Tag Archives: Clinical Psychology

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?

therapy

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.

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.