Category Archives: Therapeutic Relationship

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.

Nonverbal Cues Related to Culture

nonverbalculturalcluesI recently had a first session with a client who immigrated from India last year. I’m Caucasian and haven’t lived outside the United States. My client didn’t seem as receptive to therapy as most of my other clients, and I assume this has to do with our cultural differences. What can I do to make it easier for her to benefit from therapy?

It is good for you to begin this therapeutic relationship with an awareness that you will need to make some adjustments in your usual therapeutic practices in order for this client to benefit from therapy. When we have significant cultural differences from our clients, it is our clinical responsibility to learn about the implications of these differences for establishing a therapeutic relationship.

The first step I would suggest is to get some education and consultation on your own, with supervisors, professors, and colleagues and by accessing professional publications in print or online. Since there are many cultural groups within India, it will be important to know your client’s geographic, religious, and class identifications. The easiest aspects of this education will be general information about views of health and mental health, symptoms, and treatment. Your client will also be able to tell you about her understanding of these aspects of her culture. Issues and struggles for first generation Indian clients are reflected in movies and books. The movie “Bend It Like Beckham” and the book “Life’s Not All Ha Ha Hee Hee” by Meera Syal are examples.

In general, boundaries within the Indian culture are very different from those in the West. Many generations live together, elders are expected to be cared for, and daughters in law are expected to bear the brunt of the work in traditional homes. Explore your client’s family structure and expectations, including the family members and living arrangement she left in India and whether she lives with family members or has acquaintances in the U.S. Approach these discussions with openness and keep in mind that individuation may not be the goal of therapy for your client. The structure of a family system that fosters both a sense of connection and a sense of individual wellbeing for this client may look different than for your clients who come from traditional Western culture.

The more difficult aspects of your need for education will be learning about the relational expectations of your client’s culture including nonverbal cues (i.e., eye contact and other gestures) and boundaries. It may be helpful to supplement your education about your client’s specific culture by consulting with colleagues and acquaintances who have immigrated from other cultures. They may be able to share their observations about the unspoken practices and expectations of U.S. culture which are outside of your awareness.

Regarding Indian culture specifically, clients are likely to present as cautious, anxious, or even timid with limited eye contact. These nonverbal cues are not a reflection of avoidance or resistance to therapy, but are signs of deference. The client will expect guidance and direct instruction and will feel comfortable knowing that the clinician is the expert. Therapy initially should be somewhat structured and have clear goals.

If your client immigrated in midlife or later, be aware that many older generation Indians are not psychologically educated and as a result present with somatic problems. They may be referred by a physician rather than self-referred. Consider spending time understanding how the somatic issue affects the client’s life and overall sense of wellbeing including how it affects their spiritual practice, diet, and family life.

In addition to education and consultation, your attentiveness to your client in session will give you valuable information. You mention that she didn’t seem as receptive to therapy as other clients, so I recommend giving some thought to what you observed or inferred in her behavior. Notice the nonverbal aspects of her interactions with you, and see if you can match her level of engagement in terms of expressiveness and eye contact. This may increase her comfort by reducing the interactional discrepancies between you. Be attentive to times in the session when she seems more or less comfortable and think about what may have been different in your relational style at those times. Emotions are often communicated through nonverbal gestures as much as or more than our words, so be careful about making interpretations about her emotional state based on your cultural assumptions. Note that the meaning of nonverbal cues is different across cultures; for example, a nod of the head that indicates saying “no” in western culture means “yes” for Indians.

It may also be useful to have some direct discussion with your client about some of the structural aspects of therapy that are unfamiliar to her. Interpersonal boundaries are experienced very differently in different cultures, so the meaning of professional behavior may be different for your client than you intend. Consider telling your client about the meaning of your professional boundaries and the therapeutic frame, acknowledging that these practices may be unfamiliar to her and may even seem odd. Invite your client’s comments and be open to shifting some aspects of your boundaries in minor ways if that will facilitate the development of the therapeutic relationship. For Indian clients, examples of appropriate differences in boundaries are accepting a small gift or a hug offered out of gratitude from the client, joining in the use of humor to bring warmth to the session, and using a double-handed hand shake.

