Category Archives: Professional Identity

When to Engage in Client Advocacy

I have had six sessions with a client who initially presented with symptoms of depression. Since the first session, she has tohispanic young woman in therapyld me about being treated unfairly at her last job, which resulted in her being laid off and led to her depression. She has filed a complaint against her employer and has asked me to talk with her attorney. She would like me to write a letter supporting her complaint and describing the impact of her former employer’s unfair treatment. I feel strongly about advocating for clients in issues of justice so I would like to support her, but my supervisor has advised against doing this.

Like your supervisor, I generally recommend against taking a direct position in a complex legal case like this. I’ll outline some of the ways in which advocacy can be helpful and the reasons it is inadvisable to become involved in a legal or administrative dispute between your client and a third party.

Client advocacy is an important part of psychotherapy with many clients, especially those who come from minority cultural communities and other disenfranchised populations. Advocacy often has the purpose of facilitating access to needed resources such as contacting another agency or a government department to gain information about your client’s eligibility, accompanying your client to an intake appointment for social services or public assistance, or providing verbal or written support for your client’s application for services. We also provide advocacy to our clients when we encourage them to act in the service of their needs and goals, by providing information and/or support. For example, if your client wants to attend a community college course but doesn’t know how to apply, you might get the application information for your client, pass this on to her, and talk with her about the thoughts and feelings that arise as she completes the application. This information and support serves to empower your client in acting on her own behalf.

Your client’s request for advocacy goes beyond the functions of accessing resources and supporting her empowerment. There are several issues that are wise to consider when your client asks you to become involved in a legal or other type of dispute. First, it is important to keep in mind that you are hearing only your client’s side of the conflict and that the other party has a different perspective on the events. The ability to hold more than one point of view on the same situation is a skill that develops as part of professional development, and that ability is useful in this type of case. It isn’t necessary to challenge your client’s perspective or to try to arrive at an objective view, but it is important to remember that your view is based on your client’s interpretation of the events and their meaning.

Second, when your client is involved in a legal case she probably has at least two sources of motivation for treatment. One is to reduce her symptoms and improve the quality of her life, and another is to build support for her argument that she has been wronged and deserves compensation. The presence of these conflicting sources of motivation makes your therapeutic relationship complex, and being clear about your role and boundaries is especially important. You are on solid ground in your role as her therapist, working to help her improve her quality of life, and that requires you to refrain from taking an advocacy role in her complaint.

Third, providing an opinion in a legal case requires special training and expertise which is usually obtained after licensure. Individuals who work with the legal system in this way are functioning in the role of evaluator, with the goal of forming an objective opinion, rather than therapist, with the goal of understanding the client’s point of view. It is unlikely that you have sufficient information to determine a causal relationship between your client’s symptoms and her employer’s actions, and you are have entered a therapeutic rather than an evaluative relationship with your client.

I hope this expands your understanding of the complexity of client requests for advocacy. Please email me with comments, questions, or suggestions for future blog topics.

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.

Having Difficult Conversations with Clients

Mother and daughter having an argumentI have a client who has been 10-15 minutes late to every session since we started meeting three months ago.  My supervisor says I need to talk with her about this, but I’m afraid she might stop therapy if I confront her.  Is it possible to continue seeing her in therapy without talking about why she’s late?

I sometimes say to my supervisees and people I am training that as mental health practitioners we are in the business of having difficult conversations.  Growing into the role of clinician means developing skills to talk about issues and areas of conflict in a way that is different than usual social conversations.  I’ll discuss first some of the steps that can help us in having these conversations, then address the specific situation you describe.

Each of us comes into the clinical role with interpersonal skills that are familiar and comfortable, and these familiar strategies involve avoiding some type of discomfort.  As we work with different kinds of clients, we find that these interpersonal skills are helpful in some of the situations we face but not in others.  We also face situations with supervisors, peers, and colleagues that may challenge our familiar strategies for coping with conflict or distress.  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.

In working toward greater interpersonal flexibility, it will be helpful to take some time to reflect on the situation and your emotional responses to it.  Supervision and personal therapy are good resources to use in developing greater self-awareness.  Some steps to consider are to identify 1) the specific nature of the conflict or discomfort you feel, 2) the benefits and limitations of your familiar strategy for managing this type of conflict or discomfort, 3) the fears or worries that arise when you consider handling the situation in a different way, and 4) a small step you could take to expand your skills.  Remember that change usually happens in small steps, so think about developing your interpersonal skills incrementally rather than pressuring yourself to do something dramatically different.

