Category Archives: Preparation and Supervision

Client Requests for Records

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therapyI had a session today in which a client asked to see the notes I have taken that are part of her chart.  I told her I’d have to talk to my supervisor because I’ve never had a client ask for this before.  What choices do I have in deciding whether to give her the notes or not?

This issue was addressed by HIPAA, which created a national standard for client’s access to all medical records including records of psychotherapy.  Under HIPAA, the record belongs to the client and s/he has a right to request and receive a copy.  Exceptions are only made for instances where viewing the record would cause serious harm to the client and, in the case of child records requested by parents, harm to the psychotherapy relationship.  Most behavioral health agencies ask clients to make a written request and then provide a copy of the records within 1-3 weeks.

While HIPAA addresses client access to records from an administrative perspective, it doesn’t address the clinical issues that are often present when a client requests a copy of the current treatment record.  Your supervisor can be helpful in talking through the meaning and motivation for your client bringing this up with you.  Some factors to consider are the client’s previous experiences of secrecy and betrayal, issues of control and helplessness, interpersonal suspiciousness, and involvement in a legal case or application for disability.  Your client is more likely to tell you about the reasons she wants to see your notes if you make it clear first that you plan to honor her request.  In your next session, you can say “You told me last week you wanted to see the notes I have written for your chart.  I have the written request here for you to fill out, and I also am interested in what led you to ask for the notes.”  You can explore this further, if the client is willing to do so, by asking what she expects to see in the notes and how she feels about looking at them.

Most clinicians, especially those in field placement or practicum training, feel anxiety when a client requests the record.  You may anticipate, correctly or incorrectly, that the client will be upset or offended by things you have written in progress notes or the assessment.  Your assessment may include a diagnosis and case formulation that you haven’t explicitly shared with the client.  Your notes may accurately reflect some of the client’s obstacles to improvement and progress.  It is usually helpful to look at the record and to have your supervisor review it to identify anything that could be problematic.  Whether or not you anticipate a negative reaction from the client, it is usually wise to say “There may be portions of this record that spark questions or upsetting feelings for you.  I’d like to talk with you about anything that comes up after you’ve read it.”  Then you should follow up with a discussion in the following session about what it was like for her to look at her record.  If she has questions or was distressed by anything you wrote, I recommend being straightforward in your explanation.  If you regret anything you wrote, you can acknowledge that you wish you had used different wording or had described the situation differently.  In addition to negative feelings, she may feel pleased with her self-assertion and have an increased sense of empowerment when you respond to her request in a respectful, professional manner.

I hope you find this helpful in handling client requests for records.  Please email me with comments, questions or suggestions for future blog topics.

Psychotherapy Termination

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therapy1I will be leaving my practicum training placement 4 months from now in the summer, and this is the first time I’ve worked with people more than 12 sessions.  Some of my clients have been coming in for more than 6 months.  How much time do clients need to end therapy?

Starting at a practical level, it is usually helpful to let clients know about your departure 4-6 weeks before the end of your work if the treatment has lasted between 4 months and a year.  Less time is generally needed if the treatment is shorter and more time if it has been longer. Anyone that begins treatment with you now should know from the beginning how long you will be able to work with them. A related question that is often unacknowledged by clinicians in training is how much time you need to end therapy with your clients.  I find that the ending process is much smoother when the clinician has spent at least a month, preferably longer, reflecting on her/his feelings about leaving clients and the placement before beginning to have conversations with clients.  Supervision, sharing with fellow clinicians and personal therapy are all places to talk about this.

All of us have personal experiences with loss and we bring those feelings and reactions to professional experiences of loss.  Even though moving to a new training placement is a move toward professional growth, you are also ending relationships that have been important in your intellectual and emotional learning.  Using self-awareness about how you approach this move will tell you a lot about the ways you are accustomed to managing grief and loss.  You may minimize the importance of this step, find fault with your current placement, become preoccupied with the welfare of your clients, focus on the logistics and required documentation, or remind yourself of the exciting opportunities ahead of you.  I encourage you instead to take time to acknowledge you are saying goodbye to people who have touched your life in unique ways.

Once you have spent some time acknowledging your own emotions about the loss of your clients, supervisor and peers, you can begin to plan your conversations with clients about ending the treatment.  The main goal of termination is to create an ending that is less traumatic than the client’s prior experiences of separation and loss and that honors the client’s way of managing loss.  Your supervisor can help you review what you know about the client’s past experiences of separation and loss and how s/he manages feelings of grief and sadness in the present.  Based on this knowledge, you will be equipped to identify what can be different in your ending with the client.  You can also develop hypotheses about how the client is likely to respond.  You can expect that some of your clients will avoid coming to the final session, and saying goodbye by telephone, email or letter may be the best possible ending for some of these clients.

