Category Archives: Therapeutic Relationship

Generational Differences in Therapy

I have been working for the past year with a 78-year-old woman who has a moderate level of depression. She has a limited income, lives alone and has very little contact with other people. I have suggested several resources, including some that are online, that she could use to reduce her isolation. She agrees with me in session but doesn’t follow through. I’m starting to feel both frustrated and discouraged about being able to help her. I talked with my supervisor about ending the therapy but she told me to keep trying.

This question highlights the way in which generational differences can enter into therapy. When we work with individuals who are separated by one or two generations from us, we need to be aware of the age-related psychological issues facing our clients as well as the cultural differences that exist between us.

Starting with the psychological issues facing your client, she may be facing a high degree of loss and grief related to each of the risk factors you mention: limited income, living alone and lacking contact with others. Find out whether there were significant changes in your client’s life in the two to five years before she became depressed. If so, she may still be grieving the loss of income and financial status, the death of a spouse or close friends, and/or facing health problems that reduce her mobility. Even if these risk factors were present before she became depressed, she may have become less able to stretch her budget, participate in social activities or function independently as she ages. If you haven’t given her an opportunity to talk about feelings of loss or offered your empathy for her grief, I would suggest doing so. She will need to feel understood emotionally before she is ready to follow your suggestions about other resources that might help to improve her depression.

Another set of psychological issues arises in the fact that your relationship with your client mirrors a parent/child or grandparent/grandchild relationship for both of you. On your side, your frustration and discouragement probably include feelings you have about your parents or grandparents who faced or are facing some of the same issues as your client. Talk with your supervisor and therapist about these personal relationships to gain a better understanding of your countertransference. On your client’s side, working with a therapist who is young enough to be her child or grandchild exacerbates the sense of invisibility and devaluation she may feel as an older person in a culture that equates youth with worth. Your suggestions may feel condescending or invalidating if you are assuming you know more than she does about her experience and needs.

Moving to a cultural perspective, your client’s values and world view are different from yours due to the generational differences between you. Your client was a child during the Great Depression and World War II, came of age during a time of nationwide financial expansion, and experienced the civil rights, anti-Vietnam War and feminist movements as a young adult. Her experience of technology has spanned the period from radio and black-and-white television to internet and smart phones. It is a mistake to assume that she is comfortable, either emotionally or technologically, using online resources to reduce her social isolation. Her agreement with your suggestions may reflect a deferential attitude toward professionals who hold positions of authority, based in the values of her generation. Viewing your relationship as a cross-cultural one may help you to bridge your differences and approach your client with curiosity and interest.

I hope you find these suggestions helpful in working across generational differences in therapy. Please email me with comments, questions or suggestions for future blog topics.

What to do with Things that Can’t be Changed

I’m working with a 20-year-old woman who has a bad relationship with her parents. I’ve been encouraging her to use better communication techniques with them but their conversations always end with the parents yelling and my client feeling blamed. She’s asked them to go to family therapy with her but they refuse. How can I help her when her parents won’t change?

As therapists, we focus on the potential for growth and change, and we maintain hope for our clients when they are discouraged. This is an important and effective trait in many clinical situations; however, it is equally important to recognize and help clients deal with circumstances that can’t be changed.

The first step I would recommend for you is to examine your countertransference. Sometimes we develop unrealistic goals with and for our clients because of personal issues and feelings. In this case, I would ask yourself if your relationship with your own parents is related in some way to your feelings about your client’s situation. You may be trying to achieve something that wasn’t possible in your own life or to replicate an aspect of your life that worked well for you. Either way, work to separate your parental relationship from your client’s relationship with her parents.

Another countertransference issue that may be present is related to feeling competent and effective. Therapists in training are often more comfortable when giving advice, teaching a skill, or proving an active intervention. Reflect on how you feel when your client follows your suggestions and reports they don’t work. If it is hard for you to sit with your client’s painful feelings, your definition of therapeutic success may be too restrictive. Talk with your supervisor about what it’s like for you to be less active in session and explore the usefulness of being emotionally attuned and present.

If you are able to sit with your own feelings of discomfort you will be better able to help your client with one of her therapeutic tasks: accepting what cannot be changed. It sounds like you and she have become invested in her parents changing their behavior toward her and that change isn’t possible right now. It will feel painful to both of you to face this, but it seems to be the current reality of her life. Acknowledging this and allowing her to express her anger, fear, helplessness, and loss will be an important therapeutic intervention. It may take time and will be painful but it is in the service of her developmental growth. Accepting the state of her parental relationship will facilitate her ability to focus on other aspects of her life. She is entering adulthood and facing decisions about work, friendships and intimate relationships. If she has put these on hold to resolve things with her parents, it may be time for her to shift her attention and energy.