Applying these steps to the specific situation you mention, we start with the nature of the conflict.  It seems your supervisor is suggesting something that you perceive as confrontational, but it isn’t clear whether you perceive the client’s lateness to be a problem and why discussing it would become adversarial.  A starting point would be to explore more of your own response to the client being late and the potential meaning it might have.  This would be something to discuss in supervision as well.  It seems that your familiar strategy with managing this type of conflict is to avoid discussing it directly, so the next step would be to consider the positive and negative results of this type of avoidance in other situations in your life.  It may be that this was the most effective way to respond in your personal relationships, but remember that your job as a clinician is to help your client face and resolve the issues that are interfering with her life.  A limitation of relying solely on avoidance of potential conflict is that your client will not have an opportunity to gain insight into a pattern that may contribute to her difficulties outside of therapy.

A third step to consider is the nature of fears and worries you have about responding differently to this situation.  You express a fear that your client will stop therapy if you discuss her lateness.  This seems to reflect an assumption that she will feel judged or criticized by you and that your therapeutic alliance isn’t strong enough for a conversation about something that affects your work together.  Consider approaching the conversation with curiosity rather than judgment.  You can talk about the issue without requiring that she begin coming on time.  A small step you could take toward handling this situation differently would be to say something like “I notice that you usually come a bit later than our scheduled time and I wonder if there is anything about that you’d like to discuss.”  The client may simply say “no” and move on to another topic, but taking this step moves you into an area that has previously been fearful for you.  You can then look at the meaning of your client’s pattern and additional ways you might discuss it with her.

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

Education as a Therapeutic Intervention

I’ve been seeing a client for about six months, and she recently told me about witnessing domestic violence between her parents when she was young. I used to volunteer at a DV family shelter, so I have a lot of information about how she may have been affected by this. Is it appropriate for me to share what I know as part of her therapy?counseling

This is a good question and brings up a common situation in therapy. You have information that may be useful for the client in understanding and resolving the difficulties that led her to seek therapy, and you are wise to think through the decision to take an educational role. I will share some of my thoughts about the factors to consider in deciding how and when to bring educational information into therapy.

First, I would affirm your sense that providing education can be a useful therapeutic intervention. As mental health professionals, we have knowledge about trauma, relationships, communication, human development, family dynamics, and many other topics that are relevant to our clients’ concerns. This particular client has introduced the topic of domestic violence, and it could be empowering for her to gain knowledge that she can apply to her life.

As you consider talking with your client about the impact of witnessing domestic violence as a child, pay particular attention to the timing of her decision to share this with you and to your countertransference feelings in learning this new detail of her history. She chose to wait six months before telling you about this powerful and traumatic experience, so this means she has been waiting to feel a sufficient level of trust before disclosing this to you. Think about what it means for her to have chosen this moment in the therapy to share the domestic violence and reflect on what she wants and needs from you in response. Notice how you felt when she told you and what you feel as you anticipate giving her educational information. There may be an intense emotion you are avoiding or attempting to modify by introducing psychoeducation, especially if it represents a shift from your usual therapeutic style. Consider the possibility that your client will benefit from education about the impact of domestic violence at a later time in the therapy after you and she have talked about the meaning and feelings she has about telling you now.

Another factor to consider in your decision is your client’s culture and what this means for her expectations of you and the therapy. She may view you as an expert who has knowledge that she is lacking, and it may be more therapeutic for you to work on developing a more collaborative alliance before you adopt an educational role. Alternatively, it is possible that conforming to her expectations of your role may help her to feel more safe and trusting. Reflection on the therapeutic process so far and consultation with your supervisor will help you to sort out the cross-cultural implications of sharing your knowledge about this topic. If your client comes from a different cultural community than you, also give thought to her cultural values and norms for family relationships and the presence of physical violence in the home. Providing education requires sensitivity to cultural differences and to her current relationship with the cultural values of her childhood.

Last, I would recommend thinking about your client’s general description of her relationship with her parents and how your use of education may provide a different experience for her. If she experienced her parents as unavailable and preoccupied, you will provide a different experience by being engaged and attuned to her needs and questions. If she experienced her parents as intrusive and acting on their own agenda, it will be helpful to introduce your ideas tentatively and ask for her responses and thoughts about the information you provide.

I hope you found this blog post helpful in considering the use of psychoeducation in therapy. Please email me with comments, questions, or suggestions for future blog topics.