I hope you find these suggestions helpful in understanding the nonverbal aspects of the therapeutic relationship in a cultural context. Please email me with comments, questions, or suggestions for future blog topics.

My colleague, Fenella das Gupta, LMFT, Ph.D. Neuroscience, provided consultation in developing the content of this blog post.  See Fenella’s website at http://www.innermirror.com for more information about her practice.

 

 

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.

Sharing Client Information in a Team

Teachers TalkingI am a counselor at a high school, and the teachers often ask me about my clients’ progress. I know they have good intentions, but I’m uncomfortable answering their questions. How much should I share and how do I explain the reason I can’t answer some of their questions?

This is an example of working in a team with other professionals who have different expectations and requirements regarding confidentiality and privacy of information. Your client work is probably covered by the Health Insurance Portability and Accountability Act (HIPAA), which carries more limitations on sharing information than the regulations applicable to educational information. It is likely that the teachers know you can’t share fully with them, but your role in the school supports the students’ academic success so it is important to find ways to communicate productively with teachers. This requires that you create a collaborative working relationship with the teachers and other staff in the high school. I will recommend several steps you can take to establish yourself as part of a professional team.

One step is to have a short response regarding confidentiality requirements that you can use when a teacher asks you for specific information. An example is “you probably know I can’t share any details about the counseling, but I’d like to work together within the constraints I have to follow.” This establishes the limits of confidentiality while also communicating your desire to collaborate. Remember that teachers are often working in difficult circumstances and may be looking for support. When you can express your understanding of their concern for the students and the challenges they face in the classroom, the teachers will see you as an ally even if you can’t answer their questions. Follow your statement about confidentiality with an acknowledgement of their concern and desire for the student to get the help he/she needs.

Often, the next step will be to open a conversation with the teacher about how the student is doing in class. You might say “has anything happened lately that I should know about?” or “I’m interested in your perspective on how things are going.” The teacher’s question to you about the student’s progress may represent a desire to tell you something about the student’s life or a recent incident in the classroom. This information can be valuable background in your understanding of the student. Your client may present very differently in your counseling sessions than in the classroom or with teachers and peers. HIPAA limits the information you can share about treatment, but it doesn’t limit what you can hear from others.

You may also want to schedule a more formal conversation with one or more of your student’s teachers to ask specific questions that will aid in your assessment and treatment planning. It is wise to prepare a list of questions in advance so you can be focused in your discussion with the teacher and insure that you get the information you need. As treatment progresses, check in with the teachers periodically to get updates on the student’s progress in the classroom both academically and behaviorally. This information will enhance your review of treatment goals and help you to shape the direction of treatment.

Last, there may be times when you feel it would be helpful for you to share your impressions of the student with one or more teachers. You might have suggestions that the teacher could implement in the classroom or you might be able to provide an explanation for some of the student’s behavior that is otherwise confusing or creates conflict. If this is the case, you will need to have written permission from the parents and/or your client. Generally, parental consent is required for sharing treatment information for children under 18, but some states allow a minor to consent to treatment which would require that you get the student’s permission to share information. Even if it isn’t required by law, it is clinically sound to talk with the student about what you plan to share with the teachers and the reasons you think it would be helpful.

I hope you find these suggestions helpful in working as part of a team. Please email me with comments, questions, or suggestions for future blog topics.

Impact of Therapist’s Personal History

I have been assigned to see a 12-year-old girl whose father died a year ago, and her mom and teachers report she seems depressed.  My mother died when I was 14, so I have a good idea of what she’s going through and think I’d be a good therapist for her.  My supervisor said she’s concerned that this case could be too close to my own experience, but I think it’s good that I know what’s it’s like to lose a parent. 

This situation illustrates how our personal history informs and affects our work with clients. We have similarities and differences with each client, but the balance between the two is different with each one. When you are working with someone who seems very much like you or with whom you are heavily identified, it is important to rebalance your attention by being aware of the ways in which your experiences diverge. Similarly, when you are struck with how different your life is or has been from your client’s, you need to look for commonality.

In this example, you and your client share the experience of losing a parent in your early adolescence. It is understandable that this common experience takes the foreground of your attention when you think about beginning to work with her. However, there are some important differences that are apparent even in the preliminary information you have: the death of a father compared to the death of a mother and being 12 or 14. Undoubtedly, there are other differences between you and your client in your specific family relationships, cultural background and identities, other developmental events, and personality characteristics. I’ll discuss three strategies to maintain your attention on your client’s needs while minimizing the potential interference of your experience of parental loss.

