Tag Archives: Client

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.

Managing Silence

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

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

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

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

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

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

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

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

 

Unplanned Endings

worried therapistI 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.

Client Requests for Records

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

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

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

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

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

Termination Tasks

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I have a final session scheduled with someone I’ve seen for 6 months.  What should happen in the session to make the ending go well for the client?

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This blog focuses on the tasks of termination.  If you haven’t read the previous blog on Psychotherapy Termination, you’ll find that helpful before you focus on the logistics.

The main goal of termination is to create an ending that is less traumatic than the client’s prior experiences of separation and loss and that honors the client’s way of managing loss.  The tasks of ending treatment are the same regardless of whether the ending is planned or unplanned and whether it is initiated by you or by the client.  I will discuss one way to organize the ending into three tasks: reviewing the work you have done together, discussing future circumstances when therapy could be helpful, and sharing the experience of saying goodbye.  It can be helpful to share these tasks with the client in preparation for a final session, since most clients have little experience of ending a relationship with thought and acknowledgement of the emotions surrounding the loss.

The first task is to review the therapy, with you and the client sharing your thoughts about what you have worked on together and the changes that have occurred.  When you share your perspective, it is especially meaningful to the client to hear your memories about the early sessions.  An example is “When we began working together, you were really depressed and you had a hard time imagining how you could ever feel better.  Now you seem to be enjoying your job and time with your kids and you have ways to cope with sad feelings when they come up.”  If there are issues that are still problematic or have not been a focus of your work with the client, you can acknowledge those with a statement about how the client might address them on her/his own.

Second, the end of therapy is a time to provide support and education regarding returning to treatment in the future.  People often wait until symptoms are debilitating or until their lives are seriously impaired before seeking help, and a reminder about the steps that led up to the client’s presenting symptoms and condition may help her/him seek treatment more quickly.  Also, you can talk with the client about life transitions or developmental stages that may present a risk or vulnerability.  For example, a woman who was sexually abused at age 8 is likely to experience increased anxiety and reminders of her trauma if she has daughter who reaches the age of 8.  An adolescent who loses a parent will be vulnerable to episodes of depression or other grief-related symptoms when losses and transitions occur throughout adolescence and adulthood.  You can provide encouragement for future treatment by saying “If you find your symptoms returning again, I hope you’ll seek help again.  People often find it helpful to see a therapist when times are stressful or when there are life changes that may bring up some of the issues we’ve worked on here.”

The last task is to share the experience of saying goodbye.  Many clients are avoidant of emotions related to loss, and the depth and extent of this part of your conversation about ending may be limited.  However, at minimum you can make a statement like “I want you to know that I have enjoyed getting to know you and participating in the progress you have made.  I feel some sadness in saying goodbye, and I wish you well.”  This direct expression of your feelings provides the client with a different experience of ending, even if s/he doesn’t share her/his feelings.

I hope you find this structure helpful in organizing your final session.  Please email me with comments, questions or suggestions for future blog topics.

Working With Depression

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

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

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

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

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

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

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