Category Archives: Preparation and Supervision

Beginning Therapy with the First Client Contact

Client DisengagementI have been assigned to see a 47-year-old man who told the intake worker he had been depressed for over a year but isn’t willing to take medication. I was finally able to reach him by phone after trying 3 times, and he scheduled a first appointment. Since then, he has cancelled twice saying he is too depressed to come in. I don’t know what more to do and don’t know whether I can help him if he can’t even come to the office.

It is difficult and often frustrating to have multiple phone interactions and messages with a client you haven’t met who seems unwilling or unable to participate in therapy. One way to think about this situation, which is covered in Chapter 2 of my book, is that the therapy begins with your first contact with the client. Sometimes we think of our first telephone interactions as administrative or business tasks taking place before the therapy itself. However, the therapeutic relationship actually begins when you first learn about the client, and you are likely to have the best chance of engaging him when you approach these initial conversations as the beginning of the therapy.

In this case, thinking therapeutically begins with evaluating the meaning of the information you have so far. Your client is developmentally in mid life, and his depression could be related to circumstances that commonly occur in that life stage—loss of a job, ending of a relationship, onset or exacerbation of a medical condition, or death of a parent or another loved one. It can be more difficult to recover from disappointments and losses at mid life, when people begin to experience the narrowing of opportunities that seemed open in earlier in adulthood. His sense of worth and value may be at a low ebb, and asking for help is associated with admitting weakness in many cultures, especially for men.

You also know he says he isn’t willing to take medication. Although you don’t know why he has made this decision, it is meaningful that he shared this with the intake worker. I would hypothesize that he wishes to maintain a feeling of control in the course of his treatment, probably offsetting other ways in which he feels helpless, frightened, and despairing. He is most likely to engage in therapy if he is able to feel a sense of control with you, and so far he seems to be exerting this control by cancelling scheduled appointments.

Before contacting your client again, I would encourage you to think about how you could approach a conversation with him with the goal of communicating a view of him as capable, rather than weak, and an approach to therapy that is collaborative rather than hierarchical. He might respond well to you reframing his decision to cancel your appointments and to not take medication, then you can move on to putting the decision about scheduling in his hands. An example would be “It seems like you’ve been able to reach some clarity about what is most helpful for you in managing your depression. Would it work best if I wait for you to contact me about setting up another appointment?” If he says yes, you could ask if he would like you to be in touch in a week if you don’t hear from him or if he would prefer to contact you when he feels ready. If he says he wants to schedule a session, I would recommend offering him at least two different times so he can retain a sense of control. For example, you could say “I’m in the office three days a week, and right now I have openings on Mondays at 2, Wednesdays at 10, or Thursdays at 6. Are any of those times possible for you?”

It is possible that using the approach I recommend will result in him not beginning therapy, but I believe it represents your best chance of engaging him. Regardless of the outcome, I believe you always will be most effective as a therapist when you think about establishing a therapeutic relationship with your client from the first contact.

I hope you found these comments helpful in your initial interactions with clients before seeing them in person. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Motivations for Becoming a Therapist

I just finished my first semester in a practicum placement, and I have begun to doubt my decision to become a therapist. I decided to enroll in graduate school because I liked to talk to people and heard from my friends that I was a good listener. Seeing clients this semester was much harder than I expected, and I didn’t feel like I was able to help them very much. How can I dnew2ecide whether to stay in the program or leave to pursue a different career?

The experiences that lead us to enter the field of counseling or psychotherapy are varied but often include ways we have taken a helping role in our personal relationships. The topic of our motivations to become a therapist, covered in Chapter 1 of my book, is complex because it includes emotions outside of our awareness as well as thoughts and feelings that we can identify directly. I’ll discuss some ways you can identify aspects of your motivation that may be influencing your doubts, then recommend how to approach your career decision.