First, pay careful attention to your tendency to make assumptions in this case. It will be easy to believe that you understand your client’s thoughts and feelings without your usual level of curiosity and information gathering. Err on the side of caution by asking questions or being tentative in your reflections with statements like “are you saying you feel lost?” or “it sounds like you might be angry.” Remember that it is your job to help her on her own journey of grief and loss and that hers will inevitably differ from yours.  She may feel sad in a situation in which you felt angry, or she may feel burdened rather than afraid.

Second, be especially careful when you think about self-disclosure. You will probably think of several examples from your own life and experience that are related to your client’s pain and grief. It may seem as though sharing your experiences will let your client know you understand her and will give her a sense of hope for her own healing. However, self-disclosure always has a risk of diverting the client’s attention from her own experience to yours, especially when she hasn’t asked about your life. In this case, it may be appropriate to share minimal information with your client if she asks. For example, if she asks whether anyone close to you has died, you could say “yes, that did happen when I was a teenager” and you might tell her that your mother died if she asks for any other details. Then I would turn attention back to her experience and how she feels knowing this about you.

Third, a case in which your personal history is similar to your client’s makes supervision extremely important. You may feel that your knowledge of your client’s experience means you don’t need as much guidance from your supervisor as with your other cases. However, as noted above, there is a potential for your clinical judgment to be clouded by this similarity, so discussing this client and her progress in treatment is essential. Your supervisor’s concern suggests that she is aware of this difficulty and will be able to support you in thinking through your emotional responses to the client. You may also find it helpful to talk with your personal therapist about the emotions and memories that arise for you in working with this young woman. You may find that your grief and loss emerge in a new way as you face the issues as a therapist.

I hope you find this helpful in managing the impact of your personal history in your clients’ treatment.

Using Therapist Emotions to Understand the Client

new2I have been seeing a 35-year-old woman for about six months at my practicum site. I left the last session feeling at a loss about how to help her. She was sexually abused as a child, and I’m afraid I don’t have enough experience to be an effective therapist for her. How can I decide whether to refer her to a more experienced clinician or get more training myself?

It sounds like you had a strong emotional response to the recent session with this client that brought up questions for you about your effectiveness. Before making a decision to do something different in the treatment, I would suggest reflecting on your emotions as a way to understand the client in a deeper way. Your feelings of inadequacy and self-doubt may reveal something important about the client’s experience in relationships and her view of herself.

The first step I recommend is to take some time to identify your emotional response to the client more completely. In addition to your own reflection, you may find it helpful to talk about this with your supervisor, therapist, and colleagues. When we feel uncomfortable emotions during and after a session, it is tempting to ignore or avoid them and to take action to reduce our discomfort. Instead, take time to go more deeply into your emotions by identifying the thoughts, images, and physical sensations that accompany the emotion. If you have a mindfulness practice, use that practice to engage with your emotional experience without judgment.

After you have a more complete understanding of your emotional response in this recent session, review what you know about your client’s history, developmental trauma and losses including the sexual abuse, and her current relationship patterns. All of these experiences may be relevant to the emotion that has been stimulated in you. Think about the connections you can make between your emotions and the client’s experience. It is likely that your emotions mirror a painful experience from her past and present relationships. Ask yourself when your client has felt inadequate and ineffective with others. She may or may not have been able to talk directly about these feelings, so you may need to make inferences about feelings she has kept outside of her awareness and aren’t accessible verbally. Supervision is helpful in identifying links between your emotions and the client’s.

Last, identify ways you can respond therapeutically to your client in the face of your feelings of inadequacy. It will help to think about capacities she needs to develop or how she could manage her feelings of inadequacy with greater strength and confidence. An example might be for you to say “it may feel daunting to face the impact of your past but I think our work together can result in you developing different ways of handling the triggers when they arise” or “I wonder if you sometimes feel like giving up and it’s hard to believe things can get better.” If your client is directly questioning your capacity to help her, you can acknowledge her worry along with your commitment with a statement like “you may worry whether your difficulties are more than I can handle and I think that’s an important issue for us to talk about together.”

