Category Archives: Professional Identity

Managing Silence

I 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.

Using Supervision

I’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

I’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. You can also go to services that provide medical marijuana cards in Clearwater, FL if you want access to medical marijuana to help alleviate stress.

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

I’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

My 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.

Adjusting to Different Clinical Roles

I have worked as a crisis hotline counselor and a client advocate in a domestic violence support agency. Now I am starting my first practicum placement as a graduate student and will be doing psychotherapy with women and children who have experienced domestic violence. How will this be different than the work I have done in the past?

Your question is a common one, since many people work in paid or volunteer positions in a social service agency or helping profession before entering graduate school. There are both similarities and differences between your role as a counselor and advocate and your role as a psychotherapist.

Let’s begin with what is similar in those roles. As a psychotherapist, you will continue to be supportive of your clients and to prioritize your clients’ safety and well-being. You will also be personally touched and emotionally engaged by your clients. Your relationship with them and belief in their strengths will continue to be an importance source of healing in your clients’ growth and therapeutic progress. Many of the qualities that have made you a successful and committed counselor and advocate will continue to serve you well as a psychotherapist.

There are important differences in these roles too, as your question suggests. One of these is related to professional boundaries. As a psychotherapist, you will see clients at a specified time and place, usually once a week for a 50-minute session. You will limit your self-disclosure of personal information about your life or experiences that may be similar to your clients’ lives and experiences. You will also keep confidentiality of all information shared with you, with exceptions for safety of your client or others, unless your client gives written permission for you to share information. As a psychotherapist, you are bound by the legal and ethical requirements of the profession which are more stringent than the requirements for paraprofessional counselors and advocates.

A second difference in these roles is that a psychotherapist is less involved in taking direct action for or on behalf of the client, with the exception of situations involving imminent danger. In psychotherapy, you will be facilitating and supporting your client taking action and examining the obstacles she faces both internally and externally. A psychotherapist provides information to clients about resources that may be helpful, for housing or employment or financial assistance. Generally, a psychotherapist does not contact the resource directly, make an appointment for the client, provide transportation or assist the client in completing an application as a client advocate often does. If you believe it is in your client’s interest for you to do take direct action in these ways, I recommend talking with your supervisor to insure that is in the client’s best interest.

A third difference in the role of psychotherapist and the role of counselor or advocate is that psychotherapy includes a focus on building skills and capacities that reduce future risk or vulnerability. When the client enters psychotherapy in crisis, there is an initial focus on safety and stability of the immediate situation. Even in a period of crisis, however, there is an emphasis on developing and using coping skills. As the client’s situation becomes more stable, the therapy process moves toward exploration of more longstanding patterns that contributed to the crisis. Most psychotherapists have a goal of assisting the client to understand and shift these longstanding patterns. Crisis counseling and client advocacy generally ends when the immediate crisis is resolved and the client has reached stability.

I hope you find this explanation helpful in beginning to work as a psychotherapist. Please email me with comments, questions or suggestions for future blog topics.

Concerns About Diagnosis

I just started my first practicum placement and I am supposed to give a diagnosis to each client. I’m worried that I don’t have enough experience to make a diagnosis and that my diagnosis might create problems for my clients later on, if they or someone else sees their records.

Your concerns are common among students in practicum training. It often feels daunting to take on the role of assigning a diagnosis to your client. You may be uncomfortable with the gravity of this professional responsibility, and you may have questions about the validity of diagnostic labels that don’t include consideration of the client’s strengths and capacities. Many clinicians are aware of the potential use of diagnosis in pathologizing or stigmatizing individuals who are vulnerable to being treated with discrimination and bias. I will share several steps you can take to maximize the likelihood that your diagnostic process will be beneficial to the client rather than harmful.

The first step is to be thorough and comprehensive in gathering relevant information and considering alternative diagnoses that fit your client’s symptoms and presenting problem. If you are required to assign a preliminary diagnosis after the first session, make sure to re-evaluate the diagnosis after you have completed a full assessment. Be careful of the tendency to jump quickly to a diagnosis that you consider to be non stigmatizing, such as an adjustment disorder, that may not be an accurate reflection of the full clinical picture. I recommend reading the DSM diagnostic criteria for three to five alternative diagnoses as well as the information about differential diagnosis considerations for these diagnoses. Once you have reached a conclusion about the client’s diagnosis, review this with your supervisor to insure that your final diagnosis is the most accurate and appropriate for the client’s presentation. With complex clinical presentations, you may have a primary diagnosis and one or more secondary diagnoses.

A second step to take regarding diagnosis is to include a description of the client’s initial symptoms and presenting issues in the client record, in addition to the diagnosis itself. Usually you will complete an initial assessment which should contain the client’s report and your observations that support the diagnosis. Your progress notes should track the client’s thoughts, affective states and behavior related to the diagnosis and any changes to the diagnosis resulting from new information or progress. This insures that anyone viewing the client’s record at a later date will have a more complete picture of the client’s symptoms and functioning than is conveyed by the diagnosis alone.

A third step to maximize the benefit to the diagnostic process is to discuss the diagnosis with the client. Clinicians are often reluctant to do this because of the worries mentioned in your question. However, a collaborative discussion often results in relief and clarity for the client who may feel confusion, self-criticism and shame about her condition. I generally enter these discussions by summarizing what the client has told me and my observations, then sharing the diagnosis that fits the clinical picture. An example is ” You’ve told me that you don’t enjoy anything, that your sleep and appetite are disrupted and that you feel really down. I’ve noticed that you are pretty harsh in judging yourself and your energy seems low. All of these things are signs of depression, and I believe the diagnosis of major depressive disorder fits what you’re experiencing now.” I then ask the client what her thoughts and reactions are to hearing this and engage in a discussion of any questions or concerns she may have. If there is any indication at that time or later in treatment that the client may want her record to be shared with another party, you can remind her that the diagnosis is part of the record and talk about the implications that may have.

I hope you find these suggestions helpful in making diagnoses with more confidence. Please email me with comments, questions or suggestions for future blog topics.

Intersection of Personal and Professional Lives

My 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

One 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 don’t 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

I 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.

Diane A Suffridge, Ph.D

Consultant, training and author in behavioral health.