Your enjoyment of conversations with your friends and feedback about your listening skills are common factors in leading someone to consider the psychotherapy field. An initial step in identifying more about your motivation is to reflect on what aspect of these conversations was most enjoyable to you. Did you like the process of getting to know someone more intimately, did you like to follow their stories, were you attracted to analyzing their problems or understanding their feelings? Getting more specific about the experiences that led you to this field will give you more information about your choice to enroll in a graduate program.

Next, it is important to look at aspects of your motivation that are less obvious and may not have entered your conscious awareness. Reflect on what you didn’t do or say in your social interactions or what you avoided by being a good listener. It’s possible that you are uncomfortable with the vulnerability that comes with sharing your own thoughts and feelings. You may have adopted a caretaking role because it was expected and/or rewarded in your family and culture or you may focus on others in order to avoid facing painful memories or being alone with your struggles.

Once you have looked more deeply at your motivation, examine the benefits that have come with your interpersonal style. Being a good listener may enable you to feel effective and empowered, and it may be a source of positive self-esteem as well as praise from others. If you help your friends and family members solve their problems, you can be less worried about your own difficulties. It is natural to assume that you will feel the same rewards with your clients, but clinical work is slower and more complex than personal interactions. It can be discouraging to face the difference between your expectations and the reality of working with clients whose problems involve psychological distress, sociocultural stressors, and mental health conditions. If you decide to stay on your path to becoming a therapist, you will need to adjust your expectations and find rewards in clinical work that are different than in your personal relationships.

Having engaged in self-reflection, I recommend that you reach out to others who can assist you in addressing your career question. Discouragement and doubt is often part of the learning process, and you are likely to feel understood and reassured by talking with professors and fellow students in your academic program and with supervisors and colleagues in your practicum setting. If you’re not already seeing a psychotherapist, this is a good time to begin personal therapy to learn more about the experiences that contributed to your career choice and to explore the meaning of your disappointment as a new therapist.

I hope you found this helpful in understanding more about your motivations for becoming a therapist. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Having Difficult Conversations in Supervision

I have finished my first semester in a new practicum site, and my supervisor’s evaluation of me was less positive than I expected.  She’s been very supportive of me, and I expected her to understand why I’ve had some trouble keeping up with paperwork and applying the theoretical orientation used by my agency.  Should I talk with my supervisor about her evaluation of me?

This is the third blog in a series on difficult conversations.  Click here for the blog related to client conversations and here for the blog related to colleague conversations.  As I have mentioned in the previous blogs, growing into the role of clinician means developing skills to talk about issues and areas of conflict in a way that is different than our usual social conversations.  When we can expand our repertoire of skills in managing these difficult conversations, we are capable of being effective in a broader range of clinical challenges.

One of the issues raised by your question is the inherent tension that is felt by both supervisors and supervisees between two necessary aspects of supervision: 1) providing support to facilitate professional growth and 2) giving corrective and constructive feedback in areas needing further development.  Both of these aspects of supervision are required for you to gain skill and confidence in your clinical work, but most supervisors and supervisees are more comfortable with the support side than the corrective feedback side.  I will suggest a few issues for reflection before returning to the question of talking with your supervisor about her evaluation of you.

First, I would suggest that you examine the degree to which you experience support and feedback as polarized or incompatible.  Think about other relationships you have had with instructors and other authority figures and whether it has been hard for you to receive guidance or suggestions on assignments or work performance.  This may also relate to your experience with your parents, bringing up issues to discuss in your personal therapy.  You may be looking for nurturing and support from your supervisor without recognizing the need for correction and guidance.

Second, it sounds like you have some assumptions about what it means for your supervisor to be supportive.  Consider your supervisor’s position of responsibility for your clients’ care and for insuring that your clinical work meets acceptable standards in your agency as well as the mental health field.  She may or may not understand the reasons you have struggled in the particular areas you mention, but either way she has a responsibility to evaluate your performance accurately and to give you appropriate feedback.  Being supportive doesn’t mean that you’ll be held to a more lenient standard than your peers.

