Tag Archives: Clinicians

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.

What to do with Things that Can’t be Changed

therapyI’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.

Documentation in Private Practice

man-taking-notesI’m going to be leaving my agency internship for a private practice internship. What are the differences in requirements for writing progress notes in a private practice compared to an agency?

The requirements for documenting your client sessions are not specific to the setting, but agencies often follow guidelines set by third party funders. These guidelines may not be applicable to your private practice internship if you are not billing a third party insurer.

Before directly addressing the specific requirements of documenting sessions with progress notes, I’ll review the reasons for keeping progress notes when your client is paying directly for treatment. Under the Health Insurance Portability and Accountability Act (HIPAA), each client is entitled to receive a copy of her/his treatment record on request and you are obligated to provide one if requested.

Client records might also be requested, with the client’s permission, by another health care provider, by an administrative organization evaluating your client’s application for assistance (for example, Social Security Disability Income), or by an attorney in a lawsuit brought by your client claiming damages for emotional distress. A client record would also be required if you need to respond to a complaint or lawsuit filed by a client against you. You may believe that all of these situations are unlikely to occur with your private practice clients, but being without an adequate record could place you at some degree of risk or could create a complication for your client. You might not release the full record in some of these situations, but you would need a record in order to respond to the request.

Let’s return now to the issue of requirements for progress notes. All aspects of the treatment you provide are measured against the professional standard of care. The standard of care is the generally accepted practice used by other professionals providing a similar service. The codes of ethics of the professional associations for psychologists, marriage and family therapists, and social workers state that clinicians should keep accurate records documenting their work, without specifying the content of those records. Therefore, keeping progress notes for psychotherapy sessions is the standard of care.

There are several methods you can use to guide you in writing progress notes in a private practice setting. First, I would suggest asking your supervisor for her/his standards for the format and content of progress notes. If your supervisor doesn’t have a specific format, you could adapt the format you used at your agency internship to fit your private practice. You can also check with colleagues and your local or state professional association for templates used by other therapists.

Two resources you can check in print or online are the American Psychological Association Record Keeping Guidelines and a book by Donald Wiger entitled “The Psychotherapy Documentation Primer” published by John Wiley & Sons in 2012. These resources contain a list of the information that should be included in a progress note for each service provided. To summarize, the most important elements to include in a progress note for a psychotherapy session are: the context of the session (date, time, length, who attended, location, service provided), status of the client’s symptoms and functioning, any assessment you conducted and the actions taken as a result of the assessment, interventions provided, plan for future treatment, and your signature including your licensure status and date signed. You probably also need to include some narrative description of the topics covered in the session.

One additional issue to keep in mind is that HIPAA defines psychotherapy notes as distinct from progress notes. Psychotherapy notes are kept by you for your own analysis and may contain conjecture, inference, judgments and emotionally charged material. Psychotherapy notes are not part of the official treatment record and do not have to be released to the client or other parties. Progress notes should be factual and objective in describing your observations and interventions without the more subjective material that can be kept in a psychotherapy note.

I hope you found this information helpful in writing progress notes in a private practice internship. Please email me with comments, questions or suggestions for future blog topics.