Category Archives: First Session

Working With Depression

therapy

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.

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.