Third, I recommend reflecting on your own standards for yourself as you learn a new set of skills.  It is often uncomfortable to be a beginner especially when you have developed confidence in other areas of your life.  You may be looking for positive feedback from your supervisor partially in order to counter your own discomfort or self-criticism as you grow in a new profession.  You may also be unfamiliar with being rated as average or even below average, even though this is a predictable part of the clinical learning process.  Mastering clinical work is different from learning academic material, and you may have expected an evaluation from your supervisor that reflects your success in the classroom.

After reflecting on these three areas, give thought to how you might approach a conversation with your supervisor.  I would suggest focusing on the corrective feedback she gave you as an opportunity for you to establish goals for your next semester.  Make sure you understand your supervisor’s expectations and ask her for examples of the changes she wants you to make.  If you are uncertain about how to make these changes, ask for suggestions of ways you can improve.  It will probably be helpful to have a series of conversations about the areas you mention, so you can get progressive feedback on your performance.  It may be hard to focus your attention on areas of growth rather than areas of greater skill, but your clinical work will improve as you bring those weaker areas in line with your strengths.

I hope you find these suggestions helpful in having difficult conversations in supervision.  Please email me with comments, questions, or suggestions for future blog topics.

Having Difficult Conversations with Colleagues

I’m seeing a heterosexual couple in couples therapy, and a colleague at my agency is seeing the wife individually. Last week my colleague made a critical comment about the husband and questioned how helpful couples therapy could be. She said this in front of several of our peers, and I didn’t respond because I was shocked and hurt. I think I need to say something to her, because her negative view of the couples therapy will undermine the wife’s participation. There is a lot of conflict in the relationship but they have both expressed a commitment to work it out and stay together.

This is my second blog on the topic of having difficult conversations. It may be helpful to read the prior blog about client conversations if you didn’t do so already. This situation with your colleague is an example of difficult conversations that can arise when we share cases or consult with colleagues about our work. Growing into the role of clinician means developing skills to talk with colleagues as well as clients about uncomfortable issues and areas of conflict. You’ve already made an important first step in deciding that you need to talk with your colleague rather than avoiding a challenging interaction. I would agree that having a disagreement between the individual and couples therapists can be harmful to the client, and I would add that it can also be informative to both the individual and the couple therapy.

I would suggest that you engage in personal reflection before you approach your colleague. It is important to identify 1) the nature of the conflict or difficulty you are experiencing with your colleague, 2) assumptions you may be making about the reasons for the conflict, and 3) the desired outcome of a conversation. During this process, it may be helpful to consult with another trusted colleague or your supervisor to sort through your feelings and hear some alternative explanations or outcomes you may not have considered.

When you reflect on the nature of the conflict, identify the content or issues of disagreement as well as the emotions associated with the conflict. In this instance, you mention shock and hurt, but you may notice other emotions that have arisen since then. If you find that the issue and associated emotions are similar to interactions that have been a struggle in your personal life, it may be helpful to take this to your own therapy as well as getting supervision and consultation.

After you feel clear about the conflict itself, reflect on the assumptions you have about why your colleague made this remark. Usually an emotionally charged interaction leads us to develop explanations for our hurt or angry feelings, and these explanations often include criticism and judgment of yourself or the other person. For example, you may wonder whether your colleague doubts your skill as a couples therapist or whether she has a bias in favor of separation for couples in conflict. Consider other explanations as well, possibly with the help of your supervisor, therapist, or colleagues. One possibility is that the wife is describing her view of and feelings about her husband and marriage differently in her individual therapy than in the couples therapy. This would mean that you and your colleague are holding two disparate parts of the wife’s experience that she hasn’t reconciled.