Paradoxically, you may find that your client reports some improvement in her relationship with her parents as she moves toward acceptance. Sometimes relational conflict is exacerbated by an implicit desire for change that is experienced as an unwanted demand. Your client may have been communicating a more complex message than what you and she worked on with better communication skills. Her acceptance conveys a different message and may lead to a decrease in conflict.

Your question also raises an important issue related to treatment goals. Clients often enter treatment with a goal for change in something that is outside their control. You may have inadvertently agreed to a goal for individual therapy that can’t be achieved in that modality, so consider reviewing your treatment goals with your client. It sounds like a goal related to understanding her feelings about her parents and a goal related to de-escalation and detachment would be more appropriate than a goal about better communication between your client and her parents.

I hope you find this helpful in facing aspects of your clients’ lives that cannot be changed. Please email me with comments, questions or suggestions for future blog topics.

Mandated Treatment

I have been assigned to work with a client who has to attend therapy as part of his probation requirement. How can I build trust with someone who probably doesn’t want to be in treatment?

It is challenging to work with someone who isn’t seeking therapy voluntarily. Therapy is sometimes required as part of probation, a child abuse investigation, or other legal situation. There are complications in developing a therapeutic relationship when treatment is mandated by a third party. This blog contains a few suggestions that will help you work through some of these complications.

First, I recommend that you get clear information at the beginning of treatment about what you will be required to report to the mandating authority. Your client may come with a referral form or blank progress report that will have these instructions, or you may need to ask for his authorization to talk with the mandating authority about their expectations and requirements. If possible, it is best to report general information only, such as dates of attendance, issues discussed and treatment goals. As a therapist, you are not evaluating your client in relation to his legal situation so you cannot advocate for a specific outcome or express an evaluative opinion.

Once you are clear about what the mandating authority requires, you should share this with your client, letting him know what you will share and what you can keep confidential. This conversation is in addition to a discussion of the general limits of confidentiality you have with all clients. By talking openly with him about the reporting requirements, you establish clear and direct communication which is the beginning of a therapeutic relationship.

Second, acknowledge that your client has mixed feelings about being required to attend therapy and talk about the impact the mandate has on his ability to feel open and trusting of you. An example would be “Since coming to therapy is required rather than something you decided on your own, I imagine it will be hard to decide how much you want to talk about with me.” Acknowledging his ambivalence is likely to help him feel more trusting rather than less, and it communicates your ability and willingness to discuss things that are difficult. This should be an ongoing issue for discussion, since he will continue to have questions about trust as the relationship develops.

Third, bring up the possibility that the client may not feel comfortable sharing truthfully with you. He may have other requirements like maintaining sobriety, attending parenting classes, or detaching from conflictual or violent situations and it will be difficult to know whether he is being truthful when he reports complying with those requirements or reaching treatment goals. One way to discuss this is to raise a hypothetical question like “If you had started drinking again, do you think you’d be able to tell me?” In this way, you bring the issue of truthfulness into your relationship without being accusatory. Even if the client assures you he would be able to tell you, raising this question acknowledges the impact of the mandated requirement on his communication and relationship with you. As with the issue of ambivalence, you should raise this periodically as an ongoing issue in the relationship.

I hope you find this helpful in doing therapy with clients whose treatment is mandated. 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.

Unplanned Endings

I have been working with a client for 3 months and I thought therapy was going well. Our last session was two weeks ago and since then, she hasn’t come to sessions and hasn’t responded to my phone calls. I’m confused about why she stopped coming in and don’t know how to find out what happened.

This situation is one of the most distressing circumstances for therapists in field placement training and continues to be challenging for experienced therapists as well. We develop a sense of our relationship with the client based on our shared experience, and it is disorienting when there is a sudden change in the client’s engagement in therapy. Often this change leads to an unplanned ending of the therapy and feelings of loss for the therapist. We usually don’t know exactly what happened and the ambiguity is unsettling. I will outline several factors for you to review in thinking about an unexpected change in the client’s engagement, and I will also suggest things to consider in your response.

When the client stops coming to session and doesn’t respond to your efforts to reach out, it is useful to review your last contact with the client. Maybe she disclosed some aspect of her history for the first time, engaged more deeply with her emotions, acknowledged the importance of therapy as a source of support, or made a plan to take a positive step toward growth and healing. Any of these developments can be a source of anxiety, and the client may need to suspend or end contact to avoid feeling overwhelmed or frightened.

It is also helpful to review the client’s history, particularly regarding early family relationships. She may have experienced repeated abandonment and loss, abuse and exploitation, or feelings of guilt and responsibility. Often the client becomes more worried about repetition of these early experiences, usually outside of awareness, as she engages more deeply in therapy. It seems paradoxical, but the client may feel more frightened in therapy as she becomes more attached.

