Tag Archives: Clinical Psychology

Focus of Change

sunrise_2I have been reflecting lately on the process of change in therapy and on the complexities that may occur over time as we focus on change in different ways.  Clients often begin therapy with one of two underlying questions: “what’s wrong with me?” or “what’s wrong with my life or the people around me?”.  The first question focuses attention on the need for internal change and the second question assumes a need for external change.

When I began therapy in my 20’s, my underlying question was “what’s wrong with me and how can I fix it?”.  This question was more implicit than explicit, but I assumed the blame and responsibility for the difficulties I was facing at that time.  My therapist helped me identify my distress as linked with patterns of coping that had been in place since early in my life, and as I shifted these patterns my distress was lessened.

Like my first therapist, when I work with clients who enter therapy with the implicit question of “what’s wrong with me?” I look for ways to help them shift to the question “what happened to me and how was I affected by that?”.  This helps to relieve some of the harsh self-criticism that accompanies the original question, though there may be a heightened sense of helplessness in facing the lack of control clients had over their early life circumstances.  As they gain understanding, though, there is a growing sense of agency in developing alternative ways of managing the familiar symptoms and responses that may have been present for a number of years.

Other clients enter therapy with an implicit or explicit question with an external focus, sometimes with a desire for change in another person or in circumstances outside of their control.  When clients present with the question “what’s wrong with my life or the people around me?”, we often look for ways to encourage their awareness of the impact they have on others and the situations that are the source of distress.  This may be the client’s interpretation of events, responses that exacerbate conflict, or expectations that don’t match the current situation.  We gently explore the client’s part in the creation of distress while clarifying the differences between the outcomes that are desired and those that are possible.

Both of these questions, whether explicit or implicit, imply that blame or fault can be identified in oneself or in others and that a solution will be forthcoming once responsibility is established and the wrong is corrected.  It is easy to get caught up in this process, looking to balance the client’s misguided assignment of blame as belonging solely to self or other by pointing out other contributions to the client’s difficulty.  Someone who is harshly criticizing themselves pulls for us to point out the role of their past family experience or the actions of others, and someone who is blaming toward others pulls us to identify ways in which the client is contributing to their difficult situations.

This interplay between an internal and external focus of change may change during the course of a therapy, but it is difficult for us as therapists to avoid the polarization of blame and fault as lying within the client or within the other when the client holds a polarized view.  One of my clients had tremendous difficulty making changes in her responses to interpersonal situations, even though she could recognize rationally the need to do so.  I discovered and began to interpret that she held an unconscious belief that she was bad or wrong and that when she approached the need for change, she felt confirmed in that belief which then led her to resist the need for change.  She acknowledged that this was the case, but she continued to have difficulty following through on the steps she took that led to improved relationships.  I had only moderate success in encouraging her to take a more nuanced view of the connection between change and blame.

At other times, it may be challenging for a therapist to make a shift in focus from internal to external change, even when that is necessary. I was in therapy during a period of my life that was especially difficult due to external circumstances. I alternated between blaming myself, wishing desperately that the circumstance would change, blaming those I saw as responsible for the circumstances, and trying to shift my view of and response to those circumstances.  Eventually it became clear that I needed to make a radical change in my life in order to address the pain and distress that had begun to dominate my life.  That change included ending my therapy, which was also painful, due to my therapist’s focus on my role in the circumstances without recognizing that I had reached the end of my ability to cope effectively with the circumstances and that I needed to shift to viewing the impact of the present circumstance on my mental and emotional well-being.

I hope these reflections encourage you to look at the complex nature of the client’s focus on change as primarily internal or external.  One of the things that helps me stay on course is to notice when I begin to think in either/or terms and to remind myself that it’s usually both/and.


Termination Tasks

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?


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.

Beginning Behavioral Health Treatment

sunrise_1My agency has a lot of forms for clients to fill out at the first session. I want to build rapport in the first session but instead I’m explaining forms and getting the client to sign them. Are these forms really necessary?