Third, identify the outcome you desire for your conversation. There are a number of possible outcomes when approaching a colleague about a difficult interaction: expressing your point of view, engaging your colleague in understanding your difference of opinion, and sharing your view of possible reasons for your differences in perspectives are a few. Make sure that the outcome you identify is something that is focused on your communication and is collaborative in nature. A desired outcome of changing your colleague’s point of view establishes a more adversarial tone and is likely to lead to a deterioration of your collaboration rather than strengthening it. If you have difficulty identifying your desired outcome, check with your supervisor, therapist, or another trusted colleague who can maintain neutrality.

Once you have moved through these steps in understanding the interaction with your colleague, you are ready to plan a conversation with her. I would recommend letting her know you’d like to talk and planning a specific time and plan for the conversation. You’re more likely to achieve your desired outcome if both of you have set time aside and if your colleague knows what you want to talk about. Make sure you describe the purpose of the conversation in neutral terms by saying something like “I’d like to talk further about our work with X and the questions you raised last week about the couples therapy.” Follow that statement with some suggested times and a private location where you can talk without disturbance. When you come to the designated time and place, you may benefit from having a clear opening statement about your reason for wanting to have the conversation, setting the tone as positive, curious, and collaborative. An example of an opening statement in your situation might be “I was surprised to hear what you said last week about X’s husband and the couple therapy. I’d like to compare our perspectives to see if we can make sure the two therapies are beneficial to her.” The preparation you have done will enable you to listen to your colleague’s point of view, express yours, and work to establish common ground in understanding your client.

I hope you find these suggestions helpful in addressing difficult conversations with colleagues in your clinical work. Please email me with comments, questions, or suggestions for future blog topics.

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.

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.

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.

Holding Different Perspectives on a Clinical Situation

Couples CounselingI’m working with a couple who report very different versions of their interactions with each other. I trust the wife’s report more than the husband’s, but I don’t know how to figure out what really goes on between them. How can I determine who is more accurate?

The dilemma you describe comes up frequently in working with couples, and it illustrates an important capacity that we need to develop as clinicians. It is natural to begin with a view that there is a right, true, or accurate version of a particular situation or interaction.  However, you will learn with clinical experience that each person in an interaction experiences it in slightly different ways, and sometimes in dramatically different ways.  This requires us to develop a capacity to hold different perspectives on the same interaction. I will begin my discussion with some suggestions about this issue in working with couples, then address how it also applies when working with clients who feel hurt, angry, or misunderstood by us and when working with colleagues or supervisors.

Couples who enter therapy often present with each member of the couple invested in his or her position, trying to enlist the support of the therapist to convince their partner that their position is correct or superior. The therapist’s countertransference response is often to feel compelled to take the role of a judge and developing a verdict on the conflict. However, with rare exceptions for situations related to physical safety, the couple’s conflict is due to differences between the individuals and their ability to communicate and listen to each other.

The first step in helping a couple in this situation is for you to understand the perspective of each individual in the couple and to hold their perspectives, even if widely divergent, as valid and important. Your capacity to hold multiple perspectives can help shift the focus of the couple from a quest to identify who is right to an appreciation for each individual’s unique emotions, needs, and motivations. For example, a couple may begin a session with the wife reporting an argument in which the husband yelled at her, and the husband reporting that he didn’t raise his voice but only asked his wife to move her car into the garage. You can help both clients feel heard and understood by pointing out that the wife felt criticized and bullied, even though her husband may not have intended to criticize her, and the husband felt ignored when his wife objected to his request.

The ability to be interested in different perspectives is more difficult to attain and express when you are one of the parties in the situation or interaction. When a client reports something you said that she felt was unempathetic or when a client reports feeling hurt or angry with you, it is natural to identify distortions in the client’s perspective and attempt to correct her point of view. You will learn that this is rarely if ever successful. You need to hold your point of view without defensiveness while encouraging the client to tell you more about her experience of the recent interaction between you. Similarly, when you talk about a mutual client with a colleague who views the client very differently than you or when you experience a conflict with your supervisor about the direction of treatment with your client, you need to be able to express your point of view while being open to and respectful of that of your colleague or supervisor.