Legal and Ethical Decisions

imgresI passed my licensing exam a few weeks ago and am opening a private practice. I understand I now have to attend continuing education or training in law and ethics during every two-year renewal cycle. My practice will be pretty simple, and I don’t expect any legal issues to arise. I’ve always been an ethical person, so I also don’t foresee any problems there either. What is the reason for the requirement for all licensed practitioners?  

It is common for practitioners to think this requirement is unnecessary and burdensome and for newly licensed therapists to under-estimate the likelihood of a legal or ethical issue arising in their practices. I can’t explain the reasoning of the licensing boards, but I will give you my thinking on ways clinicians can maintain ongoing awareness of legal and ethical issues.

First, it is important to stay current on legal and ethical standards. You studied this extensively to pass your licensing exam, but you will need to keep up to date on new legislation that affects clinical practice as well as case law and changes in regulations. In addition to continuing education, you can make sure you are working with current information by joining your local, state, and national professional associations and following the updates they distribute to members. New laws and regulations are sometimes confusing, and it may be helpful to review a few different sources to make sure you are clear about your legal and ethical obligations.

Second, check your information when you need to make a decision. This is especially important when you are faced with a new or unfamiliar situation, but it is a good idea in general. Often the general guideline you hold in mind is one that represents a combination of interpreting an original source like your professional ethics code, remembering what your teachers and supervisors told you, and making your own internal judgment based on common sense. All of these sources contribute to ethical decision making, but over time your understanding may become more vague and shift in the direction of what you feel or assume rather than what is stated in the applicable law or ethical principle. Reviewing the primary source or at least a summary by an expert can correct for the changes that take place in memory and judgment over time.

Third, notice any discomfort you feel regarding issues like child abuse reporting, billing practices, dual relationships, and other common situations of legal and ethical importance. Just as your countertransference feelings can alert you to a clinical issue that needs attention, they can also alert you to an issue you are overlooking or stretching beyond the limits of ethical practice. If you find yourself justifying a decision, feeling defensive, or discounting a sense of unease, pause to examine the issue and your decision. Your discomfort may be a sign that you are making an unsound choice.

Last, seek consultation from peers or an expert consultant. It is helpful to have a regular schedule of consultation on a weekly or monthly basis, but if that isn’t possible, identify someone you can talk with as needed. If you are facing a decision or dilemma and are reluctant to share it in consultation, that is a red flag that your decision may not be in compliance with legal and ethical standards. It is better to recognize and correct an error than to continue on a path of poor decision making that may result in a larger problem in the future.

I hope you find this helpful in increasing your understanding of legal and ethical dilemmas and ways to insure that your practice remains fully compliant with regulations. Please email me with comments, questions, or suggestions for future blog topics.

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.

Clinical Issues Related to Money

LGBT therapyMy internship is in an agency that charges sliding scale fees. One of my clients hasn’t paid for the last two sessions, saying he forgot his check both times. I know he can afford it because he just came back from a big vacation to Hawaii. How can I bring this up with him and get him to pay on time?

This is a difficult clinical issue, and it’s a good experience to have during your training. If you plan to work in a private practice after licensure, you will find that the meaning and emotions associated with client payment and fees become more complicated when it represents your income and livelihood. Having this experience while you are in training and not dependent on the fees for income allows you to come to a better understanding of the issues involved for you as well as your clients.

I recommend that you approach the exploration of money and fees by reflecting first on the meaning and emotions that are present for you both personally and professionally. Often money is a way of expressing and experiencing value or validation, and it may be used as a tool to exert interpersonal power. Feelings related to self-worth are often associated with the exchange of money in a relationship. These may include entitlement, comfort, envy, shame, deprivation, and pride. Think about the role that money plays in your family relationships and the meaning of money in your cultural community. You may become aware of implicit messages like “it’s not polite to talk about money,” “you have to fight for everything you get,” “you’re only worth what people give you,” or “if you work hard enough you’ll get what you deserve.”

In addition to your personal and cultural history with money, your current status as a therapist in training includes complex relationships with money. You may have taken on significant student loan debt or received support from a partner or family member. You are probably working as a volunteer or receiving a small salary while you are accumulating hours toward licensure, and you may be working another job in or outside the mental health field to pay your expenses. All of these factors will contribute to the feelings that arise in you when your clients pay or don’t pay their assigned fees. These will become heightened when you are in a private practice and your client fees are a source of income.

