Category Archives: Preparation and Supervision

Clinical Issues at Holiday Times

psychiatrist-mental-health-doctorThe holidays are coming up soon, and I am thinking about how to prepare my clients for the issues that are likely to come up.  This is my first year in a practicum placement, so I also wonder how much to be available to see my clients during the holiday season.  

The time between mid-November and early January is a difficult time for many of our clients.  Family gatherings can trigger painful memories and can give rise to conflict over past or present disagreements.  Those who choose not to spend time with family or who are estranged from family may feel a heightened sense of isolation during this season if they don’t have relationships with a partner and friends.

In approaching the topic of the holiday season with your clients, I recommend that you adopt an attitude of curiosity and interest, free of assumption and agenda.  You have probably worked with some clients for a few months and with others for only a few weeks.  They will vary in their sense of trust and engagement with you and in their readiness to plan for upcoming events and gatherings.  You can bring up the topic with a general statement like “the holiday season is challenging for many people and I wonder if you’d like to talk here about some ways to take care of yourself during this time.”  This leaves an opening for the client to focus on the aspect of the season that is most challenging or to let you know that it isn’t a priority.

Some of the issues your clients may want to discuss are family gatherings, other social events, financial pressure, and managing stress.  Remember that your role is to support and collaborate with your client rather than to attempt to fix the dilemma.  Find out what specific difficulties have arisen in the past and ask how she would like to handle a similar situation in this holiday season.  It is usually better to apply skills the client uses in other situations or to make small adjustments in the familiar pattern rather than taking on a major change.  For example, if she has used a mindfulness exercise in other stressful situations, suggest trying that before or after a tense shopping trip.  If the client reports that the family gathering becomes heated and conflictual after a couple hours, ask if he could plan to leave after two hours before things escalate.

Regarding the question of being available to see your clients, reflect first on your needs for self care during the holiday season.  Our personal lives contain the potential for family conflict, painful memories, and feelings of loneliness as do our clients’ lives.  Be sure to make your decisions about taking time off from client work in a way that includes meeting your needs.  Consider the possibility that some of your clients will miss their scheduled appointments and that you will feel particularly frustrated or resentful if you defer your needs for time off and the clients don’t come in.

Once you have decided on your schedule for the holiday season, let your clients know when you will be out of the office and confirm the dates you are available for scheduled appointments.  Some clients don’t think in advance about the impact of changes in work schedules and children’s school schedules on their ability to keep an appointment, so it may help to reduce the number of late cancellations you have if you go through the calendar with them.  Provide your clients with information about emergency coverage during your absence, and develop a safety plan with those who are at risk or who anticipate particular difficulty at this time of year.

I hope you are able to use these recommendations for your clients and yourself in the holiday season.  Please email me with comments, questions or suggestions for future blog topics.

Client Disengagement

Client DisengagementI’ve been working with a client for about six months, and we’ve agreed on a treatment plan. However, he doesn’t seem very engaged in working toward his goals. My supervisor suggested I bring this up with him, so I asked if he has changed his priorities and he said no. How can I help him make progress when he isn’t motivated?

This is a difficult situation, and it sounds like you haven’t yet identified the reason for your client’s lack of engagement with the treatment plan. In addition to a change in priorities, this type of withdrawal could be due to his reluctance or inability to verbalize his preferences or due to pressure from someone in his life about the purpose and outcome of the therapy. Your client told you his priorities haven’t changed, but you still don’t know whether that or another factor may be explain your sense that he isn’t working collaboratively with you. I’ll make a few suggestions of ways you might work with yourself and your client to change the pattern or your interpretation and response to it.

The first step I would recommend is to identify and explore your countertransference response. You say he seems disengaged, which suggests that there is a disruption in your experience of the therapeutic relationship. Give thought to his behavior and your emotional response without making an interpretation of what it means. Also, reflect on whether your client’s behavior has changed over the six months you have worked together. It is possible that there is a mismatch between you and your client in interpersonal pace, rhythm, and emotional expression. If that is the case, the meaning you are assigning to his behavior, i.e., that he isn’t engaged in working on goals, may not be accurate. In addition, if you notice a similarity in your emotional response to this client and to other situations in your personal life, you may need to become more flexible in attuning to your client’s preferred style and not assigning the same interpretation to his behavior as you have made in other relationships. Talk with your supervisor about your countertransference and your observations of your client’s behavior to help you get clearer about why you have come to the conclusion that he isn’t motivated.

After you have checked your countertransference responses, consider bringing up the issue of your client’s engagement as a process comment. Be sure you are feeling open and nonjudgmental when you initiate this discussion. Examples of ways to bring up the issue would be “I’ve noticed that our discussions of your treatment goals haven’t been very fruitful and wonder if you have any thoughts about that” or “I’m wondering how the therapy is feeling for you and whether we’re addressing the things that are most important to you” or “I’d like to check in with you about how we’re working together to make sure I’m helping you in the ways you want and need.”

