhance their ability to respond to the challenges of life during the middle years and beyond by supporting their own health and wellness through self-reflection and thoughtful practices that promote balance and wellness in their lives.
While some adults may approach their “Golden Years” eagerly, anticipating retirement, grandchildren, or simply a new phase of life, others may dread the physical and mental effects of aging. Regardless of an individual’s age and their attitude toward the aging process becoming an independent adult may be difficult during midlife as priorities shift and family relationships and environments change.
Ageism, or discrimination based on a person’s age, may also affect some older adults, and this practice may lead to forced retirement or cause well-intentioned loved ones to ignore an older adult’s desires or opinions. The consequences of negative attitudes and behaviors directed toward any age group can be harmful not only to those people directly affected but also to entire communities and the people within those communities that depend on a healthy presence of community members of all ages.
Therapy can help older adults who may have difficulty with the transitions of aging to manage their emotions, find new sources of enjoyment and meaning, and find new support systems. Offering face-to-face sessions with each client may help build long-lasting therapeutic alliances with family members that may make it easier to overcome challenges related to changing circumstances by creating opportunities to discuss worries openly and create strategies for addressing concerns. Many older adults also enter therapy to seek treatment for mental health issues not related to aging, in higher numbers than they did in the past. This appears to be due to the fact that attitudes pertaining to mental health issues have begun to change as awareness increases. Awareness of the various resources available to meet the needs of people ages seventy and older such as wealth management may also be helpful to families to access the assistance they need to meet emotional and behavioral challenges of physical.

Cross-Cultural Mental Health Treatment

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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?

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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.

Working With Depression

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I’m worried about one of my clients who was very depressed and overwhelmed in our last session. How should I decide whether to call her before our next session?

This is a common and distressing situation for students in psychotherapy training. You may find yourself preoccupied with worry and uncertainty about your client’s wellbeing, especially if you are personally vulnerable to anxiety. Part of the developmental process in clinical psychology training is expanding your focus from alleviating your own distress to evaluating the impact on your client of different interventions. As behavioral health professionals, our primary responsibility is client welfare so all of our clinical interactions should be centered on that consideration.

Regarding a depressed, overwhelmed client, your first step should be consulting with your supervisor. This is especially important if you are in your first practicum or field placement setting and you should continue to consult with your supervisor throughout your training whenever you are concerned about a client’s safety. These situations bring up intense feelings for clinicians and it is hard to be objective in evaluating the most appropriate response when you are caught in the emotional intensity. Some of us respond to intense emotions by shutting down and minimizing the client’s risk and others of us become agitated and overestimate the risk.

Some of the factors to consider in evaluating your client’s risk, in consultation with your supervisor, are the length of your relationship with the client, whether the client’s emotional state is a change in response to a recent stressor or is more longstanding, how the client has coped or reacted to similar feelings in the past, and what internal strengths and external supports are available to the client. Clients who are new to you, who are reacting to a recent precipitating event, who use self-destructive or impulsive coping strategies, and have few strengths and supports are at greater risk. If you are concerned about suicidality, use a risk assessment tool such as the Suicide Assessment Five-step Evaluation and Triage.

If you and your supervisor agree that the client’s risk is high, you should contact the client to make a further assessment. If the client’s risk is low, you can wait until your next session to do further assessment. If there is a moderate level of risk, your decision will be based on your understanding of the meaning your intervention will have to your client. You may contact the client as a way to communicate your care and concern, but the client may experience your call as intrusive and undermining. You can develop an understanding of your client’s likely interpretation of your interventions based on your knowledge of her/his early experiences with parents and other caregivers and your observations of her/his relational patterns. A client who experienced neglect and has an expectation that others will be absent and uncaring will respond more positively to an unexpected call from you than a client who experienced abuse and intrusion. However, because psychotherapy always has the overriding goal of supporting client autonomy and self-determination, it is safer to refrain from initiating contact with a client unless there is a clear reason to do so.

After consultation and consideration of your client’s welfare, you may determine that contact with the client isn’t appropriate but still feel worried. This is the time to refocus your attention on your own coping strategies and self-care. Learning psychotherapy involves strengthening your ability to manage intense emotions and placing the client’s welfare above your personal needs. It also involves differentiating between your relationships with family and friends and your professional relationships with clients.

I hope this has been helpful to you. Please email me with feedback 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.

Beginning Behavioral Health Treatment

sunrise_1My agency has a lot of forms for clients to fill out at the first session. I want to build rapport in the first session but instead I’m explaining forms and getting the client to sign them. Are these forms really necessary?

Many clinicians feel frustrated about the amount of paperwork that is required when providing behavioral health services, especially in agency settings. Generally, each form meets a particular requirement and it may be helpful for you to ask your supervisor about the purpose and rationale for them if that hasn’t been explained to you. The two most important forms that are required by the legal and ethical standards of our profession are informed consent and notice of privacy practices. These establish a treatment relationship between you and the client. An informed consent form provides confirmation that the client knows the nature of the treatment, including its limitations, and agrees to participate. A notice of privacy practices informs the client about the exchange of information about the treatment between you and others, with or without the client’s permission. In California and some other states, clients must also be informed when the clinician is not licensed and is working under supervision. In addition to these basic requirements, your agency may have forms related to accreditation or certification, billing and payment, and collection of demographic and clinical data. Check the problems associated with crohn’s diease as well.

We often make an assumption that getting the client’s signature on required forms is an administrative task separate from the clinical work you are being trained to do. However, building rapport begins in your first interaction with the client and the way you discuss the forms and their content sets the tone for your future treatment relationship. You can convey your desire to work collaboratively with the client by introducing the forms with a statement like “I need to go over some aspects of our working relationship so that we have the same understanding of how we’ll be working together.” It is useful to practice summarizing the key points of each form so you can explain it concisely and clearly to the client.

One other tip regarding forms is to acknowledge the necessity to attend to some paperwork and express your interest in the client’s concerns. It is a good idea to prepare the client ahead of time when you set up the first appointment. At the beginning of the session, you can introduce the forms with a statement like “I’m interested in learning more about you and the concerns you have.” You can follow that with a collaborative statement like the one above or “Can we take a few minutes first to talk about some of the important points about our work together?” or “There are some things that I want to talk with you about before we begin.” You don’t have a treatment relationship with the client until the informed consent and privacy practices are explained and agreed upon, so it is imperative that you discuss these and ask for the client’s signature before moving into clinical material.

I hope you have a better understanding of the reason for the abundance of forms and can make use of these suggestions to handle them in a sound clinical manner. Please email me with comments, questions or suggestions for future blog topics.