You may wonder how to develop the capacity to hold multiple perspectives and how long it will take. Anything that helps you identify and reflect on your emotions and thoughts will facilitate this capacity, which is sometimes referred to as an observing ego or mindful self-awareness. Some helpful ways to work on this are to seek psychotherapy from a psychodynamic or other depth psychology orientation and to engage in meditation or other mindfulness practices. It is a capacity that is an area of continual personal growth, since different clinical situations will pose different challenges to our tendency to look for the one right or accurate view. You will find it easier over time, though, as you make it a priority in your professional growth.

I hope you find this discussion helpful in working with clients, colleagues, and supervisors. Please email me with comments, questions, or suggestions for future blog topics.

Resolving Problems in Supervision

img-article-are-you-too-stressed-outI am having problems with my supervisor and am thinking about requesting a new supervisor. She seems impatient and critical of me, so I feel intimidated and that makes it hard for me to take in her feedback. When I tell her how I feel, she says she’s trying her best to help me learn. I don’t know how to make this better so maybe I should change to someone else.

This is a painful situation, since supervision is a crucial part of growing into the therapist role. It’s easy to feel hopeless and think that a change of supervisor is the only alternative. My experience has been that this kind of impasse can often be improved with thoughtful self-reflection and conversation, so I’ll first suggest some ways to examine the possible dynamics of this situation. Then, I’ll outline some recommended steps to approach the conversation that are likely to make it more clear whether your supervisory relationship can improve and contribute to your learning and growth.

My first comment is that engaging in self-reflection and finding ways to shift your feeling of intimidation to one of empowerment will contribute to your ability to handle other difficult clinical situations. You are likely to face interactions with clients, family members, or other professionals that contain some of the same features of this supervisory relationship. Since your supervisor’s job is to support your clinical growth, she is likely to be most responsive to your efforts so it is a good place for you to test out some new relational skills.

To begin your process of self-reflection, I encourage you to shift your attention from your supervisor’s comments to your own response. You mention feeling intimidated, so explore the thoughts, feelings, and images that are present in that sense of being intimidated. You may identify thoughts undermining your self-worth and competence, feelings of shame and inadequacy, and/or images of yourself as a child being chastised by a parent or other authority figure. As you identify your response on a deeper level, remember that these thoughts, feelings, and images are yours and are stimulated by your supervisor but are not the only response you might have. Although your supervisor is an authority figure, you are not a child dependent on a parent’s care and approval but an adult growing into a professional role. When your supervisor gives your feedback on your clinical work, it is not confirmation of incompetence but confirmation that you are in the early phase of learning a set of new skills.

It may be helpful to talk with other supportive people while you engage in this process of self-reflection, especially if your supervisory interactions stimulate unresolved issues from your early life. Talking with your therapist, academic mentors, or past clinical supervisors may be useful. It can be hard to recognize and challenge old patterns when your feelings are strong and painful. It may also be helpful to talk with peers and friends to gain support and encouragement; however, be careful to avoid presenting the situation in a way that will lead them to see the situation as hopeless and affirm your fear that it can’t get better.

After you made progress in understanding your response, challenging some of your underlying beliefs, and grounding yourself in your clinical role, it is time to return your attention to your interaction with your supervisor. Consider the possibility that simply shifting your response from one of intimidation to collaboration will change the dynamic in a positive way. I would suggest initiating a conversation about your supervisory relationship, acknowledging it has been difficult and sharing that you have examined your response and are attempting to shift some of the things that have interfered with your openness to her feedback. State in a positive way what you feel you have received from supervision and what you wish to gain from her expertise.