Last, after you have initiated this process level discussion, respond with curiosity and interest to the client’s comments. It is especially helpful to use reflective listening, empathy, and clarification. Even if your client responds by saying “everything is fine,” you can respond with “so you feel we’re working on the things that are important to you?” to affirm the client’s statement and encourage him to elaborate. If he gives any indication of ambivalence or dissatisfaction, you can follow up on that using reflective exploration which may lead to greater understanding and collaboration between you. If he doesn’t directly express any discontent, you can still express your openness to hearing his negative feelings by making a normalizing statement. An example is “people often find that they have a mixture of feelings about therapy, so if that does happen for you I hope we can talk about it.”

I hope this discussion has been useful to you in understanding client disengagement. Please email me with questions, comments, and 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.

Using Supervision

therapyI’ve been meeting with my supervisor for about six months. I find it helpful but wonder if I could be getting more out of it. My supervisor is very experienced and I’m not sure I’m using her expertise to my best advantage.

You are wise to look for ways to maximize the benefit of your supervision. It is generally the most powerful tool for examining and improving your work as a therapist. I’ll address your question in two parts, in terms of the content and the process of supervision.

There are three content areas to cover in supervision. In order of importance or urgency, they are 1) crisis or emergency situations, 2) new clients, and 3) regular review of ongoing therapy with all of your clients.

When one of your clients is in crisis or there is an emergency such as an abuse report or need for hospitalization, you should contact your supervisor between scheduled sessions to discuss crises and emergencies when they arise, then give an update and develop your plan for follow-up in the next supervision hour.

When you begin with a new client, spend time in supervision talking about the client’s clinical presentation and issues of concern or difficulty. You should develop a diagnosis, case formulation, and treatment plan within the first four to six sessions so that your work is focused and effective. Your supervisor’s input is vital in answering your questions, helping you understand the client from a conceptual framework, and suggesting appropriate interventions.

Most of your supervision time can be spent reviewing your ongoing work with clients whose treatment is established and progressing toward the clients’ goals. Talk with your supervisor about the best way to review your ongoing work, since there is a choice to be made between breadth, or giving brief updates about all clients each week, and depth, or spending more time each week on a few clients. Make sure to present each client on a regular basis, including those who you enjoy and are making progress. It is easy to focus supervision time on your challenging clients but there is much to learn in sharing your successes and going into more depth in understanding the clients with whom you feel an easier bond.

Attending to the process of supervision will allow you to get the most benefit. One aspect of process is the quality of your organization and preparation. As you go through the week, reflect on your client sessions and make note of issues that are a priority for your next supervision hour. Examples are differential diagnosis questions, changes in the clients’ symptoms, progress or lack of progress in therapy, questions about treatment approach and interventions, conflict or ruptures in the therapeutic alliance, and strong countertransference. Your supervisor will be able to give you more guidance when you have prepared in advance and lead with the questions that are most pressing.

A second aspect of process in supervision is your degree of openness in the supervisory relationship. Supervision includes mentoring and support as well as evaluation and constructive guidance. Your awareness of the evaluative component of supervision may make you reluctant to bring in difficulties or mistakes, but the greatest learning occurs when you bring in situations that trigger uncertainty, distress, self-doubt and other strong feelings in you.

It is often useful to talk with your supervisor directly about your fears of looking bad, about your own self-criticism, and about what you feel you need from your supervisor. These conversations are good practice for talking directly with clients about emotionally challenging issues, which is part of every therapist’s repertoire. You are also likely to feel more supported by your supervisor when you take the risk to express your vulnerability and your needs.

I hope you follow some of these suggestions and increase the benefit you get from your supervision. Please email me with comments, questions or suggestions for future blog topics.

Self Care for Enhancing Well-being

calmI’m in my second year of practicum placement and I feel really burned out. What can I do to keep going in this career without constantly feeling depleted by my work with clients?

This blog continues the topic of self care, which I introduced with suggestions about work habits. We’ll look at additional strategies for self care to enhance physical, mental and emotional well being. As I mentioned before, I recommend that you choose one or two small steps to try out first, see if they are helpful, modify them if necessary, then build on those after you have had some success. It may seem as though making drastic changes is necessary, but it is easier to start with something small. You are more likely to be successful and less likely to feel discouraged by the enormity of what you are taking on. Remember you can always start again if you slip back into old habits.