Many clinicians feel frustrated about the amount of paperwork that is required when providing behavioral health services, especially in agency settings. Generally, each form meets a particular requirement and it may be helpful for you to ask your supervisor about the purpose and rationale for them if that hasn’t been explained to you. The two most important forms that are required by the legal and ethical standards of our profession are informed consent and notice of privacy practices. These establish a treatment relationship between you and the client. An informed consent form provides confirmation that the client knows the nature of the treatment, including its limitations, and agrees to participate. A notice of privacy practices informs the client about the exchange of information about the treatment between you and others, with or without the client’s permission. In California and some other states, clients must also be informed when the clinician is not licensed and is working under supervision. In addition to these basic requirements, your agency may have forms related to accreditation or certification, billing and payment, and collection of demographic and clinical data. Check the problems associated with crohn’s diease as well.

We often make an assumption that getting the client’s signature on required forms is an administrative task separate from the clinical work you are being trained to do. However, building rapport begins in your first interaction with the client and the way you discuss the forms and their content sets the tone for your future treatment relationship. You can convey your desire to work collaboratively with the client by introducing the forms with a statement like “I need to go over some aspects of our working relationship so that we have the same understanding of how we’ll be working together.” It is useful to practice summarizing the key points of each form so you can explain it concisely and clearly to the client.

One other tip regarding forms is to acknowledge the necessity to attend to some paperwork and express your interest in the client’s concerns. It is a good idea to prepare the client ahead of time when you set up the first appointment. At the beginning of the session, you can introduce the forms with a statement like “I’m interested in learning more about you and the concerns you have.” You can follow that with a collaborative statement like the one above or “Can we take a few minutes first to talk about some of the important points about our work together?” or “There are some things that I want to talk with you about before we begin.” You don’t have a treatment relationship with the client until the informed consent and privacy practices are explained and agreed upon, so it is imperative that you discuss these and ask for the client’s signature before moving into clinical material.

I hope you have a better understanding of the reason for the abundance of forms and can make use of these suggestions to handle them in a sound clinical manner. Please email me with comments, questions or suggestions for future blog topics.

Field Placement Terminology

sunset_5What’s the difference between psychotherapy, case management, mental health and behavioral health programs?

If you are new to the field of psychology, marriage and family therapy or social work, you may have questions about some of the terms that are used to describe your practicum or field placement setting. Your program may use one of the terms above or a different term to describe the type of services provided to clients.

Psychotherapy involves a relationship between a client, which could be an individual or a family, and a therapist in a private, confidential setting for a specified time, traditionally 50 minutes once a week. In psychotherapy, the therapist and client identify goals for their work together, usually related to reduction of symptoms and improvement in areas of the client’s life, which may include homework or practice outside of the session. The therapist may coordinate with other health and social service providers, but the communication is primarily between the therapist and client. There are legal regulations restricting the provision of psychotherapy to individuals who meet certain education and experience qualifications.

Case management covers a broader range of activities in which the case manager may accompany the client to appointments, contact agencies and providers to advocate for the client, arrange and facilitate the client having access to housing or other resources, and/or serve as a mentor or coach. The length and frequency of sessions is based on the client’s needs and may vary from several hours multiple times per week to less than an hour once a month. The goals are often similar to goals of psychotherapy but the client and case manager may work on other practical goals with the case manager providing direct assistance. Case managers may be paraprofessionals, clinicians in training or licensed mental health professionals.

sunrise_vert_1A mental health or behavioral health program usually provides different types or levels of service to clients. Psychotherapy and case management are often included along with assessment and evaluation, inpatient or intensive outpatient treatment, medication management, and/or psychoeducation and support groups. Services may be coordinated within a treatment team of providers with different areas of specialty and expertise. The term behavioral health has been used increasingly during the last 20 years as programs and government departments began to combine mental health services with substance abuse services. The fact that these conditions overlap in a large proportion of individuals led to the rise of integrated services provided under the label “behavioral health.”

I hope this brief summary clarifies some of your questions. Please email me with comments, suggestions or further questions.