A third area to examine is the client’s current life. She may be living in circumstances that are disruptive and distracting. Her attention shifts to more compelling priorities rather than her commitment to a weekly therapy session. Examples are volatile partner relationships, financial crises, challenges in parenting, and lack of control in job duties and scheduling. In addition, some clients find it hard to keep regular appointments when their symptoms recur or become more severe. An increase in depression or anxiety, recurrence of a manic or psychotic episode, or a relapse on substances may lead the client to withdraw from support and help when it is most needed.

Once you have considered the factors above, you can develop a preliminary understanding of the meaning of the client’s disengagement and a response that fits your understanding. Your supervisor’s input will be useful in this process both clinically and administratively, since your agency may have requirements regarding frequency of contact for open cases. Supervision is a time to reflect on your own feelings regarding this shift and potential loss. Your response to this situation will reflect your unique pattern of managing loss and rejection as well as specific thoughts and emotions related to your relationship with this particular client. There is a lot to learn about yourself and about the complexity of client engagement in psychotherapy when you face this type of disruption.

In most cases when the client has missed two or more sessions and hasn’t responded to phone calls, it is a good idea to make a final phone call in which you express your understanding that the client may have made a decision to end therapy and give a specified date about a week later that you will close the case if you don’t hear from her. I also recommend sending a written letter which acknowledges the ending, after the specified time period has elapsed. The letter can briefly summarize the issues the client discussed in therapy, describe progress that was made, and provide referrals or offer a return to you or another therapist at the agency in the future. You and your supervisor will decide the appropriateness and specific content of communication by phone and/or letter but generally it is preferable to provide a clear ending.

I hope you find these suggestions helpful in understanding and managing your feelings about unplanned endings. Please email me with comments, questions or suggestions for future blog topics.

Electronic Communication

One of the clients at my field placement has been using email to reschedule appointments and let me know about things she wants to talk about in our next session. This has been fine with me since it’s easier for me to read and answer a quick email than a phone message. However, her emails are getting longer and I don’t want to take the time to read and respond to them between sessions. How can I let her know this without causing a rupture in our relationship?

This is a good example of how communication in the therapeutic relationship can move quickly from simple and straightforward to complex and entangled. This can happen with conventional communication in person and by phone, but there are many more possibilities for complexity with electronic communication.

When communicating with clients by email, you need to be aware of security and privacy as well as clinical issues. Regarding security and privacy, email is not considered a secure form of communication under HIPAA, so you need to inform the client of the risk to her privacy for anything she sends you by email. In the future, you can include this discussion early in treatment, but you now have an opportunity to do so in response to the client’s expansion of her email communication with you. I recommend documenting your conversation about email security in a progress note so it is clear you have informed the client of the risk to her privacy and that she is making an informed choice to communicate by email.

There are also clinical issues related to email communication with clients, as you have found. Email is best used only for scheduling appointments. Some clients may also send information to you that is related to their treatment, in order to talk about it in the next session. Examples are a client forwarding an email from a family member or partner with whom she is in conflict, a parent forwarding information from a teacher about your child client, or a client wanting to tell you about something that happened or an insight she had during the week. It is safest to either let the client know you won’t respond directly to emails containing clinical information or to limit your response to these email to a simple acknowledgement and invitation to talk more in person in the next session. I recommend printing email exchanges with the client that contain clinical information and including them in the client’s record. Check with your supervisor about the policy at your field placement site.

At this point, you need to talk with your client about both security and clinical issues related to email. The conversation is likely to be less disruptive to the relationship if you begin by acknowledging your oversight in not talking about this sooner. You should let the client know about the risk to her privacy with email communication and ask if she wants to continue using email despite the risk. You can then move to a discussion of your preferences about the issues discussed by email, preferably by again acknowledging your oversight in not discussing it sooner. A straightforward description of the limits of email would be “I prefer to use email only for scheduling purposes and to save our discussion of other issues for when we meet in person. If there is something you want to let me know about, you can certainly send me that to me by email but I will wait to comment on it until we see each other.” You then can invite the client’s thoughts and reactions, again acknowledging that this is a change on your part if the client expresses confusion or worry about having done something wrong. This will relieve you of the burden of responding between sessions and will redirect the client’s communication to your sessions where you can talk about the issues in depth.

I hope you found this helpful in dealing with electronic communication. Please email me with comments, questions or suggestions for future blog topics.

Clinical Approach to Case Management

I have a part-time job as a case manager at a homeless shelter while I am gaining hours toward licensure. I don’t know what to do when my clients don’t follow through on the referrals and other support I give them. Since I’m not their therapist, I can’t talk to them as I do with my therapy clients to understand what’s getting in the way.

It is true that your relationships with clients as a case manager are different from the relationships you have as a therapist. However, some of the interventions you use as a therapist are valuable in case management, and your clinical knowledge is a valuable tool for understanding the reasons for your clients’ lack of follow through.