We’ll start by looking at physical health and well-being. This is an area that is easy to neglect especially with the pressure of classes and practicum or internship training. However, neglecting your physical health will take a toll on your mental and emotional health as well. Examine how you are caring for your basic needs for nutrition, movement and rest. Small changes in eating, exercise and sleep habits can yield significant benefits. I find that paying attention to my body’s signals results in being more productive since I’m bringing more resources to bear on my work.

Being in graduate school is a time for developing the mind. You are gaining knowledge and putting a lot of attention to your intellectual growth. This may mean that your mind is working at maximum capacity and you may find it hard to shift out of a preoccupation with your thoughts and ideas. Introducing a mindfulness practice may be helpful in balancing your mental energy. Meditation, progressive relaxation, stress reduction, and guided visualization are all readily available in online formats if taking a class isn’t feasible in your schedule. If doing a structured mindfulness practice doesn’t fit for you right now, simply spending time in nature is a great alternative.

Your emotional equilibrium will continue to be challenged as you progress through your training. Supportive relationships are the most helpful resource for building and restoring your emotional reserves. Personal psychotherapy gives you a chance to talk confidentially about the emotions that are triggered by your clients as well as your academic courses, trainings and supervision. Supportive relationships with peers and mentors in the field can help you share some of the experiences common to clinicians. In addition, strive to maintain and establish supportive personal relationships both individually and in community. It is important to engage in relationships and activities unrelated to the mental health field to provide perspective and balance.

It may seem like a big task to attend to these three areas of your health, but you can choose one activity that serves several functions. For example, following a YouTube yoga instruction will move your body and still your mind. Sharing a healthy meal or going on a hike with a good friend will meet your physical and emotional needs. In addition, any change you make that improves your health in one area will help in other areas because our physical, mental and emotional well-being are interconnected.

I hope you find these suggestions helpful in sustaining and improving your health in all aspects. Please email me with comments, questions or suggestions for future blog topics.

Self Care in Work Habits

Iimg-article-are-you-too-stressed-out’m in my second year of practicum placement and I feel really burned out. What can I do to keep going in this career without constantly feeling depleted by my work with clients?

Your concern is a universal one for clinicians. We tend to enter this field with a predisposition for caregiving others and neglecting ourselves. The emotional demands of doing psychotherapy with highly distressed individuals and families are intense and most of us reach the limits of our previously developed coping strategies during our training. This is a good time to create new routines and habits that will serve you throughout your career.

In this blog, I will suggest some general strategies that will help to build your emotional reserves and detach in a healthy way from the intensity of clinical work. The next blog will address more specific ways to attend to your physical, mental and emotional health. I recommend that you choose one or two small steps to try out first, see if they are helpful, modify them if necessary, then build on those after you have had some success. You will probably find it hard in the beginning to give attention to yourself, as you go against longstanding patterns. Be gentle with your expectations and remember that you can always start again if you slip back into old habits.

It will be easier to sustain your physical and emotional energy if you build in breaks for yourself, both on a daily basis and throughout the training year. Look at your daily routine and schedule one or two breaks if you have a full day at your placement. Use your break to eat a meal or snack, take a walk, read or watch something unrelated to your work, or talk to a colleague. Turning your attention away from your work for a period of 15 minutes to an hour will enable you to be more engaged when you return to it. If you have classes and clinical work in the same day, give yourself some transition time in addition to your commute.

Another aspect of your routine to examine is the structure of your day. It is helpful to alternate more and less demanding tasks throughout the day. Consider taking an hour to work on paperwork or do some research into resources for a particular client to break up your client hours. If you have several particularly complex or challenging clients, schedule them on different days or at different times of the day so you have other work or less challenging clients between them.

Clinicians often have a very hard time taking a vacation from clinical work. Because of our pattern of caregiving, we often feel as though we must be available at all times. We don’t feel comfortable having someone else provide coverage. However, we cannot maintain our own equilibrium if we never take a break to restore ourselves. Throughout the training year, take vacation time as it is permitted at your agency and have a colleague provide coverage for your clients so you can be free of responsibility and preoccupation. It is tempting to check voice mail or email when you’re away from the office but you will benefit more from your time off if you fully detach. Keep in mind that taking a vacation means being away from the office and not having any client contact for at least a week. Taking short periods of a few long weekends will not allow you to truly rebuild your reserves and return feeling restored.

I hope you can use these tips for developing some work habits that counter your feelings of depletion. The next blog will continue on this topic, addressing specific ways to care for your physical, mental and emotional well-being. Please email me with comments, questions or suggestions for future blog topics.

Personal Psychotherapy

therapy1My graduate program requires all students to have our own psychotherapy while we are in school. I don’t know how to find a good therapist or what to talk about in therapy since I’m not in a crisis.