I hope you have found some food for thought as you anticipate saying goodbye.  The next blog will continue on this theme with some more specific ideas about what to include in your ending process with clients.  Please email me with comments, questions or suggestions for future blog topics.

Working With Depression

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

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

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

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

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

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

I hope this has been helpful to you. Please email me with feedback or suggestions for future blog topics.

Evaluating First Session of Behavioral Health Treatment

therapy1I just completed a first session with a new client. I feel like it went pretty well, but I’m not sure how to tell. What should I think about before I see the client again next week?

Generally, we end a client session with a general feeling about how it went, as you did. It seemed like a good session, a great session, a terrible session or just okay. That general feeling is the combination of a number of factors which can be helpful to separate out. It is also important to integrate your feeling about the session with your thoughts about the clinical work and what you will do next.

Often our feeling about a client session, especially the first session, comes primarily from our experience of the therapeutic alliance. The therapeutic alliance refers to a shared feeling of working together toward the same goal. After the first session, we have a sense of whether the tone was collaborative, distant or adversarial and how easy or difficult it was to feel empathic and warm toward the client. We also get a sense of whether there were obstacles to the alliance which mean it will be more difficult to establish a sense of collaboration. When you feel the session went well, it can be helpful to think about the nature of the therapeutic alliance and how that contributes to your general feeling.

During the first session you probably got an idea of why the client is coming for treatment and learned some information about his or her life and history. You may find it useful to write down your client’s primary concerns, any safety issues that are present, and questions you want to follow up. This will help to organize your thoughts and identify areas to explore in subsequent sessions. Many clinicians feel a conflict between a desire to build rapport and an agency requirement to do an assessment and/or develop a treatment plan. However, one of the best ways to build rapport is to express your desire to understand the client’s life and goals, and this understanding is the basis for your assessment and treatment plan. You can provide focus and structure by combining empathic listening with sensitive questioning and summarizing comments. This is useful to clients whose lives are somewhat chaotic and unpredictable.

Identifying issues to discuss with your supervisor is also part of beginning treatment with a new client. You may have questions about the client’s symptoms and diagnosis, the appropriate unit or modality of treatment (seeing the client individually or as part of a family unit, referring for medication), safety concerns, or feelings that have arisen for you about or with the client. Even when you feel good about your first session and don’t have any pressing concerns, it is wise to mention the client to your supervisor so she/he is updated on your case load.

I hope some of these suggestions help you in preparing for early sessions when you are getting to know a new client. Please email me with comments, questions or suggestions for future blog topics.

Field Placement Terminology

sunset_5What’s the difference between psychotherapy, case management, mental health and behavioral health programs?

If you are new to the field of psychology, marriage and family therapy or social work, you may have questions about some of the terms that are used to describe your practicum or field placement setting. Your program may use one of the terms above or a different term to describe the type of services provided to clients.

Psychotherapy involves a relationship between a client, which could be an individual or a family, and a therapist in a private, confidential setting for a specified time, traditionally 50 minutes once a week. In psychotherapy, the therapist and client identify goals for their work together, usually related to reduction of symptoms and improvement in areas of the client’s life, which may include homework or practice outside of the session. The therapist may coordinate with other health and social service providers, but the communication is primarily between the therapist and client. There are legal regulations restricting the provision of psychotherapy to individuals who meet certain education and experience qualifications.

Case management covers a broader range of activities in which the case manager may accompany the client to appointments, contact agencies and providers to advocate for the client, arrange and facilitate the client having access to housing or other resources, and/or serve as a mentor or coach. The length and frequency of sessions is based on the client’s needs and may vary from several hours multiple times per week to less than an hour once a month. The goals are often similar to goals of psychotherapy but the client and case manager may work on other practical goals with the case manager providing direct assistance. Case managers may be paraprofessionals, clinicians in training or licensed mental health professionals.

sunrise_vert_1A mental health or behavioral health program usually provides different types or levels of service to clients. Psychotherapy and case management are often included along with assessment and evaluation, inpatient or intensive outpatient treatment, medication management, and/or psychoeducation and support groups. Services may be coordinated within a treatment team of providers with different areas of specialty and expertise. The term behavioral health has been used increasingly during the last 20 years as programs and government departments began to combine mental health services with substance abuse services. The fact that these conditions overlap in a large proportion of individuals led to the rise of integrated services provided under the label “behavioral health.”

I hope this brief summary clarifies some of your questions. Please email me with comments, suggestions or further questions.