As you respond therapeutically to the client using your understanding of your emotions as a connection to her experience, you will notice changes in her way of relating to you and changes in your emotional response to her. She may begin talking more directly about her feelings of inadequacy, she may deepen her engagement with the therapy and the pain of her abuse, or you may notice that you’re feeling more sadness about the impact of her trauma rather than worry about helping her. All of these changes are indications that you have used your emotions to further the therapeutic process. If your questions about the effectiveness of the therapy continue, talk further with your supervisor about whether a different therapeutic approach or a referral to additional services would be indicated.

I hope you find this helpful in using your emotional responses to understand your clients. 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.

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.

Client Reactions to Therapist Absence

portrait-female-therapist-office-her-patient-44629457I took some time off for the holidays, and my clients seem to be reacting to this. A few have cancelled sessions, a few have arrived late when they’re usually on time, and one said he thinks it’s time to stop therapy even though there is clearly more to do. How can I bring up the possibility that they’re upset about my being away without making the therapy all about me?

I agree with your assessment that your clients are having reactions to your absence and that it’s desirable to encourage them to talk about their feelings instead of demonstrating them in action. I’ll share some ideas about ways you can initiate this discussion and some of the reasons that clients may be reluctant to acknowledge and talk about their feelings.

Before talking with your clients about their reactions to your absence, notice and work to understand your countertransference feelings about this. You may feel annoyed, afraid, or guilty, reflected in thoughts like “don’t they appreciate how hard I work?” or “what if I lose clients every time I’m gone?” or “I guess I shouldn’t take so much time off next year.” These countertransference feelings can interfere with your ability to talk with the clients about their feelings, so wait to do so until you have understood and gotten support to process your annoyance, fear, guilt, or other feelings.

Your clients will probably have difficulty acknowledging to themselves and to you that they were affected by your absence. Our society generally values independence and autonomy over connection and interdependency, and it is unusual and unfamiliar for a professional to acknowledge the impact of a break in the relationship. Other health care and social service providers generally don’t acknowledge that the client may be affected by the provider’s absence or lack of availability. In addition, some of your clients probably coped with difficulties in their families of origin by denying their need for reliability and consistency and by shutting off their awareness of feelings of dependency and accompanying anger when their relational needs weren’t met.

Despite your clients’ reluctance and lack of practice, there are ways you can introduce the topic that will make it easier for them to engage in exploring their reactions to your time away. First, notice for yourself how the client’s behavior is different and mention this with an attitude of curiosity. For example, you might say “I notice that you were late for both of our sessions since I returned from my holiday break. That’s unusual for you, and I wonder if it might be related to the fact I was gone for a couple weeks.” This opening statement doesn’t make any judgment or assumption but simply tracks the change in behavior following your absence.

Second, it may help to make a statement that normalizes the fact that clients are affected by a break in the flow of therapy and that these emotions can be at odds with their rational or intellectual understanding of the reasons for the break. A sample statement would be “Many clients find they have feelings about missing a week or two of therapy, even though they understand the reason for my being away. Could that be the case for you?” With a client who is especially reluctant to look at her feelings about the therapy relationship, you might also talk about why this could be important to look at in light of her presenting issue or the focus of treatment. An example is “It may seem odd for me to ask about your feelings related to my being away for two weeks, but we’ve been talking about how you feel when your husband is on a business trip. It might help us understand that better if we also look at your feelings when I’m away.” This gives the client an explanation for why you think it is important to explore this and how it could help her in the area of concern to her. In some cases, it can be helpful to make a statement about the early experiences and coping strategies that interfere with acknowledging the impact of your absence by saying something like “We’ve been discussing how hard it was for you to come home to an empty house when both of your parents were working, and some of those feelings may have returned when I was away. You’ve worked hard to not let yourself know how painful that was, and it may be hard to recognize how you felt while I was gone.”

Last, let the client know that you’ll continue to notice and bring up the question of her feelings when you are away in the future. Sometimes the repetition over time helps the client to develop more awareness of the underlying emotions that aren’t accessible in your initial discussion.

I hope you are able to use these suggestions when working with client reactions to your absences. Please email me with comments, questions, or suggestions for future blog topics.