It is good practice for programs to require personal psychotherapy as part of clinical training. It will give you an experience of being in the client role that will inform your practice as a therapist. It will also be a source of support as you go through the emotional growth and challenges that are part of the clinical training process.

The question of how to find a good therapist is an important one, involving issues of therapeutic approach and style as well as practicalities. I recommend starting with the question of therapeutic approach and style since finding a match on those dimensions is essential to finding a therapist who will be useful to you. You can begin your search by asking friends or fellow students for recommendations, using the mental health benefit provided by your health insurance, and doing a search on the websites of local professional organizations. In addition, your graduate program may have a directory of recommended therapists, often alumni of the program, and you can also ask faculty for recommendations.

If you haven’t been in therapy before, it may be helpful to meet with more than one therapist before committing to work with someone for a number of months. Some people develop a list of questions about information that will guide their decision, although each initial session will have a unique flow, rhythm and outcome. At this point, you will begin to sort through the practical aspects of choosing a therapist. For most graduate students, time and money are in short supply. Keep in mind that the financial and scheduling arrangements for therapy should be sustainable for at least the period of time required by your graduate program, and possibly longer. Many licensed therapists are willing to work with graduate students at a reduced fee especially if you are able to come during day time hours that are in lower demand.

The question of what to talk about with a therapist is also an important one. The short answer to that question is that you can talk about anything that is on your mind. You may want to talk about your personal life and the changes that have been caused by your entry into a clinical graduate program; your academic courses and the personal reflections stimulated by your course work; or your clinical training and the emotional challenges of working with clients who are in distress. Most students find that clinical training is emotionally disruptive in bringing issues to the surface that you have worked on in the past or that are new and unfamiliar to you.

It is useful to enter therapy before beginning your fieldwork or practicum placement, since it is unexpectedly overwhelming to begin seeing clients. You and your therapist will have a chance to identify some of the patterns that are present in your relationships, your familiar coping strategies, and the signs and triggers of stress. This will enable you to use therapy as a source of support when you face the intense emotions that come up for new clinicians.

I hope you find these suggestions helpful in entering therapy as a graduate student. Please email me with comments, questions or suggestions for future blog topics.

Intersection of Personal and Professional Lives

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

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

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

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

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

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

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

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

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

Social Media

new1One of my clients recently mentioned a post I put on my Facebook page and I just received an invitation from her on LinkedIn.  My social media presence is part of my personal life, and I dont want her or other clients to be part of it.  How do I talk to her about this and ask her to respect my privacy?

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

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

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

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

Orientation to a New Training Site

new2I just started at my practicum or field placement site and I feel pretty overwhelmed.  What can I do to reduce my anxiety?

Starting at a new training site can be stressful, whether it’s your first placement or your fourth.  There are several things you can do to feel more confident and grounded.  As you read the suggestions below, you will probably find that some seem more relevant than others, based on your typical response to a new situation.

It is often helpful to review the requirements and procedures for your new site during the first week or two before you see your first client.  Some training agencies have a formal period of orientation and training and others are more informal.  Whatever the practice at your site, you will feel more prepared if you know 1) the treatment frame, i.e., where and when you will see clients, whether and how the client pays for sessions, how long sessions last and whether there is a limit on the number of sessions you will have; 2) the forms to be completed and signed by you and the client in the first session; and 3) agency procedures for clinical emergencies and back-up emergency supervision.  If this information isn’t provided in a formal orientation process, you can ask your supervisor or another more experienced colleague.

A second way to reduce anxiety is to think about ways to connect empathically with your assigned clients or the client population at your training site.  Often you will be working with clients who have survived serious trauma and are living with discrimination, prejudice, and poverty.  Instead of focusing on the client’s history and current circumstances, which can leave you feeling inadequate to make an impact, think about what your client may be feeling in coming to a session with you.  It is likely that she/he brings fear, shame and distrust to your first encounter as well as coping strategies that have enabled her/him to survive painful experiences.  Remember that your desire to understand your client is an essential and powerful first step in your relationship and will instill hope that you may have something helpful to offer.

Another very important aspect of managing the stress of starting in a new training site is to pay attention to your own physical, mental and emotional health.  You may be juggling school, job and family responsibilities in addition to your field placement limiting the time you have to take care of yourself.  In addition, many of us come into the behavioral health field with patterns of caretaking and self-neglect.  Working to balance our own needs with those of our clients is as much a part of the learning process as gaining clinical knowledge and skill.  You can start with something relatively simple like taking a 10-15 minute break to walk, stretch or do a mindfulness exercise during your day or bringing a healthy snack to work.  Supportive personal and professional relationships are also important, and personal psychotherapy is especially useful during clinical training.

I hope some of these suggestions help you in this overwhelming time.  Please email me with comments, questions or suggestions for future blog topics.