Once you have become more clear about how money impacts you in your clinical work, you can move to reflecting on the meaning of money for your client. Some of the things to consider are his early family experiences related to money, value, and power; cultural messages related to money and gender, since there may be different expectations for men and women; the meaning it has for him to seek services at an agency that offers a sliding scale; and the emotions associated with his financial choices. Think about conversations and interactions you have had in setting his fee, in sessions when he brings payment and when he doesn’t, and when he tells you about purchases or expenses like his recent vacation.

Your understanding of how you and your client think and feel about money will help you begin to identify the relational and cross-cultural dynamics in this therapy relationship and specifically in his recent lack of payment. A few possibilities to consider are: your client feels shamed by requesting a sliding scale fee and manages his shame by withholding payment; you are reluctant to discuss money openly and have had difficulty setting an appropriate fee and clear expectations about payment; your client devalues his emotions and needs for nurturing leading him to forget payment for a service that involves both emotions and needs for nurturing; your client associates masculinity with interpersonal power and is attempting to balance the power differential. What is important in your examination is to consider the contribution that you and the client are each making to this current conflict which will help you identify what you need to do internally and interpersonally to address your client’s lack of payment.

It may be helpful to use some of the guidance in a prior blog post about client attendance to identify a therapeutic response to your client forgetting his payment. Attendance and payment are two therapeutic frame issues that are often avenues for clients to repeat problematic relational patterns, especially those they aren’t able to articulate directly.

I hope you are able to use these suggestions in understanding clinical issues related to money. Please email me with comments, questions, or suggestions for future blog topics.

Managing Silence

LGBT therapyI have a client who has a hard time talking in our therapy sessions. I want him to benefit from therapy so I prepare for the session by having topics for us to talk about. This has been going on for several months now, and I’m beginning to wonder if there’s a different way to handle this situation.

This is a common question for therapists in training. Since the nature of our work is listening and talking, we tend to feel uncomfortable when the back-and-forth flow of our interactions with clients is interrupted by silence. One aspect of professional growth as a therapist, though, is becoming comfortable with therapeutic interactions that are different from social interactions we have with friends, family and co-workers.

When I am working with a client who doesn’t initiate conversation or falls into silence, I usually respond first by simply sitting quietly myself. Often the client will then continue with the previous line of thought or bring up a new issue that we can explore together. In the beginning of therapy, I don’t let the silence continue for more than 20 or 30 seconds especially if the client seems uncomfortable, but that is often enough time for the client to guide the direction of our conversation.

If I do choose to break the silence, I ask an open-ended question rather than bringing up a specific topic. Examples are “is there more you’d like to say about that?” or “what’s on your mind?”. If I notice something in the client’s body language, I might say “it looks like you’re feeling sad about that” or “maybe it’s hard to realize how much pain you’re in.” If you use this type of question or statement, your client will know you’re interested in his inner experience and that he sets the direction of the therapy. Usually he will feel encouraged to continue exploring the thoughts and feelings related to the current issue or to shift to an issue that feels more relevant.

When silence is a recurring part of the therapy and the client doesn’t respond to your open-ended questions or reflective statements, your task becomes one of assessment or conceptualization of the reasons for his behavior. Some possibilities are a lack of familiarity with therapy and self-reflection, social anxiety or skill deficits, and cognitive limitations. Talk with your supervisor about your client’s history, diagnosis and relationship experiences as well as the therapy process and your countertransference responses. This discussion will help you develop an understanding of your client’s experience of the therapy and choose the most therapeutic way to engage him. You may also need support from your supervisor in managing your countertransference with a client who seems passive and disengaged.

When silence is recurring, it is sometimes helpful to provide some education about the therapy process. Clients who are new to therapy may be unsure of what is expected, and clients who have a history of contact with social service systems may have been socialized to take a passive role with professionals. Giving a short description of therapy and your approach and expectations provides guidance in these situations.

Another helpful intervention is to make a process comment or question related to the silence itself. Examples are “what’s it like for you to sit quietly here?” or “it looks like you’re not sure what to say next” or “how would you like me to respond when you’re quiet?”. You may learn that the client has assumptions about your role or your reactions to him that lead to a fruitful discussion between you. For example, the client may express a desire for you to provide an answer to a complicated emotional dilemma or may be worried that you are bored by the circumstances he is describing. In general, process comments and questions serve the purpose of communicating your presence and interest in the client and provide an opportunity to talk directly about obstacles to the client’s engagement.

I hope you found this helpful in managing silence in your therapy sessions. Please email me with comments, questions or suggestions for future blog topics.