If supervision continues to be difficult after having a conversation like I describe above, the next step that may be helpful is to talk with the director of training or another clinical supervisor in the agency. Your agency may have a procedure in place for resolving supervision difficulties, which you should follow, but if not seek out someone who has some supervisory and/or administrative responsibility for the training program. A conversation with a third party may give you further insight into the difficulty you are facing and lead to a more fruitful conversation with your supervisor, or it may lead to a decision to schedule a meeting between you, your supervisor, and the third party to discuss the problems and attempt to reach resolution. A decision to change to a different supervisor is rarely necessary if you follow all of these recommended steps.

I hope you are able to use these suggestions in understanding difficulties you face in supervision. Please email me with comments, questions, or suggestions for future blog topics.

Applying for Internship Training

FullSizeRender (49)I plan to apply for internship training in a few months, and I want to work with children and families. How can I make myself a competitive candidate when my clinical experience so far has been with adults?

Your question highlights a common dilemma that isn’t limited to clinical work; i.e., how does one gain experience when the positions require prior experience? You are wise to plan for this ahead of time, and there are several strategies that will increase the likelihood of you being accepted into a training position that will give you the experience you want. Typically, there are two steps in being accepted for a training position. The first is to be invited for an interview, and the second is to be offered a position. Therefore, it makes sense to think of your strategies in two steps as well.

Your written application will determine the decision of the training agency to invite you for an interview, so let’s look at that step first. You are more likely to be invited for an interview if you submit written materials that follow the format and structure requested by the agency and are professional in appearance and language. Prepare your materials in advance of the deadline so you have time to proofread them. It is preferable to have someone else also look over them for obvious errors. If you submit materials electronically, by email attachment, be sure they are in a commonly used document type (PDF or Word document) without complicated formatting.

Familiarize yourself with the agency, and mention in your cover letter the aspects of the agency that are particularly attractive to you. You can research an agency by looking at their website, talking with other students in your program who have done training there, attending an open house if possible, and asking supervisors and professors what they know. Be careful to not make assumptions, though. I have received applications that incorrectly assumed the agency used a specific modality of treatment or served a particular client population, based only on its name.

Regarding the content of your written application, I would recommend that you both acknowledge your lack of clinical experience with children and families and highlight other relevant experience. For example, you might have done child care, teaching, camp counseling, or volunteer work. In your cover letter, explain how the work you did gave you valuable knowledge about the challenges faced by children and families and how you want to expand that knowledge by working clinically. You would be wise to take on a volunteer commitment now, even if only 5-10 hours per week, that would demonstrate your commitment to improving your skills. Also consider applying to agencies that see individual adult clients as well as children and families, so that your prior experience will be more relevant to the agency population.

If you are successful in step one, you will be invited to interview with one or more staff members. Think about the interview process at your prior placements, and be prepared to answer typical questions about your interest in the agency, your preferred theoretical orientation, your self-assessment of strengths and challenges, and your future career goals. It is also wise to prepare a short case vignette that illustrates a challenging situation that you managed successfully.

Plan your answers to interview questions about your lack of child and family experience carefully. In addition to the suggestions above which apply to an interview as well as a cover letter, consider ways in which your clinical experience with adults will transfer to child and family work. For example, you may have worked with parents and developed empathy for the difficulty of raising children when living with a history of trauma and psychosocial stress, you may have had worked with young adults facing many of the developmental issues of adolescence, or you may become aware of the impact of family relationships in your contact with the family members of adult clients living with serious mental illness. Also highlight the skills you have acquired that will transfer to child and family work such as diagnosis and assessment, case formulation, treatment planning, or the use of trauma or substance abuse treatment models. Be realistic in acknowledging how much you have to learn while describing the knowledge and skill you have attained thus far.

After your interview, solicit feedback from the interviewers if you aren’t accepted into the agency training program. Ask if they have suggestions on how you could improve your presentation or performance in the interview. This might give you valuable information about how to be a more competitive candidate for future positions.

I hope you find these suggestions helpful in applying for internship training. Please email me with comments, questions or suggestions for future blog topics.