Motivational Interviewing is a useful approach when clients show ambivalence about getting help or about changing aspects of their lives that are problematic (www.motivationalinterview.org). Using this as the basis for your work helps you establish a collaborative relationship and puts the client at the center of the decision making about change. Identifying and resolving ambivalence is a central feature. Talking with the client in a way that is consistent with Motivational Interviewing may help you to shift from a position of responsibility to help the client use your referrals and support to a position of supporting the client to identify her/his goals and the steps s/he is ready to take.

Your experience as a therapist may also be helpful in understanding the basis for the client not following through with your referrals or suggestions. You can develop a conceptualization of the client’s difficulties and strengths as you would do with a therapy client, based on the information you have about her/his history and diagnosis. As a case manager, you are probably working with more limited information than you have in psychotherapy, but you may have enough information to make some inferences about the underlying reasons for the client’s lack of follow through. For example, clients with a history of trauma may be sensitive to feeling coerced, clients who have a psychotic disorder diagnosis may misinterpret your suggestions or be confused about the information you give them, and clients who have lived on the streets for many years may need the sense of community and self-identity of homelessness to feel safe.

Another application of your clinical skill is in identifying the client’s interpersonal style with you as a way to understand her/his internal template for relationships. This will help you develop ways to work with the client based on her/his assumptions and fears about relating to others. For example, if you feel intimidated by the client you can infer that s/he organizes relationships around issues of power with one person holding power and the other being powerless. This would indicate that interacting with the client in an authoritative but non-punitive way is likely to be more productive than either attempting to take charge or responding passively. A statement reflecting this middle ground would be “I have some ideas that might be helpful to you, but it’s hard for me to sit here with you when you’re yelling at me. Would you be willing to stop for a moment and see if any of these resources are relevant for you?” Using your clinical skill in this way will result in subtle but important differences in how you talk with different clients and is likely to be more effective in helping the clients use the resources you have to offer.

I hope you are able to use these suggestions in bringing your clinical knowledge into case management work. Please email me with comments, questions or suggestions for future blog topics.

Sequential Treatment

Two women talking I just started in a new practicum training placement and one of my new clients has seen three different therapists at this agency in the last five years. I’m not sure how much of her file to read before I meet her and how to continue the work she started with her previous therapist who left last month. They agreed on new goals before that therapist left and I don’t know how to help the client meet those goals.

This is a common situation in training agencies, since many individuals who are seen in these settings need and benefit from long-term treatment over many years, but the nature of training institutions is that the clinicians usually stay only one to two years. As a result, long-term treatment is often provided in training agencies by several clinicians sequentially rather than by the same clinician. This means the clients experience some recurring disruption and loss as they form attachments and say goodbye repeatedly. Many clients seem to develop an attachment to the agency which helps to maintain a sense of continuity. Their agency attachment, or institutional transference as it is sometimes called, helps the clients weather the coming and going of individual clinicians.

One dilemma highlighted in your question relates to getting information from prior therapists rather than directly from the client. Some therapists prefer to meet the client without reading background information in order to form an unbiased impression while others prefer to prepare by reading the previous therapist’s description of the client and treatment. There are advantages to both approaches, but my preference is to read the most recent assessment and treatment summary in order to have a general idea of the client’s current life difficulties and the nature of the therapeutic relationship. I hold this as the previous therapist’s subjective opinion, however, and expect that my experience and observations of the client will differ. I pay particular attention to what the therapist found effective in helping the client make progress, so I can use a similar approach if possible.

Another dilemma is whether and how to continue a treatment that is incomplete but didn’t include you. It isn’t realistic to think that you can simply pick up where the last clinician left off and at the same time, it is frustrating for the client to feel she is starting over in telling her story. I recommend giving a brief summary in the first session of what you have read and what you understand the client’s issues and goals to be, then asking what else she would like to tell you as the two of you begin this new relationship. I usually add that I may ask her questions about her past or present life that she has told the previous therapist because it is helpful for me to hear some things in her own words. I acknowledge that there may be times she will feel frustrated at having to repeat things she told the previous therapist and I encourage her to let me know when that happens so we can talk about it.

In addition to these dilemmas, being part of a sequential treatment allows for a fresh look at the client’s symptoms and situation as you and she form a relationship that is different from her previous therapy relationships. You are in a position to re-evaluate the case formulation and treatment plan and to take a different approach to helping the client in areas that may not have responded to other therapists’ interventions. Each therapist-client relationship is unique and creates new possibilities for growth. You and she will discover what is possible as you learn about each other and develop your own pattern.

I hope you find these comments helpful in working with a client who has had a series of different therapists. Please email me with comments, questions or suggestions for future blog topics.

Contacting Other Professionals

Responding to Client Requests

Diane A Suffridge, Ph.D

Consultant, training and author in behavioral health.